§ Order for Second Reading read.
§ 7 pm
§ Mr. Peter Brooke (City of London and Westminster, South)
I beg to move, That the Bill be now read a Second time. [Interruption.]
§ Mr. Deputy Speaker (Mr. Michael Morris)
Order. I ask hon. Members to withdraw from the Chamber unless they are taking part in the debate. Further to that, I ask hon. Members who are having a dialogue on the previous Bill to do so outside the Chamber.
§ Mr. Brooke
The Bill is promoted jointly by King's college London and the united medical and dental schools of Guy's and St. Thomas's hospitals. For brevity, I shall refer to the latter as UMDS. Both are part of the university of London. I should declare an interest. I am a fellow of King's college and a member of the council of the university of London. The main campus of King's college lies at the heart of my constituency.
The Bill is designed to bring about the merger of King's college and UMDS. However, the scene is a little more complex than that. King's college already has a medical and dental school: King's college school of medicine and dentistry. Following the merger, King's college—a multi-faculty institution—will have an integrated medical and dental school made up of the present UMDS and King's college school of medicine and dentistry. I shall return to that, because the coming together of the two medical and dental schools is key to the success of the merger.
The Bill's provisions are straightforward. In large measure, they follow those of other private Acts, merging medical schools with multi-faculty colleges. The Bill has a lengthy preamble that recites the history of the formation of King's college London and UMDS. King's was founded by charter in 1829. The histories of St. Thomas's and Guy's can be traced as far back as 1550 and 1769 respectively. The Bill is self-explanatory, but, as there is only a small number of key clauses, I shall at this juncture rehearse their rationale and relevance to the purpose of the Bill that I have just described.
Clause 3 provides that King's college school of medicine and dentistry and UMDS may agree a day to be the effective date for the proposed merger. Clause 4 provides for the dissolution of UMDS, and subsequent clauses provide for the transfer to King's of UMDS's property, obligations and rights. Clauses 6 and 7, together with schedule 2, protect certain properties of UMDS for 10 years. During that period, the use of those properties may not be changed without the approval of a body that the Bill establishes, which is the continuing trustees of UMDS. Clauses 15 and 16 amend the statutes of King's college so that UMDS will be appropriately represented on the principal decision-making bodies of King's.
I urge that the Bill be accepted for three main reasons. First, it is widely agreed that the integration of medical schools and multi-faculty colleges such as King's leads to improved quality in both medical education and research. Secondly, it is only by unifying two medical and dental schools of international distinction—UMDS and King's 79 college school of medicine and dentistry—that further potential for achievement in medical and dental education, the biomedical sciences and research will be released. That is particularly true of research that increasingly relies on critical mass. Current research is about complex problems and requires big research teams and expensive equipment. Thirdly, the Bill has the overwhelming support of the respective councils of governors of the merging institutions, their staff and students. It has long been accepted that there are academic benefits—not least for students—as well as good administrative financial reasons for integrating free-standing medical schools into multi-faculty colleges.
As long ago as 1968, the royal commission on medical and dental education recommended that pre-clinical students should study in a multi-faculty environment—the London medical schools being unusual in being free-standing, independent schools. Since then, there have been a series of mergers of London medical schools with multi-faculty colleges: University College hospital medical school with University college London in 1979, St. Mary's hospital medical school with Imperial college, which are both in my constituency, in 1988, and the Middlesex hospital medical school with University college London in the same year.
More recently, the inquiry headed by Sir Bernard Tomlinson recommended that eight of the London undergraduate medical schools be merged into four faculties of medicine in the multi-faculty colleges of the university of London that teach medicine. The Higher Education Funding Council for England has been asked by the Government to take the recommendation forward. Of the mergers recommended, in addition to the proposed merger of UMDS and King's, the merger of Bart's and the Royal London hospital medical schools with Queen Mary and Westfield college has already been authorised by an Act that was passed in November, and the Bill to merge the Royal Free hospital school of medicine with UCL is awaiting Royal Assent.
As I said, the unification of UMDS and King's has the overwhelming support of the respective councils of governors of the merging institutions, their staff and students.
§ Mr. Ted Rowlands (Merthyr Tydfil and Rhymney)
As a very proud former student of King's—although not of the departments with which the Bill is concerned—I should like to confirm whether every member of staff and student supports the merger. If so, I shall vote for the Bill.
§ Mr. Brooke
I do not know whether I can say that support is unanimous, but there is overwhelming support in the bodies that are coming together for the scheme. I thank the hon. Gentleman for being present as a graduate of the college.
The proposed merger has been seen as the way forward for a long time. The two institutions began discussions about coming together as early as 1989. Indeed, before the Tomlinson report was published, they had already signed a memorandum of agreement to merge. So the development was pre-Tomlinson. Practical planning for the proposed merger is well advanced, not only administratively but academically.
80 For example, from 1998, King's and UMDS will have a common curriculum for third-year study—the first year of the clinical focus of the five-year undergraduate medical programme. By 2000, King's and UMDS will offer a joint curriculum. That advanced stage of academic planning is one of the main reasons why UMDS and King's want the merger to go ahead with all speed within a unified management structure. Delay at this stage would not only frustrate the introduction of the joint curriculum to which I referred, but, more important, reduce the morale of staff who have so enthusiastically been planning a joint future. Uncertainty would also result, with consequent adverse effects on staff, students and research teams.
UMDS and King's believe that their merger will provide unparalleled opportunities for the further development of their unified medical and dental schools as a centre of national and international distinction in teaching and research. It will improve significantly the opportunities for interdisciplinary and intradisciplinary integration in pursuit of both teaching and research excellence. Resulting economies of scale will ensure that the merged college is a cost-effective institution, both in terms of space utilisation and recurrent and capital expenditure.
The proposed consolidation of biomedical sciences, currently taught on six sites, on the Guy's medical school and hospital site will be of great advantage not only academically but in terms of cost-effectiveness. The consolidation of biomedical sciences will require new build. That can be done at Guy's without any effect on present or future hospital services. The new build will replace Hunt's house, which the NHS planned to demolish in any case when phase III of the Guy's site development opens next year. The new build project could not be realised without the merger. King's and UMDS staff could not come together in the new building on any other basis. Moreover, the merger will enable the teaching of future doctors, dentists, nurses and other health care professionals to be undertaken together.
The merger will facilitate the important linkage between the education of medical and dental students and the clinical work of a hospital site, thus ensuring vertical integration of the curriculum. It will have the further advantage of concentrating medically related research groups alongside medical teaching and hospital services for patients, thus increasing opportunities for effective collaboration and cross-fertilisation of ideas. The present first-class academic facilities at Guy's hospital site will secure for the future King's medical student a unique educational environment.
The juxtaposition of academic and clinical facilities in one place will allow integrated teaching of basic science and clinical practice—the best possible educational experience, everyone agrees, for the teaching of medicine. Taken together with the first-class facilities at King's College hospital, Denmark hill, and St Thomas's hospital, that will guarantee the prospective medical student a rich and varied education.
Concerns may be raised this evening bearing on issues of health care provision, particularly at Guy's hospital, rather more than on the proposed merger of UMDS and King's. As far as Guy's is concerned, the present proposal from the NHS is that Guy's should continue to provide hospital and health services focusing on the needs of the 81 local community. I should make it clear that UMDS is a separate legal, financial and administrative entity from the Guy's and St Thomas's hospital trust.
UMDS and King's plans for the academic development of the Guy's site have no effect on available hospital space at Guy's and do not constrain either the national health service's present plans for the future of Guy's as a hospital, or, for that matter, any future plan for the development of that hospital. A strong academic base at Guy's will support the health services there, in providing a critical mass of patient work and a range of skills and expertise in clinical terms so as to ensure continuing high-quality treatment for patients at Guy's, as well as at the competing centres of excellence elsewhere in the capital.
The medical school merger plans will have a beneficial effect on health care provision at all three hospitals—Guy's, King's and St Thomas's. The various projects, including the massive academic development at Guy's in biomedical sciences and the enhanced academic provision at King's College hospital and St Thomas's, will support the health services in providing a level of work, a range of skills and expertise in clinical teams and high-quality treatment to enhance patient care, as well as teaching and research.
King's and UMDS's vision is that, by merging, they will be able to maximise the potential of two very successful university institutions. Principally, the merger will secure the academic critical mass, both to strengthen a number of areas of academic endeavour already of an international standard of excellence and to develop new initiatives. Thus the two institutions will be able to secure a place at the forefront of health education, clinical care and research, which they do not believe to be as achievable if they were separate institutions.
Before I finally commend the Bill to the House, I allude to a happy parliamentary coincidence this evening. The hon. Member for Southwark and Bermondsey (Mr. Hughes), who is present, will know of a previous reference that I have made in the House to the year 1808, when there were six Members of Parliament for my constituency, three representing Southwark and two for the rest of Middlesex. The debate this evening is surrounded by a major constitutional debate, redolent of the days of Wilkes, who was a Member of Parliament for Middlesex and subsequently lord mayor of London. It is a happy coincidence that this debate should be surrounded by a debate on a great constitutional development while the hon. Member for Southwark and Bermondsey and I demonstrate the longevity of both our constituencies.
I commend the Bill to the House.
§ The Minister for Health (Mr. Gerald Malone)
I am glad to have been able to catch your eye early in the debate, Mr. Deputy Speaker, to set out briefly the Government's support for the measure. I congratulate my right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke)—as is customary when I follow him in a debate—on setting matters in their important historical context. I shall venture no suggestion that the rest of the House is somewhat relieved that the number of hon. Members has changed somewhat in the intervening 188 years. I shall leave that to the judgment of others.
My right hon. Friend set out the history of this much needed and welcome change which those involved wish to put forward. I welcome the Bill, which will take 82 forward the agenda of all those involved. My right hon. Friend was right to point to the consensus among academics, clinicians, students and all those concerned with providing a high quality of medical education and research in this part of London, who have worked so hard to make the change possible.
As my right hon. Friend said, the plans have been the policy of the university of London for many years. He rightly pointed out that they continue independently of any health care provision changes that may be debated at present. The move towards uniting the medical schools with multi-faculty colleges will provide a broader base for teaching and improved links with basic sciences. But although they are independent of the changes now being implemented in the health service in south-east London, there are close working partnerships between the university and the NHS, and it is important for the provision of health care that those partnerships be reinforced in a number of ways.
It is sensible for the NHS and the medical colleges to work together constructively on all the changes, which will bring benefits to patients, and also support important teaching and research interests. It is in the interests of Londoners that they should have access to the full range of health services that they need, and it is also important that London's role as a centre of high-quality medical education and research be sustained and fostered. The latter ambition is at the root of the Bill.
My right hon. Friend rightly referred to the three reasons for or principles behind the change—quality in research and education; the fact that research nowadays needs to be on a supportable scale; and the principle of support from the institutions involved. Those are very important and underpin the Government's welcome and support for the Bill. We are pleased to work with the university of London and the Higher Education Funding Council for England in ensuring that service, teaching and research interests are balanced and that plans proceed in parallel to achieve coherent, consistent and managed change.
The schools and the college have close links with associated NHS hospitals, and those will be further supported with the collocation of teaching and research facilities with clinical services on the Guy's hospital site, as my right hon. Friend rightly said. Many of the new services being developed at Guy's include state-of-the-art day care and diagnostic services, and it is important that academic and research work is carried out in collocation with those.
One of the great strengths of our NHS is that we are able to provide research in parallel with service commitments. UMDS, King's college medical school and King's college London are recognised as organisations of high reputation that are successful in their own right. Their wish to come together will reinforce that excellence and produce new opportunities for the future. The proposals are widely supported. I am pleased to add the Government's support to plans that will ensure that a long tradition of outstanding medical education and research in south-east London will continue, which will be strengthened by the Bill.
§ Mr. Simon Hughes (Southwark and Bermondsey)
I am privileged to be able to take part in this debate and I do so wearing my hat as the Member of Parliament for 83 Guy's hospital, which, as the right hon. Member for City of London and Westminster, South (Mr. Brooke) introduced the Bill by saying and the Minister and other colleagues will know, is one of the sites for the united medical and dental schools—one of the partners in the proposed merger.
I must give one word of historical reply to my neighbour across the river, the right hon. Member for City of London and Westminster, South, who like me represents a constituency with one of the oldest pedigrees in the country. There have been Members of Parliament for Southwark since the 13th century. I believe that there have been more than 400, reflecting the fact not that they have each had a short span, but that there were two at a time for each of the constituencies until last century.
One of the great pleasures of a constituency such as mine—which is more rightly now called Southwark and Bermondsey, reflecting the two old boroughs south of the river—is looking after and advancing the causes of those institutions that are historically part of our community. We do so conscious of our history, but also conscious of our present. It is no mistake or accident that two of the greatest issues facing the Governments of our time are the futures of our education and health systems. The Bill is a microcosm at the higher education end of that debate, as it concerns the best arrangements in one part of the country for the best conjuncture of education and health.
The question is simple: to merge or not to merge. I will not divide the House on Second Reading. My job is to pose some questions that flow from the proposition of the right hon. Member for City of London and Westminster, South that there should be a merger—a proposition supported by the Minister.
The House will be relieved to know that I will not repeat the speech of the right hon. Member by tracing the history of how we come to be here. Due to a series of developments in London medical education, we have ended up with a merged medical and dental school south of the river, on two sites: the St. Thomas's site in Waterloo, just over the bridge from here in the constituency of the hon. Member for Vauxhall (Miss Hoey); and the Guy's site, at London Bridge in my constituency.
A merger is proposed between that institution and King's college, which provides academic teaching on the north bank of the river and clinical teaching on the south bank at King's College hospital, Camberwell. Ancillary issues are involved: students live in residential institutions, which are scattered around and are mainly south of the river.
It may surprise the right hon. Member for City of London and Westminster, South to learn that I do not intend principally to raise issues to do with health care and Guy's, although I am concerned about the linkage. The right hon. Gentleman stated three propositions as unarguable—one touches on the intervention of the hon. Member for Merthyr Tydfil and Rhymney (Mr. Rowlands). They are perfectly credible propositions, but I want to question them in turn, because there are counter-arguments.
The first proposition is that it is widely agreed that integration is a good thing. Although that is so, several reputable people dispute it in the case of London teaching hospitals and schools, so it is not an unarguable proposition.
84 The second proposition was that there is a critical mass for medical and dental academic institutions. I agree that there is, but I take issue with the claim that the merger is necessary for, and will produce, that critical mass. Indeed, the merger will make for a much larger institution than is normal in this country and countries of a similar size, and much larger than is recommended. It will be a very large institution, and there are arguments against it being so big.
Thirdly, on the intervention by the hon. Member for Merthyr Tydfil and Rhymney, I will not assert that the proposal does not have considerable support—I cannot do so. I do not doubt that there is majority support. However, I am aware from approaches made to me that that support is not unanimous, or even overwhelming. The people who are probably the most troubled are the students, but others who are academically involved in UDMS and, I gather, in King's—that is not in my constituency, so I know less about it—have certain concerns.
Given that I think that there will probably be no recorded vote on Second Reading, the hon. Member may want to make further inquiries, and I can put him in touch with some of the people who are concerned about some of the implications. I am grateful for his interest as a former graduate of King's, which is an eminent university college.
The right hon. Member for City of London and Westminster, South first tackled the drafting of the Bill, which is straightforward. The proposition is that, if there is to be a merger, one needs such a Bill. I will not discuss the details of the drafting, which will be a relief to some of those involved in it, whom I have known for a long time—I would not want them to be offended, but that is a more personal matter.
The Bill provides for an appointed day for the merger, and the date pencilled in is August next year. My collaboration will depend on whether I get assurances on and satisfactory answers to my questions—the date may have to be later.
Two other matters arise from the Bill's drafting. First, it will be a blessed relief to those living south of the river that we will lose a name that no one understands and gain one that, in theory, everyone would understand. The united medical and dental schools could be anywhere from John o'Groats to Land's End, or certainly from Aberdeen to Plymouth. It was not a very clever title—it was a bit clinical. I would not defend such a title, in which the historic names of the two original hospitals were lost.
However, I am not sure that the new title provided for in clause 12—the Guy's, King's College and St. Thomas' Hospitals' Medical and Dental School"—is a wonderful solution. It will not fit with ease on a rugby shirt, a rowing vest or anything else unless one is a very large fellow indeed, or a large woman. [Interruption.] Women's rugby is all the rage nowadays, and it will be an Olympic sport before we know where we are. Some of the people to be seen at St. Thomas' hospital and Guy's would be good candidates—if they do not play rugby already.
85 It is a minor issue, but we must get the name right. We want one with which we can all associate. No matter where they were educated, all hon. Members will agree that names matter a great deal.
§ Mr. Rowlands
I do not quite understand what the hon. Gentleman objects to. The Local Government (Wales) Act 1994 left us with Rhondda Cynon Taff.
§ Mr. Hughes
I remember that debate. I was educated in Wales and I still follow Welsh issues. However, even Rhondda Cynon Taff is only a third as long as the name proposed in the Bill. I do not want make a big deal about that, but it is a muddle that tries to get everyone's name into the title.
Thirdly, I should like the right hon. Member for City of London and Westminster, South to deal with the historical concern about the trust funds that belong to the trustees of the existing institutions. As in all such cases, there is some concern that, if the trust funds are merged, control will be lost and their original historic purposes will not be fulfilled.
I have seen the memorandum from the Charity Commissioners that says they are happy, and I know how the law on the merger of trusts works. There is, to put it mildly, nervousness that there may be a loss of control of funds that were given for particular purposes as a result of the merger. If there continues to be discontent, could the trust funds held by the trustees of the various institutions remain separate and be excluded from the Bill? That could be done under the law. If it would allay concerns, I might well argue for it.
The section of the documentation supporting the Bill called "The rationale for the merger" sets out the merged colleges' seven strategic objectives, which the right hon. Member for City of London and Westminster, South summarised.
First, there is the issue of critical mass. It is argued that the merger of two successful university institutions will result in the critical mass necessary to obtain a secure, linked set of academic centres of excellence that will enable us to keep our international reputation.
We are talking about institutions that already have a high international reputation. London medical schools dominate the top ten list of institutions that receive Medical Research Council funding. In the international lists of institutions with the highest academic standards and their research grants and successes, UMDS does extraordinarily well.
For example, in 1989 the French newspaper Libération published a guide to the top 100 universities in Europe. London's medical schools came top of that guide, which stated:The density of its network is such that this premier position is in no way a surprise: the different colleges of the university each on their own cover the full range of specialities.There is a strong argument that it is the nature of the current institutions that attracts interest, investment and bright students from elsewhere.
A London university medicine administrator told my office only last week that Singapore and Malaysia will pay for their students to study in England only at Oxbridge or London university. For medicine and dentistry, they will not pay for them to go anywhere else. 86 I am sure that there is no dispute in the House that it is important that any change we make to the structures must safeguard and enhance the academic reputation and international pre-eminence of the institutions.
If we merge the two institutions, what will the student numbers be? What is the pattern of academic institutions in Britain and elsewhere? A learned article in the British Medical Journal in 1993 entitled "Undergraduate Medical Education" appeared in a selection of articles called "London after Tomlinson". It is both recent and academically attested. I hope that it will make my argument clear. It states:The Tomlinson report recommends the incorporation of all medical colleges into multifaculty institutions without giving any academic evaluation of its desirability … There are, however, few data to support the thesis that undergraduate medical education is more effective when conducted in a multifaculty environment.I shall return to that point.
The article continues:the resulting medical colleges within the capital would be extraordinarily large, with some medical student intakes approaching 350. The General Medical Council's proposals for undergraduate education strongly recommend a reduction in the factual overload often generated within basic science faculties.The article then debates integration, to which I shall return, before addressing the numbers question, about which it states:If the Tomlinson proposal was grounded in the belief that such mergers would produce economies of scale there is in fact little evidence to suggest that economies of scale exist in institutions that have merged.Our personal prediction would be that in 10–20 years the debate will focus on how to unscramble these large schools, bringing ourselves into line with those in the United States, where intakes of 100 to 150 students are deemed desirable.The new college will be considerably larger than other institutions in this country or in the United States. In paragraph 195, Tomlinson predicted that an intake of more than 200 to 250 would be bad, managerially and organisationally. The merger will produce an intake of 300. Chicago and Johns Hopkins, one of the most prominent medical schools in the United States, have a maximum intake of 100; Stanford's maximum is about 65. Are we sure that such large academic intake cohorts will benefit students?
People are seriously troubled about that. On the mainland of Europe, there are often hundreds of students doing an academic course at any one time. It may be possible to get away with that with academic teaching—a point that replicates our debates about class size. I am doubtful about that argument, and it has never been our tradition in England. In medicine, dentistry and applied sciences generally, the argument is even less strong.
The merger will also produce a dental school much larger than all other dental schools in Britain. Apart from Glasgow, dental schools have student intakes of less than 60. The optimum size recommended by the royal colleges and others is between 65 and 75. The UMDS figure is at present 88. I am not merely advancing a layperson's argument; the Nuffield inquiry into dental education, for example, made that point.
It has been put to me by academics and students that a dental school that takes 140 students a year would, under any foreseeable arrangements, be unmanageable. For heaven's sake, let us examine whether the critical mass 87 will not be far too big. Where is the evidence that such a big school will work? There are no parallels, and the proposition is not supported by the academic evidence.
The second strategic objective argues that the merger willimprove significantly the opportunities for interdisciplinary and interdisciplinary integration in pursuit of both teaching and research excellence.That might be the case in parts of the country where there is not already a federal university. The parts of the university of London about which we are talking are near each other. London students are part of a larger family—if they want to mix, they mix; if they do not want to mix, they do not.
My university experience suggests that medics, dentists and vets do not naturally spend all their time with students studying other subjects, but traditionally stay together. It may be argued that that is not a good thing socially, but the argument for such mixing seems less well made in London than in any other place in the country as the collegiate structure already provides such opportunities.
I accept that UMDS is a free-standing university medical and dental school, and that such institutions are now in a minority. But that does not mean that its students are isolated either from those undertaking the other professional training mentioned by the Bill's promoters or from students studying other subjects. It is not as if UMDS students will be miles away from other students, whether undergraduates or postgraduates, studying something else.
There is also the questionable argument whether it will be better to integrate in this way. I challenge that argument, not because I believe that it is definitely wrong, but because strong and valid academic arguments suggest that it is not necessarily good. The arguments are as follows: if a highly regarded, internationally successful medical and dental school already exists, the benefits of merging may well be outweighed by the disadvantages. To put the question crudely: will the merger result in a sum greater than its constituent parts?
The recent experience of Bart's, Queen Mary and Westfield, and the London, which have done a double merger, shows that the merger may bring no short-term advantages, although it is accepted that it may have long-term advantages. Can we be sure of the long-term advantages when it looks as though there will be few, if any, short-term advantages?
Unit costs per student in London are already less than the national average. London medical students do not cost more than other medical students. Students at UMDS cost the taxpayer not more, but less, than average. What is the advantage of merging with another institution when that does not necessarily bring better value for money?
There are some strong arguments about the nature of the academic teaching. One argument is that there will be generic teaching—that has been going on at UDMS for some time. There is an argument that one can have too much generic teaching. There is an argument that, if someone is studying medicine or dentistry, he wants specific teaching and does not necessarily want to be entirely integrated into a course of life sciences.
At Bristol university, the joint lectures that were set up between the dentists, medics and other life science students have been abandoned because they became too 88 general. It does not automatically follow that it is a good thing for non-clinical teaching to be carried out with other people if it is inappropriate. It would be the same as insisting on all-class teaching, when it would be more appropriate to set or stream. We must be satisfied about what we are doing; we must not blindly undertake such a policy when there is evidence that it has not worked elsewhere.
There are already links with other institutions—UMDS has strong modular links with University college London, for example. Why should it not be better to continue with that mix-and-match form of curriculum development rather than put everyone together on one integrated course as the proposal suggests? If the proposal were adopted and life sciences, medicine and dentistry were integrated, would that work in practice?
We must consider the fact that people studying for an ordinary life science degree such as biochemistry have a traditional academic year cycle, while people studying for a medical or dental degree have different cycles—they go on location to other hospitals, they go on electives elsewhere, they undertake six-month stints in different places, and they have shorter holidays. There are practical questions about whether the system will work. Those questions are raised both by the students and by those who teach them. They say that they are achieving perfectly good results, so why should anyone seek to integrate them when that may be contrived and unnatural?
The third strategic objective argues that the merger willprovide a cost-effective institution, both in terms of space utilisation and recurrent and capital funding.There are some serious questions to answer. I gather that the proposal will cost about £140 million—I should be grateful for confirmation. I also gather that, of that figure, about £70 million will be for the new biomedical block that is to come to the Guy's hospital site. I should say in passing that I hope that everybody will talk about it as the Guy's hospital site, not the London Bridge site—a title that has started to creep in as a way of writing Guy's hospital out of titles. Not surprisingly, the people at Guy's do not take too kindly to that.
Another question which arises links this debate to the one about Guy's hospital. The current proposal that the Minister of State and his colleagues are advancing about Guy's hospital will leave vacant considerable amounts of space in at least one of the tower blocks that currently form part of the Guy's hospital site.
It is no good looking at the cost of the academic development separately from the costs of the health service development. The cost of the health service development is the cost of Philip Harris house, which has escalated from about £50 million to well over £100 million. There is the cost of new build for mothers and children at Riddell house and other sites at St. Thomas's hospital and other further capital developments—all of which are eventually meant to be recouped in lower revenue costs.
There are serious concerns that, under the Bill, we are committing ourselves to large amounts of taxpayers' money which happens to be in the pocket marked "education" rather than "health". Under the heading of health we have committed ourselves to further money to build unnecessary buildings. They are unnecessary, because space will be available in buildings that already exist.
89 The Minister said that next year—I will believe it when I see it—the building at Guy's hospital that was to have been called Philip Harris house—history is being rewritten, and it is now to be known only as phase III—will eventually be open. It was due to be opened about two years ago, but there have been all sorts of problems and some less well explained delays. The National Audit Office is currently investigating the matter.
That building is meant to accommodate many of the health service facilities on the Guy's hospital site, but there will still be the two other relatively recently built buildings that are intended for health use. It will be helpful to know whether they will be used for health, or whether, as people at Guy's hospital and in the neighbouring community fear, they will be left virtually empty. In that case, they could be put to academic use. If so, why spend £140 million to put up buildings, some of which will not be needed because the necessary space will be available on part of the same hospital site at Guy's?
That is why I say that the cost-effective use of space and recurrent and capital funding must be examined in the context not just of the Higher Education Funding Council for England budget, but of the funding budget of the Department of Health. It is no good disregarding the fact that there will be a cumulative cost to the taxpayer, so the two must be looked at together.
The fourth rationale for the change is that it will consolidate the biomedical sciences currently taught on six sites on the Guy's medical school and hospital site at London Bridge. I understand the frustrations that have led to King's seeking to rationalise the use of its properties; working on one site instead of six would, of course, be an improvement. I will therefore not argue against the fourth rationale, but I want an assurance in writing that all the biomedical sciences will indeed be on one site. It is no good arguing for consolidation if students are moved either to the Denmark hill site in Camberwell or to the St. Thomas's site at Waterloo. We need to be sure that everything will be consolidated on the one Guy's hospital site.
The fifth argument is that the teaching of future doctors, dentists, nurses and other health care professionals should be combined. The idea is to integrate teaching in the health service, and I agree with it. It seems a worthwhile objective, with which I would not quibble.
The sixth proposal, however, cannot be borne out by the facts. It is that we should link the education of medical and dental students to the clinical work of a hospital site,thus ensuring vertical integration of the curriculum, the key requirement of both the General Medical Council and Dental Councils in relation to future medical and dental education".That would be fine if, after accommodating all the medical and dental students in the new buildings at Guy's hospital, the teaching were done on the same site. But the Minister for Health and his colleagues have been busy shipping most of the in-patient beds away from Guy's hospital and off to St. Thomas's. That will defeat the object of the Bill. Academic work will be done on the Guy's hospital site, with out-patients, mental health patients and patients using the 112 elective beds, but most of the beds containing the patients on whom the students will need to learn will be at St. Thomas's, a mile or so down the road.
That is nonsense and unnecessary. If academic work is to be consolidated on the west side of the Maze pond—the western half of the Guy's hospital site—then the 90 eastern half on the other side of the road should be used for medical health care. There is room to do that, because there is certainly room for a hospital with the number of beds needed to make the project viable on the other side of the site.
It appears that, wittingly or unwittingly, the Government are trying to implement two contradictory policies. Consolidating teaching with clinical practice is more important than ever nowadays, because students do not do a straightforward two-year pre-clinical and then go on to clinical: they start clinical work earlier. On the other hand, the Government are so arranging things that students can do this less frequently. The students in the combined institution will spend all their lives doing their lectures on one site, occasionally talking to out-patients and those who occupy the remaining beds there, but for all other work with patients, they will have to go to another site. That is exactly what we want to avoid.
The vertical integration of the curriculum with the clinical work of the hospital site will thus not be achieved by the Bill. The solution is to vary the proposals of the Minister for Health and his colleagues, who, over time, want to move most of the beds down the road to the St. Thomas's site. There is a good academically backed case for keeping a reasonable number of medical and surgical beds at the Guy's hospital site, where it can act as a secondary and tertiary hospital.
That is not inconsistent with the Government's strategy—I agree with it—of rationalising specialties; but that does not necessarily mean rationalising all specialties on one site—certainly not if the money does not add up. The longer the process continues, the more Philip Harris house and the building programme will cost. It will then become less necessary to start building on other sites, such as the mother and baby site at St. Thomas's.
When this Bill, as opposed to the merger, was first thought of, there was a proposal to have hospital services on both sites. Guy's and St. Thomas's would merge into one trust, so the reorganisation of services had not yet been fully worked out. Since then, however, cardiac, renal and neurological services have been rationalised, as had to happen because there was a need to consolidate. But there was then a failure to take into account precisely what the optimal mix of specialties and beds would be.
There are strong academic arguments to the effect that hospitals with up to 1,400 beds—that is what the merger implies—are far too big in terms of organisation, morale and business management. The Americans, the Scandinavians and academics in the UK are, according to all I read and hear, reaching the view that great big hospital sites bringing all beds under one roof no longer offer the best hospital organisation models.
That being so, the best logical solution is to use the space of the Guy's site and the space that King's decided it did not need in New Guy's house and Guy's tower for the original health service purposes. That will also be cheaper, because it will integrate academic and clinical work, and it will allow out-patients at the Guy's hospital site as well as other sorts of treatments there. This idea is also consistent with the fact that the most modern building in the entire health service, Philip Harris house, will just have been built.
Finally, the last rationale is that the merged college will be able to concentrate medically related research groups alongside medical teaching and hospital services for 91 patients, thus increasing the opportunities for effective collaboration and cross-fertilisation of ideas. Hooray and amen to that. In that case, let us have the teaching and the clinical activity on the same site, so that the research, teaching and clinical activity can be together. If it is the plan for Guy's to be the academic site, let it be the academic site, but do not, at the same time, pull the rug from under us and take the medical activity away. It is not so easy to take the dental activity away.
The logic behind this argument is fatally flawed. People are arguing for the integration of a medical and dental school with a university college, which is fine; and they are arguing to put it on one site, which is also fine. However, they have realised that the site will lose most of the clinical activity that is needed.
I shall ask the Minister a specific question, and I am keen to get a specific answer. Will he give an undertaking that, after the proposed merger, the students will not be going to the King's college site or to the St. Thomas's site for their academic teaching? If they continue to go to the King's college site or to the St. Thomas's site, the purpose of consolidating will not be met.
It will be nonsense if, in theory, we consolidate and bring the three sites together, but, in practice, a significant number of the students still have to be bussed to three different sites south of the river. We need to be clear about this: either we go down a put-it-all-on-one-site road or we do not. If we do not, the merger is not nearly as justified; if we do, for heaven's sake let us put the clinical activity in the same place.
How much of the cost of the whole merger project and the creation of the whole new academic site is dependent on the private finance initiative? It is a coincidence that the debate is taking place on the day that the annual conference of the British Medical Association started. One of the BMA's great concerns—apart from the fact that it thinks that the health service is greatly underfunded, with which everyone in the health service could not but concur—is that the PFI has been dreamed up by the Government as a way of saving money, but that it has never been proven to be a good idea. There is no evidence that the PFI is delivering the goods.
For example, it was reported in the national press at the weekend that in Scotland the flagship of the PFI still has not had its contract signed—in fact, I understand that none of the PFI contracts has been signed. Last year, the Treasury was unpersuaded that the PFI was a good thing, and the Treasury Select Committee has expressed many doubts.
The people running the hospitals and the people in the health service are concerned that the PFI means that we will be signing up to deals that commit the provision of a set of services and facilities for 10, 20, 30, 40 or 50 years to someone else, and that the health service will not have the power to manage it. Some crucial questions in relation to this issue are: how much is dependent on PFI?; how secure is the PFI money?; will it be there?; will it be guaranteed?
One of my concerns—it is shared more widely; in fact, my hon. Friend the Member for Bath (Mr. Foster), the Liberal Democrat spokesman on education and employment matters, has voiced this concern in the past, and may elaborate on it if he catches your eye, Mr. 92 Deputy Speaker—is that there have been many examples in the past where the promise of capital finance has never been delivered. What guarantee is there that the money is secure? What guarantee is there that it will not be cut in the years ahead? I refer to south London and to the Institute of Psychiatry, which is on the Maudsley site on Denmark Hill. It has had to face significant cuts, which has made it extremely difficult for it to carry on its work.
If we are going to have the proposal, does the money come with it? Will the Minister or the sponsor say that it will be guaranteed, and that there will be no going back? In addition, is that logical and consistent with all the development and all the money that is being spent at the St. Thomas's site and at the King's college site? Will that expenditure militate against future expenditure to provide some similar services at Guy's, if that is the implication of the Bill?
I have expressed the concerns of the students and the academics. I now refer to what seems to many local people to be a better solution. We may be rushing to go down a complete merger road when there may be a solution that goes in the same direction but does not have the same disadvantages. Is a gun being placed at the heads of the UMDS and King's college? How much is this an entirely cost-driven question? The Higher Education Funding Council is literally saying—because these are its instructions—"We are going to go for the cheapest option, as opposed to the one that produces the best answer for medical education in London."
Tomlinson said in his report that changes in University Funding Council funding have led to pressures for more efficiency in teaching. These changes have increased the need to rationalise resources and to remove the duplication of posts. I subscribe to that view. However, one increasingly gets the impression that things are being so cost driven in higher education and in the health service that we will do so at the risk of academic excellence or the best arrangement of academic or medical resources.
Would it not be possible to have a federal structure, instead of a merger, for King's college medical and dental school and UMDS? Why could there not be a closer collaboration that allows them to develop how they want to work together rather than have them forced to come together? Why can that not be pursued, particularly if it would be no more expensive than the current proposals—and, indeed, might save some of the costs? Some eminent people concerned with this debate would have no problem with such a structure.
I understand that it is simply the funding authorities that are saying, "Even if it is cheaper or the same cost, we will not pay up unless you go down the road that we insist on." That seems to be going beyond the remit of the funding council. Its job is to provide funds for the best service; it is not its job to take away decisions from autonomous institutions. If they decide that something is better or more efficient, they should be allowed to pursue it.
That has happened over the river. As hon. Members will remember from debates in this place over the past few years, Bart's was forced to merge in two stages—there was a federation of east London colleges in the 1980s, and it has been forced into a merger in the last few years.
That was not a happy experience for everyone—there were certainly some very unhappy academics and students. It was argued that the merger put at risk some 93 of the things that the individual institutions had developed, such as their academic expertise and their reputation. Those of us south of the river still need to be persuaded. Are we going to have a forced marriage? It has to be done with the voluntary consent of everyone, not because they have a gun to their heads.
Is there a danger under clause 5 that some of the money currently held by the trust funds of the two institutions will be lost to other activities at King's? I do not mean that other areas of King's should not be properly funded, but is there any risk? There must be a factual answer to the question. Can any of the money currently held by the trustees of UMDS or by the trustees of King's college medical and dental school be directed away from medicine and dentistry to elsewhere?
If we are going to go down the merger road, what evidence is there—not from this debate, not from people in the university of London and not from people in the colleges in question, but from friends elsewhere—that a much bigger institution would do any better academically? London university has some continuing small academically excellent institutions. The London school of hygiene and tropical medicine, for example, has managed to retain its academic excellence in spite of its small size. The school of oriental and African studies proves that institutions do not have to be big to be better in academia or to punch their weight in the world's research journals. The more the Internet and university computer networks are used, the less we need to force people to be together on the same site.
In any event, collaboration is only so good, in that many of the links are with the private sector, especially for the health service—for example, with the pharmaceutical companies and international conglomerates. Why cannot they continue to fund the organisations as they do at present?
What about the students? My understanding is that a report in 1990—the second report of the Departments of Health and of Education's steering group on medical and dental education—proposed a set of undergraduate policies and plans for medical and dental students so that development of sites and their studies should always be enhanced by better teaching practice and circumstances. That has not been done, and the formal consultation process with the interested parties has not taken place. Why not? The interested parties should have a say through the procedures that were recommended.
I wish to make a specific point about dentistry, and the dental hospital and dental school that is currently at Guy's. The proposal would mean that there would be about 2,200 biomedical students on the Guy's site. I am worried that, if we have 450 medical and dental students—that could be the maximum—together, the logic of merger will not be carried out. That group will be too big to be taught together, so it will be split up anyway. I understand that the physical geography of the proposed buildings means that the group will divide into two. If that is the case, the solution is not a solution. It would create a big organisation, but the students would have to be divided up after all.
The dental school is the highest rated dental school for academic results in the country. The school, the students and many of the people associated with them have expressed reservations, for the reasons I gave earlier. We have seen the closure of three dental schools in the past 94 15 years. Given those facts, there is a real risk that, if we consolidated the dental teaching on one site, the institution would paradoxically become much more vulnerable, not much stronger.
There are other dental schools around the country, and people who are cynical and sceptical feel that it would be easy, once the dental school was based at one institution, to say at some stage in the future—if other services were moved away—"There is no medical clinical work on the Guy's site, apart from out-patients, and there is only dental clinical work being conducted on the Guy's site, and it would be sensible to put the clinical work together with academic work, so let's consolidate the dentistry elsewhere. We don't need it here."
Clearly that would be nonsense, and a betrayal of the tradition. I do not suggest that that is in people's minds at the moment, but it is a possible outcome if we consolidate in a way that people are unhappy about and that the students, lecturers and teachers have not been persuaded is the right way.
Where are we? The proposal on the table appears to be led by the Higher Education Funding Council. It appears to be based on the fact that it will be cheaper, yet strong arguments suggest that it will not. It appears to be based on the fact that it is universally agreed, but significant groups of people are unhappy. The proposal appears to be based on the fact that it will consolidate teaching between life sciences and medical and dental science, but some people who have experience of doing that have thought better of it and unstitched such arrangements elsewhere.
The proposal appears to be based on the premise that we need a big institution, but all the best practice elsewhere suggests that such a large number of dental and medical students would be too big and other institutions are smaller. It appears to be based on the premise that we will put everybody together on one site, but, as I have clearly argued, the understanding is that we would not get everybody on the same site; nor would we get medical activity in teaching terms and medical activity in clinical terms on the same site.
There are some serious flaws in the argument. It is not surprising, therefore, that the proposal has taken so long to get so far. It is not surprising that, in recent months, in the words of somebody who spoke to me about it, there has been a lot of shadow boxing, but not everybody has been willing to sign on the bottom line. Yes, the councils have approved the proposal and, yes, eminent voices are in favour, but they are all in favour only on balance, with reservations or with concerns.
Before the House completes its consideration of the Bill, I give notice that, if my questions are not answered—not only for my purposes, but for those who have come to see me about the issue—a whole raft of amendments will be tabled on Report. We probably should not as yet accept the proposals, no matter how tight the time deadline.
I want some assurances. I hope that this debate will have flagged up my questions. I hope that the summer recess will allow us to get those assurances and some satisfactory answers. I hope, above all, that the conjunction of the plans of the Department of Health for health provision on the Guy's hospital site and the plans of King's and UMDS and the Department for Education and Employment for academic provision on the Guy's hospital site will result in a logical conclusion.
95 If the institutions are to merge, the site must have beds and in-patients and a secondary and tertiary hospital, and if they are not to merge, the proposal should not go through backed by arguments that are, to say the least, contradicted by some people with an academic interest. I hope that we will get some answers tonight, and all the remaining answers and some policy changes on some of the key issues in the months ahead.
§ Sir Roger Sims (Chislehurst)
I cannot possibly claim to have the detailed understanding of the implications of the Bill that the hon. Member for Southwark and Bermondsey (Mr. Hughes) has just so effectively demonstrated, but the House will be aware of my especial interest in Guy's hospital. I have worked with the hon. Gentleman for the past two or three years in an endeavour to retain Guy's hospital in its present form and largely on its present site.
My right hon. Friend the Member for City of London and Westminster, South (Mr. Brooke), in explaining the proposals in the Bill, sought to emphasise that the proposals for the combined medical schools are separate from the hospital, which is administered by the local NHS hospital trust. That may be so technically, but I put it to him that they are closely linked in practical terms. The public perception is that hospitals and teaching schools are one and the same.
I believe that the proposals to transfer a substantial number of medical services from the Guy's site to the St. Thomas's site are flawed. I said in a debate that I initiated in the House about 18 months ago that I thought that the Secretary of State's decision was based on inadequate and inaccurate information. No evidence has emerged since then to cause me to change that view. I urge my hon. Friend the Minister for Health to reconcile his opposing positions: on the one hand, he advocates the Bill and all that it implies and, on the other, he is involved in implementing the proposals to merge Guy's and St. Thomas's and to transfer services.
In my brief contribution, I emphasise the points made by the hon. Member for Southwark and Bermondsey. If much of the teaching is to occur on the Guy's site, it is difficult to justify moving so many of the medical facilities and the patients to the St. Thomas's site. That is not logical. If we are to develop a fine medical school on the Guy's site, patients are an essential part of the learning process. It seems extraordinary to try to develop teaching facilities on the Guy's site while transferring medical facilities and the patients to another site.
My hon. Friend the Minister must also justify the cost of the exercise. It seems extraordinary to spend so much money on new buildings for the St. Thomas's site when the present proposals will mean empty accommodation on the Guy's site, both in Philip Harris house and in the tower blocks. I urge my hon. Friend—who wears two hats as Minister responsible for implementing this legislation and also those proposals endorsed by the House regarding Guy's and St. Thomas's—to consider whether he can justify both policies. I have made clear the sorts of changes that I think he should make. As he considers implementing the Bill before us, I hope that he will realise that my case for substantially modifying the plans for Guy's vis-à-vis St. Thomas's is now even stronger.
§ Mr. Don Foster (Bath)
I come to the debate with a completely open mind on the rights and wrongs of the proposed move. Having listened to the contributions by the right hon. Member for City of London and Westminster, South (Mr. Brooke) and my hon. Friend the Member for Southwark and Bermondsey (Mr. Hughes) and the brief but plangent contribution by the hon. Member for Chislehurst (Sir R. Sims), I remain fairly open-minded about our approach to the issue.
My hon. Friend and the hon. Member for Chislehurst asked important questions which must be answered before a final decision is taken. For example, my hon. Friend referred in passing to the important issue of the private finance initiative and the role that it must play in funding some of the proposed work if the merger goes ahead. I do not know whether my hon. Friend is aware that there is considerable confusion about the role of the PFI in the education sector.
There has been interesting correspondence between the Department for Education and Employment and the Treasury on that matter. The Department believes that the PFI should be in addition to the normal capital allocation procedures, whereas the Treasury views it as a substitute for those procedures. There is clearly a difference of opinion that will have implications for whether funds will be available to ensure that the required capital work takes place.
I was interested in the remarks of the right hon. Member for City of London and Westminster, South, who referred to the longevity of his constituency and to some of his predecessors. He is in the Chamber and may be interested to learn that my constituency dates back at least as long as his. I also have some interesting forebears. In the 1800s, the local Member of Parliament, Mr. A. J. Roebuck, was the first hon. Member to propose the state funding of education in this country.
If Mr. Roebuck were here today, he would be interested to listen to our debate on the funding of medical and dental education. He would have noticed the interesting timing of today's debate. Many people who are concerned about higher education in general, and about dental and medical education in particular, will arrive at the Palace of Westminster tomorrow to express their real concerns about existing funding difficulties in those areas. We are discussing the merger of two institutions that may require additional funding of £140 million or possibly more in the context of significant cuts in higher education funding. Therefore, we must ask: will that money be available?
This debate takes place within the context of real concern about the present funding of clinical and academic education. Mr. Deputy Speaker, I am sure that you are aware that universities' capital incomes were slashed by about 31 per cent. in last November's Budget. There was an overall funding cut of 5 per cent. and at least a suggestion that further cuts would follow. Those capital cuts came on top of a 28 per cent. real terms reduction in funding per student in the past six years.
Those figures are clearly important to the debate, as we are told that the proposals will save money. We are told that they are driven largely by the savings that may accrue from economies of scale. However, we know that the proposals will cost a great deal of money initially and no evidence has yet been produced of any savings in the long term. Before the House passes the Bill, hon. Members 97 must receive a clear answer on whether money will be made available to fund the up-front costs of the merger. Clear evidence must be produced that economies of scale will produce savings that will not prove detrimental to the quality of future medical and dental education.
People with those concerns may well look back to other mergers that have taken place, for example in the 1970s, when Bart's was told to merge with Queen Mary's. It was told that funds would be withheld from it if the merger did not go ahead. It went ahead, but none of the money that was promised to fund the merger was made available until about 12 or 13 years later, in 1985. We must be absolutely sure that the funding will be made available in this case. I hope that the right hon. Member for City of London and Westminster, South will say what assurances the Government have given him that funds will be made available.
I have also said that it is important that we are given a clear sign that there will be economies of scale to save money, but in a way that will not be harmful to dental and medical education in this country. One concern which has not so far been expressed is with the way in which cuts may be made that will have a direct effect not only on medical and dental education but on the medical and dental care of people in London.
There was some interesting correspondence recently between the Minister of State, Department for Education and Employment—the hon. Member for Mid-Worcestershire (Mr. Forth)—senior people within the Committee of Vice-Chancellors and Principals and medical schools around the country. For example, in the middle of May this year, the chairman of the CVCP's medical committee wrote to the Minister expressing considerable concern that the Department for Education and Employment had been quoted as saying that there wasno direct link between the level of university grants and the delivery of NHS patient services".The chairman went on to describe what he saw as an "inextricable triad" of teaching, research and patient care. Yet, in subsequent correspondence, the Minister seemed not to accept the intricate link between the two.
That is why it was so pleasing that the Minister for Health talked about his acknowledgment of the links between teaching, research and patient care. If the merger is to go ahead, we need an assurance that it not only will bring about improvements in the teaching and medical side of dentistry but will not in any way harm patient care for people in the capital.
§ Mr. Simon Hughes
My hon. Friend will be aware, as I am, that one of the great concerns outside is that there will not be sufficient medical or dental students, as in many other professions. One important factor in establishing confidence is that students should have confidence in their choice of institution, feel keen to go there and believe that it is a place where they want to study, and that they do not go off and do something else.
Does my hon. Friend agree—
§ Madam Deputy Speaker (Dame Janet Fookes)
Order. The hon. Gentleman is making a very long intervention.
§ Mr. Hughes
I shall shorten the last sentence, Madam Deputy Speaker.
98 Does my hon. Friend agree that the views of students, those who represent them, as well as the views of patients, are vital when we consider specific proposals, as well as general policy on health and education?
§ Mr. Foster
My hon. Friend makes an important point. There appears to be a fair body of evidence that suggests that there is much support for the proposal of the right hon. Member for City of London and Westminster, South. It is nevertheless important for, and incumbent on, all hon. Members to take careful account of those who are critical of these proposals and to ensure that, before the final version of the Bill is passed by the House—if that is to be so—we answer their questions clearly.
My hon. Friend made another important and relevant point: whether the Government will make sufficient funds available to ensure that we meet the targets for dental and medical training that they established. I do not know whether he is aware of this, but there was an interesting exchange recently in another place, when Baroness Fisher asked Her Majesty's Government:How they intend to guarantee the necessary finance to train an additional 500 doctors by the year 2000 in view of the impact upon university medical schools brought about by the 28 per cent. cut in their funding over the past six years and the further 5 per cent. cut for teacher training imposed in the last budget.In response, Lord Henley drew attention to the fact that the Government would take into account concerns about funding for medical and dental education. He said:However, the Government have to take into account the wider considerations, such as the burden on the taxpayer and the need to control public expenditure.He went on to make a similar point, saying that very difficult decisions have to be made about how they allocate the sums of money that are available for higher education. He said:We believe that the medical side of higher education receives its fair share."—[Official Report, House of Lords, 19 June 1996; Vol. 573, c. 316–18.]"Fair share" in that context has led to significant cuts. That is why we need clear assurances that additional money will be made available in the short term to fund the merger.
We are asked to accept that the merger will lead to economies of scale. My hon. Friend has already expressed the views of a number of people who believe that there is no clear evidence that that will be the case. The medical and dentistry secretary at Queen Mary and Westfield, for example, recently said that, from its recent experience of merger, there have been no short-term advantages, but acknowledged that there might be some long-term advantages. There is little evidence to show that any economies of scale will accrue from this merger, certainly not the evidence expressed in the debate. I hope that some evidence will be provided before the end of the debate.
As my hon. Friend the Member for Southwark and Bermondsey said, it is worth taking it into account that economies of scale are usually assumed to come from an expansion of an institution; yet, as we heard earlier, because teaching may take place on a number of different sites, there may not be evidence of the economies of scale in this case.
There is also the point expressed in paragraph 195 of the Tomlinson report, which suggests that an intake into a medical school of more than 200 or 250 would not 99 necessarily be a very efficient way of doing things in managerial or organisational terms. It is interesting to note that the merged college will have an intake of about 300. Even within the Tomlinson report, which advocated such a merger, there is evidence to suggest that in this case it may not have managerial or organisational advantages.
I repeat that I have an open mind on this issue, but I hope that, before the end of the debate, we will be given clear answers to the questions that other hon. Members and I have raised. I am sure that we all look forward to the winding-up speech of the right hon. Member for City of London and Westminster, South.
§ Mr. Henry McLeish (Fife, Central)
I shall try to be brief, and confine my remarks to what the Minister said earlier.
The hon. Member for Southwark and Bermondsey (Mr. Hughes) made a number of detailed points, and the right hon. Member for City of London and Westminster, South (Mr. Brooke) will doubtless wish to deal with some of the issues that he raised with the benefit of local knowledge and an interest in the subject.
I welcome the Bill, which, I hope, will enable the aspirations of the promoters to be realised. There is no doubt that medical education and research in London is important not only to the capital but to the nation and, indeed, the world. The House would, I think, expect any Bill such as this to enhance rather than detract from what is already happening.
The hon. Member for Southwark and Bermondsey raised the question of property, which is linked to the issue of the private finance initiative. In its response to the Tomlinson report, the British Medical Association mentioned concerns about the merger—concerns, rather than objections to what was being discussed. In paragraphs 13.4 and 13.5 of that response, entitled "London's health services education and research: response to the Tomlinson report", the BMA states:There is concern, however, that the use of split sites for amalgamated schools will lead to a lack of space and facilities which will make it difficult to deliver the curriculum being proposed by the GMC … It is a matter of some concern that the Report considers that the costs of rationalisation can be self-financing through the sale of medical school assets.At that point, post-Tomlinson, it was feared that the merger might have an impact on not only the use of sites but the quality of education.
An article featured in The Times Higher Education Supplement on 26 January this year raised the whole question of the private finance initiative. I do not want to inject too harsh a political note into the debate, but it is clear that the PFI has not been the remarkable success for which the Government hoped. The article suggested thatKing's College London and the United Medical and Dental Schools"—which are being merged—are looking to clinch the biggest deal so farunder an initiative worth £125 million. No one would deny that such an initiative requires investment, but it is important to set that against the performance of the Government's other PFI projects. The point is worthy of 100 concern, and I hope that the right hon. Member for City of London and Westminster, South will address himself to it. If a significant investment is required, can we be guaranteed that it will be delivered through the PFI? It has not been delivered to provide hospital improvements, refurbishments and new building, and there have been major problems in other regards. There have been delays, and many people find the PFI a cumbersome way in which to attract capital. When a consortium is involved, it may be interested in more than just the bricks and mortar that the merger would no doubt require.
The article in The Times Higher Education Supplement points out that a final decision would have to be made by July this year. As he is not here, the Minister cannot respond, but I hope that the right hon. Member for City of London and Westminster, South will tell us whether the PFI is on track, and also whether a decision must indeed be made by July. I suppose that the obvious further question is, "If not, why not?" The project will clearly require investment; the Government have gone down the PFI road, and it is clearly in the promoters' interests to know the current implications.
§ Mr. Simon Hughes
There is another question which neither the hon. Gentleman nor I asked, but which people outside may ask. Who are the prospective partners? When funds are required for a project involving health education and medical research, some people might not be regarded as necessarily very desirable partners in a consortium because of vested interests in the pharmaceutical industry or other industries. That is another question to which the right hon. Gentleman might usefully give us an answer.
§ Mr. McLeish
I was going to touch on that. The illuminating article in The Times Higher Education Supplement tells us thatSix consortia have been invited to make detailed bids, out of the 30 that made initial inquiries.Linked to that statement, and perhaps extending the concerns expressed by hon. Members, is the statement thatThe successful private finance consortium will have to provide additional services over and above the basic construction and financing of the new building. Lynn Carlisle, co-ordinator of the PFI project, said the colleges would be looking for proposals for campus management.That raises some of the issues that have surrounded other PFI projects. Is it a question of buildings? Is it a question of refurbishment? Is it a question of site acquisition and development? Or does the issue indeed extend to the provision of services? That has a material bearing on the merger, and, unfortunately, on whether the consortia can secure the adequate return that they seek.
The article poses another question by suggesting that'the project was proving popular with developers partly because some valuable West London buildings belonging to King's College will be refurbished for non-educational uses.That is in the context of a very significant merger involving many changes in land use and building construction. Perhaps it should happen, in terms of the viability of the project, but surely these issues will interest the community in London. They are certainly important in regard to the medical and educational aspects. Given all the problems surrounding the PFI, we must be given some indication this evening that the project is 101 proceeding, that there is interest and that the nature of the deal that is ultimately struck will favour the college and schools that are being merged and not—as PFI projects suggest—the developers.
We support the initiative, but some solid points have been made which require a response. I hope that the right hon. Member for City of London and Westminster, South will deal with funding and, in particular, the PFI.
§ Mr. Brooke
With the leave of the House, I shall reply to both the debate and the questions that have been asked. All who had the pleasure of listening to the hon. Member for Southwark and Bermondsey (Mr. Hughes) will probably agree that the debate has consisted of variations on a theme, and that the hon. Gentleman provided the theme while other hon. Members provided the variations. The hon. Gentleman's speech, which lasted just under an hour, was interesting throughout, and I personally enjoyed it.
At the beginning of his speech, the hon. Gentleman referred to the name. As I know from experience elsewhere, the name is a matter of potential difficulty. I continue to derive pleasure from the existence of a finger post in Lincolnshire that directs people to the villages of Mavis Enderby and Old Bolingbroke: under those names has been added the graffito "the gift of a son".
The hon. Gentleman mentioned trust funds. I can assure him that there is no risk of any trust funds being inappropriately diverted. If the money cannot be spent on the purposes for which it is intended, it cannot be spent, and remains in the trust fund. The hon. Gentleman also spoke at length about critical mass. The issue here is not the critical mass for good and strong groups; it is research. Such a critical mass is necessary for research, enabling a full range of specialities alongside each other to allow synergy and cross-fertilisation. Perhaps I was at fault in not using the phrase "critical mass" in my introductory speech.
The numbers to be taught—
§ Mr. Simon Hughes
I do not wish to pre-empt the right hon. Gentleman, but—if he is not already planning to address it—can he address the point about the size of entry cohorts, which was one of the critical mass sub-definitions that I was very keen to explore?
§ Mr. Brooke
That was the very next point that I was going to address. If we examine Hansard in retrospect, we will find that I had just embarked on that point.
The numbers to be taught are of the order of 300 to 330 medical students per year, as the hon. Member for Bath (Mr. Foster) quoted. That allows the development of effective cohorts of students with different backgrounds and for the possibility of having a mature graduate entry cohort who would be capable of staying together as a cohort and of being taught as a single body.
There are three teaching hospitals involved, so that it is possible in planning terms to assign particular teaching hospitals to particular cohorts. But that is still a matter for 102 the future, and it is a matter on which the hon. Member for Southwark and Bermondsey may wish to remain in correspondence with interested parties.
§ Mr. Brooke
I will give way, but the hon. Gentleman must not assume that I have inexhaustible knowledge.
§ Mr. Hughes
I am grateful, and I shall not intervene too often. The right hon. Gentleman's answer troubles me because he suggested as a reason why 300 or more students would not be too many the fact that they may be spread among the three hospitals. The logic of the proposal is that they will all come on to one site to work on one hospital. I therefore wonder whether he has a briefing or the knowledge to be able to explain what appears to be a discrepancy between the two arguments.
§ Mr. Brooke
I cannot do that. The hon. Gentleman's preoccupation was that the numbers would be overwhelming. I am saying that, because we have the potential of teaching in different cohorts, we can make use in some respects of the multi-site background.
As for the dental schools, there are mechanisms in hand for the clinical experience element to be taken in two large successful dental hospitals, which is perhaps an example of the point that I made a moment ago. It has not yet been decided how that should be done. The hon. Member for Southwark and Bermondsey was of course right about the numbers that he quoted. It may be that there will be two separate cohorts, which in that respect will be divided between the two dental hospitals. It is also possible—although this is still at the unresolved and planning stage—that that may be done on a year-by-year basis, so that one year a student will be in one hospital and in the next year in the other hospital.
There is a potential for having separate specialisations in the two hospitals so that one hospital will concentrate on some specialisations and the other hospital on other specialisations. There is currently some degree of complementarity and overlap. One can therefore see why the matter is still in the planning stage and not yet resolved. The fact that we have that combined strength in the two hospitals provides potential protection for the future on the issue raised by the hon. Member for Southwark and Bermondsey at the end of his speech.
The argument for co-ordinated teaching is not about joint biomedical teaching, but to ensure that the clinical professions are able to undertake appropriate clinical classes together. I doubt that there will be integrated science teaching. That is probably a false assumption. Some joint classes may be given, but the buildings are riot being designed on a scale to take life science and medics together. The planning of the new building on the Guy's site is not envisaged so that both could be done in one place.
The matter of costs was raised by the hon. Member for Bath and by the hon. Member for Fife, Central (Mr. McLeish). The private finance initiative process means that currently the actual costs are necessarily unknown in detail. In response to the question from the hon. Member for Fife, Central, however, I can say that the PFI process is currently on track. That is not to say that it will continue to he on track, but it is currently on track.
103 I can confirm the figure of £140 million, which the hon. Member for Southwark and Bermondsey asked me about, of which £70 million—or approximately half—will go into the biomedical building on the Guy's site. A figure of between £40 million and £50 million will go into the refurbishment of the Cornwall house site.
The hon. Member for Southwark and Bermondsey referred in his speech to this being all taxpayers' money. It is taxpayers' money if one regards the sites that King's will be selling in west London as taxpayers' money, but those sites already exist. The hon. Member for Fife, Central also referred to an article in one of the educational papers, and the potential for developing sites in those areas. Part of the equation is the money that will be realised from those sites. Moreover, the biomedical activity will be brought from six different sites, including those in west London, on to a single site.
§ Mr. Hughes
I stand corrected on the matter of where the money will come from, and I understand the point made by the right hon. Gentleman. Can he help us with the tally at the end of that set of sums? I am grateful for confirmation of sum of £140 million in total. Does he have—if not, I shall be happy to receive it from him later—the breakdown as to how much will be PFI money from the private sector, how much will be money from the sale of current assets and how much will be properly defined taxpayers' money from the Higher Education Funding Council?
§ Mr. Brooke
I cannot answer that question. I have been given a breakdown which shows that £54 million will come from the health service, £20 million from the Higher Education Funding Council, £7 million from the united medical and dental schools—of which £2 million will be from the special trustees and £5 million from UMDS itself—and then the money from property sales at King's. It is too early to give the hon. Member for Southwark and Bermondsey the detailed answers that he sought on the PFI process earlier.
I realise that the tower at Guy's affords an opportunity. It gives the hospital an opportunity for additional health uses—within the health service, about which the hon. Member for Southwark and Bermondsey expressed some skepticism—as well as what I would describe as trust-focused academic-clinical research. In other words, employees of the trust as against employees of the medical school will be engaged in the research, which is of course one of the bonuses and the glories of the two systems being side by side.
The hon. Member for Southwark and Bermondsey wanted an assurance on the consolidation of the biomedical activity. All candidates and all students will have a base there. If there is any academically desirable science teaching that needs to be done at a clinical site, that can and will be done. There is a degree of flexibility in the planning, but I do not think that we are yet at the 104 point of absolute definition—perhaps understandably. because until the Bill is passed we do not know that we have the commitment to progress.
I know that the hon. Member for Southwark and Bermondsey did not mean to be disparaging in any way when he referred to talking to out-patients, but that is one of the major advantages of the strong Guy's site, which will enable a student to follow a case. The student may now see individuals in out-patient's, but he will be able to follow the case on a local basis thereafter. That is particularly so because given more rapid discharge from a bed, the less easy vertical integration will become. That is critically true in the early years of the curriculum. If the health service decides to put the clinical service on to Guy's and St. Thomas's, there is no potential planning problem.
I have responded to the question whether students will be bussed. The answer is not for the first years, but some science-related clinical services will be taught while students are on their clinical placements. I said that we are in the process of testing the PFI, so I could not give a more definitive answer. In reply to the hon. Member for Fife, Central, I can say that not only is that testing currently on track, but, overall, the Hunt's house site was due to be handed over to the combined medical schools, in planning terms, in December 1996. The site is now due to be available in July 1997. That is not certain, but a reasonable assumption.
§ Mr. Don Foster
We understand the right hon. Gentleman's difficulty in giving categorical PFI assurances, and we accept those that he has given. However, what assurances are the Government giving as to the £54 million expected from the health service and the £20 million from the HEFC?
§ Mr. Brooke
'They are part of the existing plan. I cannot be more definitive. If the hon. Gentleman wants to enter into correspondence with the Bill's promoters, he is free to do so. I have sought, from somewhat sparse knowledge, to reply as fully as I can to the debate. The HEFC for England has approved the business case, subject to the testing of the PFI process—so we cannot answer the question, "Will it be PFI?"
The hon. Member for Southwark and Bermondsey asked whether the enterprise is cost driven. Both UMDS and KCL started their dialogue by academic argument—they wanted merged departments. They needed to persuade the funding council that that was the way forward, rather than the council putting a gun to their head. The proposed physical location is the best option to achieve that end. The HEFC is not dictating the solution, but it requires proper academic and financial valuations before it gives its seal of approval.
§ Mr. Simon Hughes
Although it is clearly good for students learning medicine and dentistry to see out-patients, it is as important for them to see in-patients. What is the logic of having academic teaching and students on the Guy's site and most of the in-patients on an entirely different site?
§ Mr. Brooke
One disadvantage for my hon. Friend the Member for Chislehurst (Sir R. Sims) and myself is that my hon. Friend the Minister spoke early in the debate, so 105 there was not the opportunity to intervene with certain questions. The questions of my hon. Friend and of the hon. Members for Southwark and Bermondsey and for Bath are more for my hon. Friend the Minister than myself.
The Bill's purpose is to secure a merger that would not be achieved by a federation, as was half hinted. If one expects an organisation such as King's to commit £70 million raised through the sale of its property to a new location on the Guy's site, that must be done with proper control and capacity for planning. I again commend the Bill to the House.
§ Question put and agreed to.
§ Bill accordingly read a Second time, and committed.