HL Deb 03 July 1979 vol 401 cc308-58

6.46 p.m.

Lord ANNAN rose to ask Her Majesty's Government whether they are satisfied with the provision for medical education in London and whether the policies of the Department of Health and Social Security and the University Grants Committee could be further co-ordinated to meet the needs of the London Medical Schools and Institutes.

The noble Lord said: My Lords, as a Vice-Chancellor of the University of London, I must immediately declare an interest, because London is the largest centre for educating doctors and dentists. It possesses 12 general medical schools and five dental schools, which teach both undergraduates and post-graduates. There are two schools which teach solely postgraduates and there is also a federation of 13 research institutes of post-graduate medicine and dentistry. These schools and institutes educate one-third of all medical students in the United Kingdom. Indeed, because Scotland is somewhat over-generously provided with medical schools for its population, London University educates one-half of all the future doctors in England and Wales. The new provincial medical schools are, of course, developing fast, but the Department of Health and Social Security is still asking London to provide the same number of doctors annually. What is more, London's post-graduate reputation makes it the Mecca of medical scientists from all over the world and in a very real sense the secular Mecca of our friends in the Arab States who come to London to obtain medical treatment.

Yet this inevitable concentration of medical talent in the country's capital is now in a desperate state. Why is this? There are five reasons: first, the misguided criteria applied by the Resource Allocation Working Party, which is called, in the jargon, RAWP; second, the erroneous principles used in calculating the special increment for teaching, called in the jargon, SIFT; third, the 1974 reorganisation of the National Health Service, which caused the mismatch of the four Thames regions then established to the brute facts of the location and the number of teaching hospitals. The fourth reason is the failure in reorganisation to recognise the inevitable conflict between the needs of medical research and health care. The final reason is a certain inability of the right-hand of Government, the DHSS, to inform its left-hand, the DES and the UGC, what it was doing.

The proposition from which RAWP started was as follows. It assumed that London tries to educate too many medical students in relation to the available population. That is not so. In fact, London has a better ratio of students to population than any of the cities where new medical schools have been established. Even the ratio in Inner London, from which population has been draining, is more than adequate compared to that of other cities. I ask the noble Baroness, Lady Young, to consider the following figures. Cambridge has 250 potential patients per student; Oxford, 400; Southampton, 750; Bristol, 1,100; Leeds, 1,200; and London 2,000. Only Greater Manchester has more than Greater London, with 3,500. But if you compare Inner London and Inner Manchester, Manchester has 700 and London 750. The point is that the provincial medical schools rely on their regional rather than their city populations.

RAWP is a battlefield upon which many battles have been fought over the past four years. It is littered with the corpses of memoranda, and the combatants upon it stand dazed and deafened by the volley of reports. I shall not weary your Lordships' House by deploying élite troops of arguments which have made no impression as yet on the enemy's position. No one in London for one moment denies, or contests, the democratic fact that population is leaving London and that the new schools in the provinces need funds. But the Department of Health and Social Security seems to be under the impression that the teaching districts in London receive allocations in excess of the health services they provide.

May I take just one example to refute this. Would your Lordships consider the figures for the area health authority in which you are at this moment sitting? In 1977–78 the revenue allocation was 23 per cent. compared with hospital expenditure of 25 per cent. The deaths and discharges of patients stood at 23 per cent. The accident and emergency attendance stood at 25 per cent., and the total outpatient attendances 28 per cent. Those figures show that these hospitals are doing more work than they are given funds for.

The trouble is that according to the RAWP formula they are said, these medical schools, to be over-funded. Why is this formula wrong? RAWP insists that allocations should be based on standardised mortality rates as well as on population. This almost suggests that we are dealing with a national death service rather than a National Health Service. But this formula of SMR fails to take into account illness, disablement, loss of working time by ill health, social deprivation, and, above all, the commitment to commuters who use the London teaching hospitals rather than their home hospitals. These factors too ought to be taken into account, and they are not taken into account because they are so difficult to quantify.

RAWP fires with two barrels. It takes money out of London to finance teaching hospitals in the Midlands and the North. It also takes money out of the London teaching hospitals to finance hospitals in the home counties. Because money is needed in Bedfordshire and Hertfordshire, Charing Cross Hospital today faces an immediate cut of £660,000. If inflation rises at 15 per cent. it will face a cut of £1 million. The same fate, I would guess, would face St. Mary's, Hammersmith and the Middlesex in that region. It will also probably affect all the schools in the North-East and the South-East regions.

What will happen? Wards will be closed. The day unit, surgery and investigation, could be closed. The baby care unit could be closed. So could the rehabilitation unit. The cervical cytology service could be halved. There could be a 50 per cent. reduction of out-patients. Of course there is an alternative. The alternative is simply to close down the whole accident and casualty service. That would be a radical step. But whatever happens there will be fewer beds and medical students will just not be taught some subjects.

Now for the effect which the reorganisation of the Health Service has had on the medical schools. That reorganisation took no account of the peculiar situation in London. Of course there were consultations. In 1970 the noble Baroness, Lady Serota, was chairman of a London working group set up by Mr. Crossman to advise on the way in which the boundaries for health care in London might be drawn. Yet at the very first meeting, despite the pleas of my predecessor, Sir Brian Windeyer, the chairman ruled that London could be treated no different from any other part of the country. Although he and the deputy chairman of the UGC pointed out the absurdities that would result, I am afraid that no change took place. Nor, I regret, did any change take place after the change of Government in that year. I am afraid that the noble Lord, Lord Aberdare, was equally inflexible.

What are these absurdities that I alluded to? The national pattern is to allot one medical school per region. But in London there are two area health authorities which contain three general medical schools and their hospitals, and there are three other areas with two medical schools in them. Only the South-West Region conforms to the national pattern, and even that has an additional so-called university hospital at Roehampton which is concerned with the Westminster Medical School.

This rigidity in the way in which the regions were planned means that, whereas in the provinces the region tends to regard the facilities and expertise of its medical school as a special asset to be supported and encouraged, in London the regions and the authorities take the medical schools for granted. For it is at area health authority that the real damage occurs. However, many medical schools there are in the area, they are allowed only one representative, whereas if there are several local authorities each nominates to the authority. A health authority has to consult very many organisations before it can change the use of the facilities of a hospital—and one body can stop it making the changes it thinks necessary. That body is the community health council which, by definition, represents purely local interests. It does not even represent the interests of the users of the hospital, because the users often come from other districts, and in, the case of London, from other regions in the Home Counties. You cannot close a single ward without consulting the community health council. But the area authority has no obligation whatever to consult the university or medical schools, even though its action could make it impossible for a school to teach some subjects in the curriculum.

Under the present set-up there is bound to be a hopeless conflict between the London teaching hospitals and the area authorities and community health councils. How can one reasonably expect local councillors and deeply concerned members of the public who know the deficiencies in their local mental hospitals, or geriatric treatment centres, not to take funds for these admirable causes from what seem to them well-provided teaching hospitals? The present National Health Service structure prolongs this hopeless conflict of loyalties. It is exactly like asking Balham how much our country ought to spend on defence. How can these participatory bodies recognise the long-term national interest and the responsibility for teaching the new generations of doctors? There is no longer any direct allocation to teaching hospitals; they have to fight for their share from the regions. So I beg the Government, when the Royal Commission on the National Health Service reports, to reconsider the regional boundaries in London and the whole of the substructure.

Someone at this point may be asking under their breath, " What about SIFT? "—the special increment for teaching. It is claimed that SIFT covers 75 per cent. of the median observed additional costs per student in the teaching hospitals due to teaching. I am very much afraid it does nothing of the sort. The additional costs in a teaching hospital arise not only from its undergraduate but from its postgraduate commitment. SIFT entirely ignores research. The additional costs arise from the inevitable expense of everything in London. They arise from the cost of dental schools, which carry an enormous load of service work—for instance, urgent dental treatment, radiology, and orthodontic appliances. Yet SIFT covers only a quarter of dental costs. SIFT recognises only local authority boundaries and it ignores demographic facts. So far from the London teaching hospitals being short of patients, patients come to them in droves because they have heard of the quality of the treatment there.

I can, naturally, understand the argument which runs, " The University Grants Committee gives the University of London a block grant and if its medical schools are suffering, it is the fault of the university, not of the Government ". The non-medical schools in the University of London and their institutes have over 36,000 students. The medical schools and their institutes have 9,000 students. Medicine takes 40 per cent. of the university's budget. We really cannot afford to give it more without gross injustice, yet there is no doubt in the minds of everyone that our medical schools and institutes are suffering from malnutrition.

That is why last autumn I asked Lord Flowers, who, as the Rector of Imperial College has no attachment to any medical school, to be chairman of a small working party which would have on it clinicians from outside London University and the chairman of a provincial regional authority. I asked Lord Flowers how we were to maintain the present standard of medical and dental education and research in London and meet UGC targets for student intake. I then told him that he should he prepared if necessary to recommend the closure or radical reorganisation of one or more medical schools or institutes and, if so, which those institutes and schools should be. I leave your Lordships to imagine the dismay that this has caused throughout the medical staff and the courage which the deans of the medical schools and their senior academic colleagues have shown in accepting the need for such surgery.

I shall not guess what Lord Flowers and his colleagues will recommend, but this I do know: to economise, you always need to spend additional sums initially. If we are to help the DHSS, we need their financial help, and we need them to co-ordinate that help with the UGC. It has not always been easy to get that help in the past, but matters have improved greatly this year and I want publicly to thank Mr. Parkes, the chairman of the UGC, for getting a settlement on a matter which has dragged on for three years—namely, what costs and what arrears the University of London should pay for the maintenance of the medical schools embedded in the newly-built hospitals.

I shall not drag your Lordships through that Serbonian bog, except to say that we now have a settlement, a rough and tough settlement which of course I shall contest, but nevertheless I am grateful indeed to the UGC and, I am sure, to the DHSS for any help they have given in this matter. But I must warn them that the UGC has told us that of the additional £4 million it is going to give London to settle its £9 million arrears, leaving us to pay £5 million, that £4 million will be paid at only £1 million a year. I shall find it very difficult to advise the University of London that they should pay the hospitals more than £1 million a year. We pay what we get.

There are two other public servants I should like to thank in the DHSS. One is Sir Patrick Nairne, the Permanent Secretary, and the other is the Chief Medical Officer, Sir Henry Yellowlees. I very much thank them for giving us such help as they have given over the setting up and work of the Flowers Working Party. Medical education is, after all, really financed from two sources, the UGC and the DHSS; the UGC through the block grant which the university receives, and the DHSS through the teaching which the National Health Service consultants and registrars provide. The closer we in the UGC sector can work with the DHSS the better we like it.

But let me say this to the noble Baroness: I am blamed by many of my medical colleagues in London for setting up this working party. They believe that if it does recommend the phasing out or reorganisation of one or more medical schools, the DHSS will once more reduce the student targets for London-trained doctors and force us then to close a couple more medical schools, and so on. I therefore urge the noble Baroness to explain to her right honourable friend the Secretary of State that, in the Flowers Working Party, London is giving a hostage to fortune, and that, if that hostage were shot at the Elephant and Castle, it would create a bitterness in the medical schools which would not only cripple the schools but bring an end to all co-operation with the DHSS. I ask the noble Baroness to remember how doctors can on occasions be roused, as they were when Mrs. Castle was Secretary of State for Health and Social Security.

There are a number of things the Government could do to restore the morale of the medical schools, and I shall list them. Naturally, I do not ask the noble Baroness to give an assurance on any of them, but perhaps I may give her a shopping list: abolish Area Health Authorities; re-examine the powers of community health councils; recognise that in medicine consensus management is the enemy of standards and progress; re-establish the old authoritative collaboration between the management of the hospital and the dean of its medical school so that decisions, and above all quick decisions, can be taken; give teaching hospitals the same exemption from the fight for priorities within the region as has been given to the postgraduate institutes—at the very least, can we not devise a better means of protecting their research and teaching budget by, say, the device of top-slicing so that whatever level of health authority makes the decision is not being asked to choose between national and local needs?

These medical schools, dating back, as Bart's does, to the reign of Henry I, are still (my pride must make me say this) the head and the heart of British medicine—acknowledging of course, as I do, the admirable standards set at Edinburgh, Birmingham, Leeds and the other medical schools outside London. It is inevitable that London will be the centre of medical education and research. It always has been and I like to hope it always will be. But it will not be if its blood supply is diverted by pouring money into small hospitals and participatory administration, with its proliferating committees. And, if the heart can no longer pump blood to the head, medical research and medical teaching are doomed in this country. I say to the Government: reform, reform, reform!

7.8 p.m.


My Lords, I rise with great trepidation to follow that speech by the noble Lord, Lord Annan, on medical education; I am not a medical educationalist. I have to admit my interest in this debate as the regional chairman of the only London region that has only one teaching hospital in it, and therefore no doubt has less problems than some of the others. I could have wished that Lord Annan had phrased his Question slightly differently. I agree with him 100 per cent. that co-operation between the DHSS and the University Grants Committee on medical education is tremendously important, but he left out what it is all about, and that is the service we jointly give to the patient. I wish that would have been in the Question, though I know it was in the back of his mind.

I speak as a regional chairman and much of what Lord Annan said I agreed with completely, but he was, in my view, talking basically about undergraduate medical education in London and the undergraduate medical schools. As a regional chairman, I am responsible for providing in my region—this applies to all the London regions—not only the facilities for undergraduate teaching but also all the facilities for post-graduate teaching, which in many ways is one of the most important things that the region has to do.

The noble Lord, Lord Annan, very carefully explained the problems that face all the London regions under RAWP, and spoke of how we find difficulties in funding the increase of students in the medical schools in London as proposed by the DHSS. He touched upon the cost allowance per student that is given under SIFT for undergraduate education, which, as lie said, is 75 per cent. of the median cost between the teaching hospitals and 45 other hospitals taken at random in the country. Even if that calculation were correct—and it never can be—it still leaves an enormous sum of money to he found by the regions.

Apart from that, since reorganisation, the region is responsible for major capital development within its region, and my region happens to be one of the regions that is building a new teaching hospital, in our case at Tooting. Although the DHSS makes a 35 per cent. contribution to the cost of the building of that hospital, the cost bears no resemblance to the building of an ordinary DGH, and as a result there is an enormous and severe drain upon the capital resources which are at our disposal in the South-West Thames region; and the same applies to all the other London regions.

So we have this problem under RAWP. The noble Lord, Lord Annan, is quite right to point out that there are 12 medical schools here, that one-third of the medical students are trained in London, and that the London regions represent four of the five " losing " regions in RAWP. This will inevitably create problems because the money is just not there.

As a regional chairman, I am committed to medical education because, like all your Lordships, I believe that without medical education there is no future for medicine within this country. I am not saying that we are necessarily right in the way in which we are going, and before I sit down I should like to mention one complaint that I have against the DHSS and one that I have against the medical people in this country. It is desperately important that we should not let the standards drop, but in view of the fact that we have 12 teaching hospitals in London we cannot under RAWP keep up the standards. It is impossible under our financial allocation. To put it mildly, feelings of envy are created in the other Thames regions; they claim that too much money is going into teaching.

Although the Thames regions are considered to be rich regions, within those regions there are very poor areas. I hope that the Government will remember this and will take it on board. Our problem as administrators is almost insoluble. I believe that there will be an increasing trend to out-post medical students from the London hospitals into non-teaching hospitals within the region. The Government should be aware of this because the moment it happens there will be tremendous demands from the other hospitals for the upgrading of their facilities in order to be able to take care of medical education; and they would need those facilities so as to be able to educate the future doctors of our country. So because we have the 12 teaching hospitals (due to events in history) we are faced in the London region with an impossible situation.

Apart from undergraduate medical education, the regions are responsible for all post-graduate medical education, and that is funded solely out of the regions' normal allocation. It is true that most of the post-graduate hospitals are in London, but within the hospital service itself the amount of post-graduate education that we can afford to give is of the utmost importance because medicine is advancing at such a rate nowadays that five years after a person has qualified as a specialist in any discipline he needs more education; the science has moved forward.

So there is here a tremendous drain on the finances of the Health Service, and I believe that it is here that perhaps the DHSS, and the National Health Service as a whole, have made a mistake. We have tried to provide too much expert treatment at people's front doorsteps. In many ways we have gone too far in developing a large number of regional specialities, and as the noble Lord, Lord Annan, indicated, we should look at the whole of the Thames region. We should have fewer specialised centres, but at the same time ensure that it is easy for patients to get to them. This would have enormous advantages, particularly for medical education. First, the NHS could make the optimum use of all the expensive equipment that goes into a specialised unit. A much larger number of patients could be treated at such centres than can be treated in the smaller units around the country. This would have the greatest impact on medical education because it would mean that the clinicians, the consultants, and the students, in the form of senior and junior registrars, would have enough material in order to develop their expertise. I believe that this is an area where the NHS has fallen down— particularly since reorganisation—because of the demand for specialist centres everywhere.

In London we have 12 undergraduate medical schools, and I believe that in view of the financial constraints under which we live, these medical schools can no longer demand local access to all specialities. The medical schools must co-operate and set up London centres where the 12 medical schools can gain expertise.

The other day the Director of the Office of Health Economics, George Teeling-Smith, said: There is a clear balance in which convenience and economy play a relatively minor role and the issues of safety and efficiency are paramount. On this basis there seems to be a clear-cut case for highly specialist units covering very large areas ". This is where the DHSS has fallen down in many ways and has not provided what is needed in medical education, despite having the best intentions in the world towards serving the patients.

I also believe that perhaps the medical schools themselves have not helped the DHSS as much as they should. As a regional chairman I often receive complaints that there are not enough senior registrar posts and that there are too many students chasing too few jobs. That is not true. In my opinion such complaints arise because the medical schools tend to turn out many students who want to become surgeons or physicians. We are living in a world where what we are going to need are a lot of other specialties. We need consultants in mental handicap, in child and adolescent psychiatry, in anæsthetics, in geriatrics, in radiology, in community medicine and in some sub-specialties of pathology. I can advertise for a consultant in mental handicap, for which I have seven vacancies in my region. I can advertise three times, and I get no applicants.

It seems to me that the whole attitude of medical education has to change, because what we are facing in the future is an aging population. We need people who will concentrate on these specialties, and they are not coining forward. I believe, not only that the Department of Health should look at the encouragement we can give—it may have to be financial—to get people to concentrate on these specialties, but also that the medical educators of this country have to accept that these specialties are interesting specialties, and must try to enthuse their students to go into them. They must become academically respectable, which so far they have not been. There are departments of social medicine and general practice in most teaching hospitals, but there is still a need to convince the clinician of the value of these departments, and really to integrate them into the training and into medical education.


My Lords, may I interrupt the noble Baroness simply to say that the applications I receive from medical schools requesting the creation of posts in community medicine, in geriatric care, in radiology and in matters of that kind which the noble Baroness has just mentioned are innumerable. The trouble is that I have not got the funds to give to the medical schools to create these new posts.


I am sorry, my Lords; therefore, let us ask the Department of Education and Science to produce the funds for that particular kind of education. But, on the whole, the balance is in favour of surgery and medicine, and I believe that in medical education we must look towards the future, where the needs in these unpopular specialties are enormous. For instance, when I talk to consultants in mental handicap they admit that it is because there is a resistance to accepting them on the same level as consultants in other specialties; and I believe that we might need to use financial encouragement. I should think that that was the tragedy. I believe that a change of attitude in the whole of undergraduate and postgraduate medical training could create the right possibilities.

7.23 p.m.


My Lords, we must all be grateful to the noble Lord the Vice-Chancellor of the University of London for initiating this debate and for developing his theme so clearly and so forcibly. I suppose nearly everyone concerned in the administration of the Health Service would agree that, whatever it merits, the reorganisation of 1974, like the simultaneous reorganisation of local government, was an expensive mistake. Developed from a Green Paper by Mr. Kenneth Robinson and brought into effect by a Conservative Government, it was in general a bipartisan measure of entirely excellent intentions. But in practice it resulted in the introduction of an additional administrative tier that, in a service already short of funds, ate up monies which should have gone to modernising and rebuilding the hospitals; while the doctrinaire decision of the last Government to close paybeds gratuitously forfeited many millions of pounds while doing nothing to shorten waiting lists, which have increased.

In particular, administration by the Department, with an overriding emphasis, in itself laudable enough, on the district service, and a passion for egalitarianism which regards " centres of excellence " as a dirty phrase, has resulted, not in a levelling up but in a levelling down which has had deplorable effects, in particular on the teaching hospitals, whose morale and high standards are of vital importance to the wellbeing of the service. I speak as a layman but with some knowledge and experience of these matters, having been, like the noble Baroness, chairman of a regional hospital board administering 150 hospitals; having been, for more than a quarter of a century, on the board of governors of Hammersmith Hospital, the only general post-graduate teaching hospital in the country, and latterly, until the reorganisation, its chairman; and having been chairman for a decade of years of the Royal Postgraduate Medical School and of the British Postgraduate Medical Federation, a highly important school of the University of London, of which the school at Hammersmith is the largest constituent part.

Hammersmith Hospital is unlike the great and historic undergraduate teaching hospitals in having no substantial endowment funds to mitigate the effects of inadequate finance from Government sources. It was a poor law hospital. I had in my office there the last survivor of the original crockery, a saucer with the inscription, " Hammersmith Parish Workhouse ". That is what it was. Although Hammersmith Hospital and the Postgraduate Medical School there have a worldwide reputation; although they attract for specialist and consultant training qualified doctors from every country in the world to the number of 700 or 800 at any one time; although their work is so widespread that a few years ago there were no fewer than 50 consultants practising in the city of Melbourne alone, on the other side of the world, who had received their consultant training at Hammersmith; although the Postgraduate Medical School at Hammersmith is housed in fine modern buildings built by the school itself with monies raised from every part of the Commonwealth—in spite of all these things the hospital on which the school depends is still housed in the old poor law buildings, of which the most modern is 75 years old and the greater part very much older than that.

I hope my noble friend on the Front Bench, when she comes to reply—and I feel rather apologetic, for I know that hospitals do not themselves fall within her parish—will be able to tell us when we may hope for a start on the rebuilding of that hospital, the plans for which were agreed and approved, the necessary demolitions carried out and the decanting buildings set up before the reorganisation of 1974, when, overnight, reorganisation brought everything to a standstill. I hope she may be able to tell us how soon this most urgent rebuilding, without which the work of the school cannot be fully effective, will be able to go forward. Meanwhile, the effect on the morale of the staff and the handicaps under which they work are utterly deplorable.

There is one other facet of the existing arrangements to which I should like to refer. I think my noble friend who speaks from the Front Bench for the health services has a note of it, with a particular instance of its effect. It is the anomaly by which area or regional special services, which are inevitably expensive, are financed out of district allocations so that either the district service suffers disproportionately or these services cannot be adequately financed at all. Being area or regional special services, they ought to be financed out of area or regional allocations, if, indeed, they are not the subject of special allocation from central funds, as I think they should be. I hope that the Minister may be able to tell us that this very necessary change will be made.

What I have said may sound rather like a despairing bellyache, but before I sit down I must express my unqualified admiration for the staff who work unremittingly to overcome the ill effects of the unfortunate administrative set-up and the inadequacy of funds and who, in spite of everything, give a magnificent service to the public. For their work, no praise can be too high.

7.31 p.m.


My Lords, it is an unusual thing for me to intervene in a debate on a subject of this kind. I do it with great diffidence, especially after the vigorous and expert speech of the noble Lord, Lord Annan. My interest arises from my chairmanship of the King's College Hospital Medical School. This school, as your Lordships will know, is acknowledged to be one of the leading institutions of its kind in the country. I must admit from the outset that my knowledge of these subjects falls far short of that of others who have spoken and who will speak in this debate and who have spent their lifetime in medicine and university administration.

In considering Lord Annan's Unstarred Question, I should like to make five short and rather elementary points. First, London has an enviable reputation for its medical schools. I know this very well from my experience in the Foreign Office. There were several times in our foreign relations when almost the only friendly link which existed between this country and certain other countries was the professional medical link based for the most part on long-established contact with our London medical schools and hospitals.

Anyone who has lived in the Middle East and the Far East could not fail to be aware of this. In my view, it would be a great pity if the Government adopted policies which had the effect of diminishing the reputation of London as a highly respected centre of medical education. I am in principle sympathetic to provincial claims, but not at the expense of accepted and acclaimed institutions at the centre. This country, I believe, is small enough in size for us not to find it necessary to indulge the provinces beyond a certain point.

The second point that I wish to make is that there can be no doubt that the cuts imposed by the Resources Allocation Working Party will result in a reduction of beds in the London teaching hospitals, with an inevitable reduction in the facilities for teaching. This is a serious matter. There is undoubtedly a fall in the population in the centre of London although, in the King's College health district, we find it very difficult to reconcile the Government figures with what is happening on the spot. Moreover, will not the fuel situation also delay, if not reverse, the movement of population from London? Furthermore, King's College Hospital accepts regional and supra-regional commitments to the tune of nearly £3 million per annum, for which we receive inadequate financial recognition.

Thirdly, the noble Lord, Lord Annan, looks for further co-ordination between the Department of Health and Social Security and the University Grants Committee. If I do not know much about medicine, I nevertheless know a little about bureaucracy and the ways of Whitehall. I have an instinctive sympathy for the excellent civil servants of the Department of Health and Social Security and the members of the University Grants Committee who know that a call for co-ordination is more easily heard than acted upon; and, from my short experience it seems to me that the present organisational machinery of the Health Service is at fault and is certainly an impediment to proper co-ordination. I hope that the Royal Commission will propose reforms and revisions which will remove the inevitable conflict of interests between too numerous authorities.

Fourthly, may I make a special plea on behalf of my own medical school? I am advised that since the re-organisation of 1974 there is in practice great difficulty in financing capital schemes, the cost to be shared by the Department of Health and Social Security and the University Grants Committee. We have plans for the extension of the dental school in King's College Hospital and the need for it has the full support of the University Grants Committee and of the regional health authority. Yet there appears to be no means by which the apportionment of the cost can be defined; and progress is consequently held up. I would ask the Minister to look at this particular case to see whether we can proceed with what is an accepted and agreed requirement for enhancing the facilities at the medical school.

Lastly, any newcomer entering this particular field of activity cannot fail to be impressed by the zeal of the majority of people who work in it. At this moment of time they are a little bewildered by the number of committees considering it: the Royal Commission, the Flowers Committee and what I believe is known as the London Consortium. The sooner these uncertainties come to an end, the easier the co-ordination for which the noble Lord, Lord Annan, looks can be achieved.

7.39 p.m.


My Lords, when I received a month ago an invitation from the noble Lord, Lord Annan, to speak in this debate, I wrote to the deans of our 12 London medical schools, to the deans of our 13 institutes of the British Postgraduate Federation of the University of London, to the Presidents of the Royal Colleges and to several others. All of them kindly replied almost at once and at length. Some were kind enough to invite me to go and speak with them. My remarks this evening will he based on some of the points that they have made and I hope that they may be of some little use to the noble Lord, Lord Flowers, and his Working Party on Medical and Dental Teaching Resources. I shall not mention many names, either of individual deans or hospitals or of the post-graduate institutes.

First of all, may I say something about the problems of our medical schools. Not all the deans agree with the reason that has been given by many for the need for some of the schools to be closed down. That reason is that so many people have left London, that there has been a movement of residents out of London, and that has left too many medical schools for the remaining population. One dean has suggested that London has in fact as favourable a population/clinical student ratio as had any of the other cities in which new medical schools have been established, indeed as have many other cities. Medical schools outside London rely to a large extent on regional rather than city populations, so it is asked: " Why cannot London do this, too? "

Another important development is that because of daily travelling difficulties and the expense of getting to and from work, more and more people are now coming back to live in Greater London. Points which suggest that a medical school might be moved, combined with another, or even closed, include: How many patients will live in or near its drainage area? Has it a pre-clinical school? What is the range of its clinical and academic departments and how good are they? Has it a department of general practice and community medicine? How old are its buildings? Will they have to be rebuilt in the near future? How much strain will be put on one medical school by the entry of a number of students from another who may join it? How much money will have to be spent on such a change? All these and many other points will need to be taken into consideration, including an intangible factor such as the tradition of public service which the school has given to the community and for how long, and how many people will be badly upset if it is swept away?

We are assured that, whatever schools are affected by these changes, the total output of doctors in medical schools will not be changed and we are also told that the total funding of schools after the changes have been made will be the same as it is now. We are told that the cost of producing a doctor in London is very much less than it is in the provinces. Many of the deans and members of the medical school staffs feel very strongly indeed about much of this. One of them, writing about the proposed move of St. Bartholomew's and the London Hospital's medical schools to Queen Mary College, said that in his opinion: " It will be an incredible waste of money ".

It has been asked: " Should the number of post-graduate institutes of the British Postgraduate Medical Federation of the University of London be reduced perhaps from as much as 13 (that includes the Institute of Dental Surgery) to about seven? Should some of them move? Should any of them join up with a medical school or with another institute? These institutes have been playing a unique and magnificent pioneering role in post-graduate medical education and research in Britain. Of the doctors who attend them, about 55 per cent. are from London, about 35 per cent. from the rest of Britain and about 10 per cent. from overseas. They are highly thought of in the Commonwealth and other places overseas. They may well give us an opportunity to exercise leadership in the European Community. Every effort should be made to preserve them.

One dean tells me that he could fill his course at any time with doctors from the Arab countries alone. But the institutes have recently been asked by the Government to reduce their intake of overseas doctors by 7 per cent. on the 1976 figure. One dean writes that it is incomprehensible that any Government should take such a step.

We have read and heard a great deal about these institutes and their possible reorganisation, rationalisation, absorption, co-ordination, phasing out, abolition, amalgamation, incorporation, redeployment or relocation. We have even heard about integration which is a term that I do not like. Integration is what the cat offered the canary! That is not really a suitable term in this context. It is the earnest wish of all the institutes I think that, whatever changes are made and wherever they go, they must retain their identity and autonomy. They must keep their own management structure—with their boards of governors or their possible replacements—and must remain independent in deciding how they should spend their money in allotting priorities for research and so on.

If a post-graduate institute is absorbed into a medical school many people think that its important contribution to its special subject would almost certainly be reduced. On the other hand, the impact of a large and busy institute might easily unbalance a general medical school; the work the institute does may not be really suitable for teaching undergraduates or for general professional education.

Ideally such an institute should be based on a single site with room for expansion and with minimum travelling requirements for its staff. A good point was made to me by one dean: too much or too frequent reorganisation tends to lower the morale of a staff and impairs recruitment. For its research work an institute may need a considerable amount of laboratory space and expensive equipment. One dean suggested: " Small units cannot do epoch-making research I replied that Dr. William Harvey carried out his experiments which led to his discovery of the circulation of the blood 400 years ago by himself in a small room, and much of Charles Darwin's thinking and work on the origin of the species took place while he was sharing a cabin in the small ship, HMS " Beagle ".

Post-graduate institutes are very keen, naturally, on their own precious basic scientists who help them enormously, and the academic and scientific teaching of young doctors after vocational training is one of their main jobs. A leavening of academic work and some active research will help a young specialist, they say, quite rightly, to " think scientifically " and to encourage his critical faculties, especially during the first 10 years of his career. One dean wrote that he felt that in time this highly academic involvement, even if it takes an extra year of training, should be an obligatory part of the post-graduate teaching of all doctors. I would query this. For young general practitioners there is much learning to do to prepare them for their future jobs, and much of this is non-academic.

Some of the institutes have made a definite point—already touched on by the noble Lord, Lord Annan, and by the noble Baroness, Lady Robson—about co-ordination between the UGC and the DHSS. At present the division of financial responsibility between the two bodies is governed by a paper, HM(73)/2, allocating to the UGC support of undergraduate teaching schools and post-graduate courses up to Ph.D and M.Sc, while the courses organised by the university are regarded as those initiated by the regional postgraduate committees and should be funded by the DHSS. This has led to difficulties, the UGC feeling that it is not responsible for the support of those units for which the major undertaking is specialist post-graduate medicine, while the DHSS is naturally reluctant to take over anything more than it has at the moment. Some deans feel very strongly about much of this. One of them said to me: " To move this institute and to amalgamate it with an undergraduate medical school would be an unmitigated disaster ".

The noble Lord, Lord Flowers, asked for evidence from general practice. During the last few years there has been a swing towards a broad approach to medical care, both in hospitals and in the community, and an appreciation that this is becoming increasingly critical in a society where many opportunities for prevention lie outside hospitals and are related to the behaviour of our patients in their environments. I, and many others, hope that the Flowers Working Party, when looking at our diminishing educational resources and at what will be needed in future in London, will consider carefully and favourably those medical schools which are fostering this modern approach.

About half our medical students still go into general practice. When there, they treat about 90 per cent. of the medical problems of the population without sending them to hospital. What they need most in the later stage of their medical education is preparation for their own subject. Most of those who want to go into general practice have decided to do that by the end of their general professional training. They do not want highly academic teaching or to spend too much time with basic scientists or in being taught about highly complicated pathological processes or various specialised surgical, electronic or other super-specialist techniques: nor do they want to be involved in other highly academic exercises or in research, however much all this may be advantageous to the young specialist. Clinical competence is acquired by participation in medical care in the branch of medicine which a doctor chooses.

In their vocational training they want to be given expert advice from experienced general practitioners on all the community and behavioural aspects of their future work and on how they can care properly for the multiplicity of organic and psychological illnesses that they will meet later in their practices. These will set them thousands of problems, starting with the care of young children at home and ending with the proper care of the elderly, the dying and the bereaved.

Departments of general practice, which I was very pleased to hear mentioned by the noble Baroness, Lady Robson, with full-time staff, have been founded in five of the twelve London medical schools, with a full-time professor in charge of two of them. There are also sub-departments of general practice, with full-time staff, but without a professor, in all but one of the others. The two Chairs of General Practice in London are paid for at present not by the University Grants Committee or by the DHSS, but through private benefactions. These departments of general practice have a most beneficial effect on the standards of general practice in the districts around them. They are connected with one or more local general practices, all of them in poor districts; and, in these, members of the department work and take an active part in the practices, supporting the local community services. They have done in the past, and can do in the future, a considerable amount of useful research into the problems of their special branch of medicine.

Medical schools in the United Kingdom outside London have done even better in this respect. They train about two-thirds of our doctors. The four medical schools in Scotland, one in Wales and one in Northern Ireland, all have full departments and professorial chairs of general practice. In England, the 12 medical schools outside London have 11 departments of general practice and five professorial chairs. In Canada, every one of its 12 medical schools has a full department of family medicine. London schools might well follow their example.

In conclusion, may I say that the attitude of most of the deans and others from whom I have heard about these possible changes has been very reasonable. One of them said to me: " If we are told we should go, we shall of course go; but we shall want to be shown very clearly that such a move is essential ". From a careful study of their reports I have begun to realise what an enormous and far from simple problem this is, and how some traditions must surely be broken and several people hurt and upset. But the matter is urgent and must be clarified very soon. The noble Lord, Lord Flowers, and his working party have an extremely difficult job. We look forward to reading their report, and I am sure that we all wish them well.

7.57 p.m.


My Lords, the country as a whole should be grateful for the existence of your Lordships' House at the present time, if only because it has enabled the noble Lord, Lord Annan, in his customary forceful manner, to initiate a study of very great importance. His cohorts, if I may so call them, are Peers and Peeresses of enormous distinction in the medical field, in the social field and in senior positions of administration. Fools rush in where angels fear to tread, and I feel that in intervening here with my own somewhat limited experience of only having served on the house committees of a mental hospital and a children's hospital makes my qualifications on the subject of this debate perhaps a little suspect.

A short time ago I received an invitation to visit Hammersmith Hospital to spend a long time, and a very fascinating time, in their renal dialysis unit. I should like particularly to pay a tribute to the Dean of the Hospital and to Professor Peters, the Director and Professor of Medicine, for having been so helpful and having explained matters to a layman in as simple terms as possible during that particular visit. From the relatively little I saw there, I should like to bear out all that my noble friend Lord Cottesloe, with his distinguished associations with that fine hospital, has said.

Certainly some of the buildings are anything but conducive to the very fine work which is carried out. I think that is particularly true of the research laboratory departments, where I noticed three of four young men carrying out what were undoubtedly experiments of extreme importance in the kind of conditions which even those of us who work in Parliament would complain about most bitterly. Our working conditions in either House of Parliament are nothing to shout about, but those people were working in the most cramped conditions that one could imagine. One wonders how this work is carried out in some of our smaller hospitals. I find the position frightening, because I have seen some of it for myself.

The renal dialysis unit works quite wonderfully. I was fortunate enough to sit in on three or four case studies and noticed a lot of very long words, many of which I would not begin to comprehend, but I did, at least, manage to comprehend to a very large extent what was going on. Certainly, the presentations, not only from doctors from this country but from doctors from as far afield as India, Australia, the Commonwealth and other countries, were masterly.

I should like to quote the example of one young New Zealand girl who was over here on holiday. She is, in fact, a nurse by profession, but she took a job manning a petrol pump. I do not know whether it was due to that job, or whether the job exacerbated her condition, but the fact is that at the moment she has acute renal failure. Her kidneys are not working and she is receiving a very long period of dialysis. I shudder to think what might have happened to that girl, and I wonder whether she would be alive today, if she had not been discovered by a quite junior registrar in a large hospital near Slough and taken immediately to Hammersmith Hospital. If, as one must hope, she pulls through and is fit enough to have a kidney transplant in due course, much if not all of the credit must go to those who work very long hours at that great hospital at Hammersmith. That will not have been the first such case and it certainly will not be the last.

It impels me to ask my noble friend whether funds could he set up for round the clock renal dialysis, especially for young people who could do what is more or less a full job of work if they were able to have dialysis outside working hours, and whether the increased amount of work which they might manage to do at their own jobs would offset the cost of the necessary skilled labour.

We all know that just about every department in this country has to cut its budget. This would have happened which-ever Government had been returned a short time ago. But there must be priorities here and this is the kind of thing which could be very usefully done. Charitable foundations have shown enormous generousity and have given much to these hospitals, but at the moment they have more and more calls on them, so that funding for the schemes inherent in this Question, and in making the implications of the Question work, will undoubtedly have to come from central Government. There may be delays in the implementation of some of these schemes, but I hope that the Government will bear in mind the fact that those who work in these hospitals, in whatever capacity—whether as consultants, registrars, laboratory technicians or nurses—are those who ensure the health of people in this country.

The most valuable premium that one can pay for a healthy country, and a country which can increase productivity which is so badly needed not only in this country but the world over, can be paid only if we get the best possible medical results. In hospitals such as Hammersmith and the London teaching hospitals, we have the personnel and the equipment. As has been said by people who know more about this subject than I do, we need more buildings and more upgradings, and this is a priority which no Government, no matter how stringent the times may be, can afford to overlook.

8.8 p.m.


My Lords, in common with others, I express my gratitude to the noble Lord, Lord Annan, for initiating this debate, and particularly for the eloquent and forceful way in which he made his case. It is a subject that is near to my heart, not because I have any extensive experience of it, but because for the last seven years I have been connected with one institution; namely, the Royal Postgraduate Medical School at Hammersmith, about which the noble Lord, Lord Cottesloe, and the noble Lord, Lord Auckland, have already spoken.

At this stage, I fear there are few new points that can be made, and therefore I shall try to be very brief. I can only hope to underline some of the points already made, but I start with a general proposition. It seems to me that in the post-industrial age, when Britain is really looking for a new role, one of the major contributions that we can make is by using our skills and our experience, particularly in the arts, in literature, in the sciences and in education generally. Indeed, the Government have recognised this for some time; for example, in the assistance which they have given over the last 10 years to the Commonwealth Scholarship Commission, which has brought hundreds of outstanding candidates from Commonwealth countries for general training here. In this field, only the highest quality is good enough. I believe we have that, but we must concentrate on what we do really well and go for excellence.

I believe that nowhere is this more true than in the field of medical education, and particularly of that education in London. The Royal Postgraduate Medical School is an essential constituent in the complex of London's medical education. Indeed, in my view, it is really uniquely qualified to provide postgraduate medical education and to develop research on the basis of clinical practice, because of three things. First, the variety of the skills practised and the tradition of multidisciplinary co-operation which has been established; secondly, the very special and close links with Hammersmith Hospital, because the majority of the consultants are academic employees of the school; and, thirdly, the high quality of the staff which it has always been fortunate enough to attract.

The noble Lord, Lord Cottesloe, gave an account of the record of the school. I would add to what he said only one statistic; namely, that since 1970 the school has provided 55 professors, 58 readers and 83 lecturers. Those are quite remarkable figures and emphasise the importance of the role of the school in training teachers. And, of course, its record in heart research, in cancer research and in other fields is well known. Indeed, I recall very clearly that in the 1960s, when I was in Canada as High Commissioner, the reputation of the school throughout all the Provinces stood very high. Students from the school were practising throughout Canada. However, as we have heard this evening, present realities bring some chill winds. Most of the difficulties have already been mentioned and I have no desire to add to the gloom. The problems centre around organisation and finance, and finance is the pervading anxiety.

The reduction in real terms of the grant which the Postgraduate Medical School has received from the university since 1974 has involved drastic and continuing economy measures. It has led to the freezing of academic and technical staff posts, with, obviously, a serious effect on research work. At the same time, many of the policies of the Department of Health and Social Security have also had harmful effects. The implementation of the resources reallocation policy, when there has been no decline in the hospital workload, has this year seriously restricted patient services. That is serious enough in itself, but the long-term effects of the resources reallocation policy, if carried through, mean that development money would not be available to translate research into clinical practice.

Secondly, the reorganisation of which we have already heard and about which I strongly agree with the noble Lord, Lord Annan, means that there is an inevitable conflict between the national and long-term needs of training and research and the immediate short-term needs of patients which it is almost impossible for the area health authority to reconcile. Indeed, it is an unfair question to put to them. I believe that this presents a very real problem, and it is one which ought to be tackled very soon.

There are a host of other problems which affect medical schools. Some of them are, in my experience, quite new in degree. They stem from the growing complexity, in recent years, of administration and from the multiplicity of bodies which are concerned. It is not only a question of central government and local government; local government health services, universities, the University Grants Committee are also concerned. On top of all that, the maw of the investigatory process are quite insatiable. Committee follows on committee; working party follows on working party. And all the time there is a Royal Commission brooding over us so that our future is uncertain. The multiplicity of committees which senior staff have to attend, and the mass of memoranda produced, so alarm me that I cannot understand how any work gets done.

Underlying all this are the various constraints of our present discontents. At Hammersmith there is in particular the problem to which the noble Lord, Lord Cottesloe, referred of the constant delays over rebuilding the very old buildings at that hospital. There is also the disruption caused to work by the working out of what is at present euphemistically termed " the industrial relations position ". All of these things inevitably have an effect on morale, so it is obvious that a great deal needs to be done if we are merely to maintain our present standards, let alone advance them as we should hope to do.

It does not seem to me that anybody can be satisfied, in the terms of the Unstarred Question tabled by the noble Lord, Lord Annan, with the present state of the provision of medical education—least of all, perhaps, the Government. Equally, we all recognise the tremendous constraints imposed by the present state of the economy and the overriding needs in the financial sphere. Unless, however, the economy picks up, to the extent that considerably more finance can be made available for the kind of things which have been outlined, it seems to me that we shall indeed have to reconcile ourselves to being a second-class nation. And that, I am sure, is something none of us wants.

I do not wish to end on a negative note. Instead, I want to confirm what was said by the noble Lord, Lord Cottesloe: that those who are engaged in this work at the Postgraduate Medical School are men and women of determination, of imaginativeness and sometimes of brilliance. During a recent visit to the school I was delighted to hear one of them say that despite all the frustrations, difficulties and troubles, it is an exciting place to work in because something new happens every day. That, my Lords, is surely the spirit that we need. I am sure that the Government will agree with that, and I hope that they will go as far as they can to encourage it.

8.17 p.m.


My Lords, the Unstarred Question which the noble Lord, Lord Annan, has asked the Government has two parts to it. First he inquires whether satisfactory provision has already been made for medical education in London. I agree most strongly with the noble Lord, Lord Annan, and the noble Lord, Lord Garner, that the Government cannot but feel that the provision is inadequate.

As a doctor, I was delighted to hear noble Lords so distinguished for their knowledge of medical matters speak so well of medical education in this city. The second part of the noble Lord's Question concerns co-ordination. I wish to speak about the co-ordination of education in the medical sphere and to confine myself to that point, because this is my present interest.

We all know that the practice of medicine, and its learning, has become increasingly complex. Everybody recognises that medical education is now a continuum. There has to be co-ordination between undergraduate, postgraduate and continuing education. In recent years, the concept of the university hospital has become manifest. It is the concept of a centre where education is given in basic matters which will equip a doctor to follow whatever bent he mazy have in his postgraduate period. It is essentially an educational period in the life of a young doctor at his medical school.

Those regions which have only one medical school are fortunate, in that their hospital can clearly be a university hospital. In those regions where there are many medical schools, they are under grave difficulties. This point was made by the noble Lord, Lord Annan. He also touched upon the difficulty of the coterminosity of medical services and local government services, distorting and twisting the natural spheres of medical educational interest that are required for the medical schools. This is surely a matter that should be looked into very carefully and one where co-operation and agreement could be reached if the principle could be conceded that the boundaries of the two interests need not necessarily correspond.

The noble Baroness, Lady Robson of Kiddington, rightly pointed out the necessity for academic training in the unpopular specialties. She suggested that they should be made academically respectable. That is clearly a function of the university hospital. She went on to suggest that there should be centres of excellence; they should be large, they should be adequate but they should not be numerous. This is a point that is clearly highly sensible, but there is an educational consideration here, particularly—I feel almost exclusively—in the undergraduate part of education, and that is that, if you have to move students a distance to go to these centres of highly specialised or highly expert training, time is spent, and their time is valuable. Equally, if you bring the experts to the teaching hospitals you infringe what is now regarded as [...]n important educational principle of participation, of learning in groups and learning by discussion and you risk a didactic approach that is out of date.

Co-operation and co-ordination are absolutely essential now that general practitioners have accepted that they must have a proper training if they are in fact to become principals in the National Health Service. Here the institutes in London University have a great part to play, as indeed does the postgraduate hospital with its more general aspects. In particular, I think the institutes are of the greatest importance because they have three distinct spheres of activity and influence on the medical world—and I use the word " world " advisedly. Their international effect on our reputation and our fame is beyond question. Their part in London and London University medical life is also beyond question, but they have, too, a United Kingdom significance that is very considerable. It is this: they play—and in my view will play—an ever-increasing part in continuing education—the absolutely essential education for all doctors throughout the whole of their careers—and in so doing they can play a greatly significant part in helping to solve one of the great difficulties of this day, namely the assessment of competence to practice in a technical sense rather than the competence to practice in a medical sense, by which I mean illness or deterioration in the capacities of the doctor. It is extremely difficult to know how to do this and the one clear guiding line is postgraduate and continuing education.

These institutes and postgraduate education in general can have another very significant effect on one of the great problems of medicine at the present time; that is the imbalance between the number of young men and women in training and the number of posts and opportunities of a permanent career nature at consultant level that are available. One way in which that could be helped—not entirely solved, but significantly helped—would be to get these young men and women into permanent consultant posts with full [...]inical responsibility at an earlier age. This could be done if it was accepted that, given a proper, adequate and efficient training, the great expertise that may be required of those particular persons to fill the job to which they are appointed, could be acquired in the post-appointment period—in other words, from continuing education. Here, in a national problem that worries us all greatly for the future of medicine, and indeed the Health Service, the institutes and post-graduate activities of London would play a national as well as a local part. For this reason, I beg that the Government and the noble Baroness, Lady Young, will consider that these institutes should have a national element as a part of their funding, because this does exist and it could exist very much more.

My last point is again on co-ordination. It was illustrated to me the other day by an interesting arrangement that has recently been achieved. The Camden and Islington Area Health Authority have succeeded in converting a geriatric consultant post into a university post, tenable at University College Hospital, by providing the money for a senior lectureship at University College Hospital, to be held in the department of geriatrics. In fact, the money has come from the Inner City Partnership Organisation but the principle is there of National Health money being used to fund and to supply a senior lectureship, held at University College Hospital but in fact service given at the Whittington Hospital, a district general hospital. The results are a higher quality candidate, a higher quality consultant, than would otherwise have been obtained for the care of the geriatric patients in the Whittington district. Another result is that the students of University College Hospital see practical geriatrics being tackled in the more real and usual setting of a district general hospital and at the same time there is close liaison with the academic centre of University College.

This is not a single or a unique example. There are others going on in London at the present time. I am told, however, that financial stringency will make this increasingly difficult, that, at any rate at the present time, it is a slow process, and that to embark upon the arrangement concerned means the expenditure of time and some delay. Here is, manifestly, co-operation between the UGC interest and the National Health Service interest, profitable to both, both gaining from it. Surely there should be some system whereby such co-operation can be facilitated and made quicker, more efficient and more usual; some means by which the real advantages to both sides can be discussed. I know little or nothing of the workings of bureaucracy; I cannot express a view as to how much co-operation there is over the big matters that the noble Lord, Lord Annan, and other noble Lords have been discussing, but over this beginning, this thing that already exists in the field of co-operation, I feel there is a great future. I hope that, when the report of the noble Lord, Lord Flowers, the Royal Commission report, comes out, and all the discussions take place, great thought will be given to this word " cooperation ".

8.31 p.m.


My Lords, I also would like to pay a tribute to the noble Lord, Lord Annan. I sincerely believe that if this question can be resolved or alleviated he is the person to do it. We have to recognise that the relationships between London medical schools and their university was entirely different from relationships elsewhere between universities and medical schools. Medical educa- tion in London was for many years centred on the voluntary hospitals, and as some were founded well before the university they only came slowly to accept or even recognise university attitudes and ideas. Whereas in Birmingham the medical school functions as an integral part of a multi-faculty institution, and is indeed the university's faculty of medicine, this is not true of London. Under these circumstances, and I quote from the Royal Commission on Medical Education: It is not surprising that each of the independent medical schools in London have found great difficulty in attracting financial support comparable with that made available to other medical schools in Britain ". This puts me in mind of the fact that between 1947 and 1952 there were earmarked UGC medical grants, and I just wonder whether in the circumstances the channels of communication in provincial medical schools were better and more of that earmarked money went there than into London. I suspect there were difficulties in London.

The Royal Commission also said that the situation should not be allowed to continue. It expressed the view that the general pattern of London medical schools was no longer satisfactory and would become increasingly less so in the future. They believed the time had come to forge stronger links with the university in order to give the medical schools access to the expanding world of scientific knowledge. They recommended that in future each medical school should aim to become an integral part of a single multi-faculty institution, similar, in other words, to other university medical schools.

Curiously enough, in all this detailed consideration the Royal Commission on Medical Education managed to complete its examination without considering the question of the delivery of medical care to the people of London, and gave no consideration, so far as I can determine, to the fact that the population of London has since the First World War markedly altered and is now substantially reduced. The population now has fallen to a little greater than it was in 1921, and the 1981 projection anticipates a further 10 per cent. reduction. The reasons the Royal Corn-mission recommended that the number of undergraduate medical schools should be reduced to six were primarily academic ones.

The noble Lord, Lord Annan, has referred to the London situation and the funding of teaching hopsitals and medical schools by the Department of Health and Social Security and by the University Grants Committee. May I also say straightaway that there is no doubt about the very great contributions that London medical schools and teaching hospitals have made, not to British medicine, but to world medicine. They are world-important institutions.

At the end of World War I, of the returning medical students, half went to Scotland and the other half came to London, and even today London trains nearly 40 per cent. of undergraduate medical students, though they go far and wide to get their clinical experience. Following the Royal Commission's Report in 1968 there was an increase in the University of London medical school's intake. More places were immediately required so that the programme of expansion in training medical students could achieve the recommended target. Whether this should continue now that the new provincial medical schools are well under way is one of the problems facing those who are inquiring into such matters. Already, in fact, the figures in London are tending to exceed the Royal Commission's projections against the background of a falling population.

Until 1948 those teaching hospitals were voluntary hospitals, and one important effect of the 1946 Health Services Act was that they came under central Government control through the board of governors system. The emergency medical services of the war had laid the foundations for such a change, which was inevitable, because the hospitals would have been quite unable to raise the necessary funds for their continuance in any other way.

The period 1948 to 1968 was the period of hospital development in the National Health Service and a substantial part was focused on London. But by 1968 important changes were in the offing. The plans for a hospital-based Health Service were in doubt. Moreover, an examination of the changes in the Health Service in that period showed that the development of the existing medical schools and teaching hospitals, our centres of excellence, to keep up with the advances in clinical medicine, had resulted in a situation where the rich became richer and the poor and under-provided remained so. Staff would not go to these areas. Some preferred to emigrate. Other major changes were taking place also. There was the growing realisation that so many illnesses were due to specific environmental factors at work or at home, and the realisation that preventive medicine and health education were necessary, desirable and also cheaper.

There were other changes. One was the development of the social services and the need to integrate them with the health services on a number of levels. Another was the complex nature of the provision for, and the delivery of, modern medical care. A whole range of professions, new and old, are now involved in this. The co-operative effort of a large and varied team is required. People have to be trained to do this vital task. The day of the doctor and the nurse acting substantially alone are over.

Views about medical education were also changing. Medical education had been traditionally divided into two parts, undergraduate medical education and professional training. The first was the prime responsibility of the university medical schools, the second increasingly part of health service provision, and depending very substantially on in-service training and maintenance of standards by the Royal Colleges. The Merrison Report of the Committee of Inquiry into the regulation of the medical profession recommended that medical education should be a continuum; there should he no artificial division between undergraduate and professional training. This view has now been accepted by the profession and we can look forward to radical changes, I hope, under the guidance of the noble Lord, Lord Richardson. Perhaps even the opportunity will occur of shortening the period from undergraduate to fully-trained specialists.

There is another change which is related to cost but has a much wider significance and is central to the London problem. That is the need to align medical teaching developments with clinical developments. We can no longer afford to create small inefficient units at high cost for the purposes of teaching medical students. Medical students in the future will have to go to those areas of the Health Service where the principal activities they are studying are centred. That, as the noble Lord, Lord Richardson, has said, means complicated and difficult changes in the teaching curriculum, but personally I think that it must come. And, of course, in those Health Service centres undergraduate and professional training could be seen as a continuum. Many long-established teaching hospitals which have become centres of specialist medicine—and thereby enormously expensive—are not very suitable anyway for the training of the medical student, and the costs can no longer be justified unless professional training is continuous in the same place and the centre is cost-effective from the Health Service point of view.

One feature about doctors is that they tend to settle where they are trained and there are large parts of the United Kingdom—including large centres of population—which are under-doctored. The situation in the East Midlands is being substantially rectified by the setting up of the Nottingham and Leicester medical schools. Scotland has four medical schools. The West Midlands, with a population similar to that of Scotland, has one of moderate size. The West Midlands is under-doctored and medically deprived. There are areas within it that cannot recruit doctors. It requires one, or perhaps two, more medical schools and clinical teaching centres. These are required for Health Service reasons to create and maintain quality medical care in the region. I believe that the public will demand the increased allocation of resources to make that possible.

London is a national centre for postgraduate and continuing specialist training. Should the undergraduate population here be cut, certainly some of the smaller, isolated, specialised institutions should be rehoused with the larger institutions. The constructive redevelopment of London medicine, in the light of the factors mentioned, is of the utmost importance to the whole country. However, the bill for doing that is so large that it will have to be phased, I believe, over a quarter of a century and the Health Service and education Votes at present cannot do that. There will continue to be demands for large provincial medical schools. They are essential regional centres for the development of the Health Service. London should concentrate on what is does best and is uniquely placed to do.

18.45 p.m.


My Lords, I had not intended to participate in this debate and I must apologise for not having put my name down on the list of speakers. However, I confess that I was stung into speech by listening to the eloquent plea of the noble Lord, Lord Annan, about the starvation of our London medical schools. I was filled with horror when he spoke of the threatened closure of one of them. Previous speakers have emphasised, I cannot help feeling almost inadequately, not only the national standing of our London medical schools, but their international status as well. That is why I view with alarm the statement made by some of our legislators that London is over supplied with hospital facilities and that the crying need is to reduce those that exist in London and to siphon them off to those parts of the country which are under-doctored.

One can destroy a hospital overnight. However, to create a hospital—which, after all, in some cases is the work of centuries of successive outstanding figures in the world of medicine—takes decades, and perhaps even centuries. The tradition that attaches to the London medical schools all over the world is something that one cannot create easily in the provinces.

Others have spoken of the trememdous international reputation of our London medical schools. Of course, our provincial medical schools are also institutions of national standing, some even of international standing. However, London is fortunate in having its 12 medical schools centralised in a small area where there is close inter-communication and exchange of ideas which is of enormous value in terms of medical effort and clinical research.

Our main aim must be to maintain at all possible cost the excellence of our teaching and research. There is a real danger in reducing the annual intake of medical students. Various committees have been appointed and have reported from time to time estimates that vary enormously in their assessment of the future medical needs of our country. I believe that this is a subject which is totally irrelevant. Our duty should be to maximise the intake of medical students as much as we possibly can, and I say that for at least two reasons. The greater the number of medical graduates, the greater the pool of medical ability that can be creamed off in the directions of medical research. That is why it is of the utmost importance to try to increase, wherever possible, the number of medical students admitted each year into our various teaching hospitals.

It is a truism that no medical education is ever wasted. Even those doctors who have given up practising medicine and have gone into other fields have enriched their careers and the resources of our country through having received a medical education. In industry, law, literature, and even poetry, doctors' names stand out among the great figures of our time.

Equally, it is true to say that a nurse's education is never wasted. I am told that nurses make wonderful wives and marvellous mothers. Therefore, any type of higher education is bound to be of enormous value to the country. There are many instances that one can give of people who have abandoned medicine, but they are none the worse for that, although medicine itself may have suffered.

Another reason why we should maximise our medical intake is that there is no real danger of this country having too many doctors. Doctors can be useful in areas outside this country. They can, of course, serve in under-doctored areas within our midst, but there are so many under-doctored countries all over the world where a medical education in this country can be of enormous benefit. It is a two-way traffic. Other speakers have referred to the large number of English medical graduates to be found in the universities of the Commonwealth and other countries throughout the world.

With all the medical facilities in this country, with all the development that has taken place under the National Health Service, we find people from other countries who can afford to do so still gravitate to London for medical treatment. We know of vast new hospitals that have been built in the Arab sheikhdoms. But the fact remains that those who are able to obtain the benefits of medical treatment in this country will leave their own countries in the Arabian Gulf and come to receive their medical treatment here in England.

We must ask ourselves what has happened to private benevolence. Other speakers have referred to endowments which our hospitals have received over the centuries. But now, under the National Health Service, apparently the flood of private benevolence has almost dried up. Many hospitals now obtain help from patients who have benefited by their services, and made voluntary contributions to the friends of the hospital. Many hospitals, including my own, have founded a trust for medical research in connection with their own medical schools. Surely there must be thousands of grateful patients, who now receive medical services free, who would like to show their gratitude in some outstanding manner and contribute in some way, I would hope, to the field of medical research and clinical excellence.

The other point which I should like to drive home as forcefully as I can is that this craze for economy can so easily be overdone. If we continually persist in parading our poverty, we are in danger of generating poverty. Money spent, perhaps on a somewhat lavish scale, in the field of medical research is not money that is ever wasted. One example of false economy may be cited in the story of a medical specialist who was said to have combined in himself the speciality of geriatrics with the speciality of paediatrics. It might be a form of economy perhaps, but it was said of him that he was born senile. In other words, senility is a disease which can easily afflict our legislators just as it has afflicted our hospital buildings. One would wish that our legislators might also be immune from the on-going process of senility, or, if not immune, one hopes that it will not afflict them too obviously.

8.54 p.m.


My Lords, it is not my intention to take issue with my noble friend Lord Annan because I am not unmindful of the strength of his case and his reason for addressing your Lordships in the way he has. I cannot help but believe that we must pass this way again in the not too distant future when the Royal Commission reports and when the Flowers Working Party, set up by my noble friend Lord Annan, also reports. It may be that the noble Lord felt that he ought to get in the first stone. Perhaps I ought to qualify my statement that I do not intend to take issue with him tonight by saying that, with some of my friends, I might well join him in seeking to abolish the area health authorities. However, I can assure him that he will be in for a great deal of opposition if he attempts to abolish the community health councils, which, for many of us, are the only safe-gards for the users and which represent the consumer.

Having said that, I find myself—at least, I think that I shall do so—in sympathy with the Government. For we are living in a fool's paradise if we think that in the immediate future there will be anything like the amount of money we need to put the National Health Service on the level which I believe everyone in your Lordships' House would like to see. There will certainly not be an inexhaustible source that will be able to supply money for new buildings. Unless we accept that as a fact of life, we shall be living in a fool's paradise.

I do not want to say anything about the Resource Allocation Working Party—commonly known as RAWP—because my noble friend Lord Annan dealt with it. But it is a factor. It was designed to try to give a fair and reasonable amount of money to the various regions. We may differ—as I am sure we do—in the actual amount. However, let us keep in the forefront of our mind one important fact; it is that the duty of every Government is to ensure that there is an adequate coverage of all medical services throughout the country—not a greater coverage in one area and little in another. I believe that that is the main task of Government in relation to medical services.

Time and time again, the noble Baroness, Lady Ward of North Tyneside, asked me when I was a Minister what we were going to do for the North-East. She was right to do so, because many areas were the poor relations of the big cities, and money from the better-provided areas had to be diverted to the North, to the Midlands, to the North Midlands and particularly to the North-East.

Reference has been made to the fact that here in London we have 12 teaching hospitals, two postgraduate medical schools and 13 medical institutes. It may be that I am naïve; it may well be that I really do not have a grasp of some of the situations. But it seems to me that there can be no justification at all for having 12 teaching hospitals in London, 11 of them until quite recently within a stone's throw—albeit a pretty long throw—of your Lordships' House. They are Westminster, Middlesex, St. Mary's, St. Thomas', Bart's, Guy's, London, University College, St. George's and, until recently, Charing Cross and the Royal Free. Can we really justify 12 medical schools of the calibre of each one of those—and I acknowledge their calibre—here in London within such a short distance of each other? I remember Aneurin Bevan saying as far back as 1948 that St. George's should go out of London. Half of it has gone to Tooting or Wimbledon (I am not sure which area) within the last two years, but the other half remains.

I believe that, deep down, the noble Lord, Lord Annan, realises that something has to be done about this. If you look at the terms of reference of the Flowers Working Party, you will see that they are to consider: the redevelopment of resources available for medicine and dentistry; in the event of closure, or radical reorganisation, of one or more medical schools or institutes, which these should be; and how you transfer students and staff to other schools without reducing overall student numbers.

I believe it is recognised that we in London are over-serviced. I do not think that there can possibly be any sound or reasonable argument for maintaining so many centres of medical excellence—and I accept that they are centres of medical excellence—or showplaces of high medical technology in so small an area. It is for that reason that I welcome the Flowers committee. Having listened to the noble Lord, Lord Hunter of Newington, I am sorry that he was not put on the committee. I found myself warming very much towards some of the things he said, and which I felt need careful consideration.

The terms of reference of the Flowers Working Party certainly envisage closure and reorganisation of some of the existing teaching hospitals. The argument about the effectiveness of our teaching hospitals, particularly those in the London area, has been going on, as every noble Lord in the medical profession knows, for some considerable time. But there has been no real attempt to research into the scope and function of teaching hospitals. It may well be that the Royal Commission will do it for us. It may well be that the Flowers Working Party will do it. But the sum total of the complaint made tonight by most, if not all, speakers points to the need for a re-evaluation of what is being done. The sooner that it is done, the better.

We have a situation in which a large number of teaching hospitals are each providing similar specialties. I am not, as is all too apparent to your Lordships, a member of the medical profession. My only interest in it is a long one: that of the working of the National Health Service, and the time that I had as a Minister in the Department of Health and Social Security. But I believe that providing such a large number of teaching hospitals in the London area, each offering similar specialties, is wasteful in time and money, and it is doubtful whether full use is being made of all those facilities.

I may be open to a good deal of criticism in saying that, but I know that three years ago, when it was important that I should be X-rayed urgently, living in Oxford, I could not get it done for seven weeks notwithstanding the urgency. But I was told that I would get it done in a London hospital immediately. So I brought my letter from my GP, not wishing to have any special treatment, took it to a London teaching hospital and was X-rayed immediately. Now perhaps I am drawing too much from that. We need to look at the needs of the country as a whole; the real need in particular areas. I believe there are large parts of this country starved of teaching hospitals. We ought to be thinking of opening teaching hospitals in areas where I believe there is a very real need. I am told that the London teaching hospitals draw 80 per cent. of their people from South-East England, 15 per cent. only from the rest of the country, and 5 per cent. from abroad.

Local residents in London must suffer, I believe, to maintain the teaching and research which is being done in our London teaching hospitals. The patients are not presenting medical problems and difficulties which would come under the heading of high technology. I am talking about patients generally. I am concerned at the number of beds teaching hospitals claim to be necessary in their discharge of the responsibilities of a teaching hospital. I think that there is too much weight given to specialisation and research in what is a belt of medical schools situated closely together. In fact, hospital beds for specialisation are rarely those needed by a population which is using resources increasingly as a result of age and psychiatric illness. Can we be sure that local residents do not suffer in order to maintain this teaching and research?

I am glad that one of the tasks of the Flowers Working Party, as I understand it, is to inquire into the commitment to academic work, its present form, and its present level. The point may be raised that if bigger but fewer units were established for training it would involve students in extra travelling. But would this really cause any hardship in view of the closeness of the existing teaching hospitals? I understand that already half the clinical teaching at the Middlesex Hospital is done at the Central Middlesex Hospital in Harlesden. I understand that that presents no problem at all.

It must be at least 10 years ago that it was proposed that the Middlesex and St. Mary's hospitals should be combined. The real question is whether it is right, having regard to the needs of the country as a whole, to have so many centres of excellence and medical high technology in London. I cannot think that it is right, and I hope that the Flowers Working Party will approach and carry out their task without fear or favour.

I look forward, as I am sure a large number of people do, to their findings and I look forward with some confidence to the recommendations of the Royal Commission on the National Health Service. I say sincerely that Lord Annan has raised this subject at a moment when we should begin thinking about the future and, if he has succeeded in doing nothing more, he has caused us to prepare our minds for the bigger discussion which is to come, and I hope it will come fairly soon.

9.9 p.m.


My Lords, I am sure the whole House is grateful to the noble Lord, Lord Annan, for introducing this debate and indeed to the entire galaxy of experts who have taken part. Speaking as one of the non-medical people present, I can only say I feel like that thoroughly unpractised tennis player who has been knocking a ball about in the garden and suddenly finds herself on the centre court at Wimbledon—a somewhat alarming experience. However, I hope that whatever else I may do or not do, I will take to heart the words of the noble Lord, Lord Hunt of Fawley, and not use the word " integration " at all, and I shall use his nice little analogy of the cat and the canary in some other speech; I am sure it will come in handy.

It goes without saying that my department and my colleagues will study this debate closely and it will of course also be studied by my right honourable friend the Secretary of State for Social Services, Mr. Patrick Jenkin. Lord Annan, in introducing the debate, made five important points and at varying times all the other noble Lords who have taken part in the debate have either raised them in similar form or have further elaborated on them. I shall try to refer to them all in the course of my remarks.

The subject which Lord Annan has raised is of course of great importance to the country. The significance of the role of the University of London in medical education and research, both in the United Kingdom and internationally, cannot be over-emphasised, a point to which the noble Lord, Lord Greenhill, with his vast experience at the Foreign Office, drew our attention, as did the noble Lord, Lord Garner. It is currently responsible for the education of almost one-third of the country's medical students and has a great tradition and fine reputation to preserve. Her Majesty's Government recognise both this and the problems that now face the University's medical schools and institutes, which this debate has illustrated.

The noble Lord asked whether the Government are satisfied with the provision for medical education in London. It is clear, listening to the debate, that the situation which has been described is a difficult one and that a great deal of co-ordination will be needed to find solutions to the problems which have been discussed. I should like to record at the beginning of my remarks that I do not consider that these problems spring from a lack of liaison between the University Grants Committee and the Department of Health and Social Security. This was the fifth point made by Lord Annan. My understanding is that there is a great deal of co-operation between the two departments. But what is unfortunately a far more intractable problem is that there is a very real conflict of interest between the needs of medical education in London and the wider needs of the National Health Service, a point well brought out by the noble Lord, Lord Wells-Pestell. Although I would not follow him in all his remarks, I was grateful to him for drawing our attention to the very real economic problems that underlie the difficulties of the National Health Service. I hope therefore that noble Lords will agree that the Government must give consideration to finding a balance between these interests and to trying to seek a solution to the problems now facing the University, and perhaps I may enlarge on that.

For mainly historical reasons, the London teaching hospitals are concentrated in a relatively small area. Many people from outside London are admitted to the teaching hospitals, but the majority of their patients come from inner London. The population of this area has been declining for a long time and trends show that this decline is likely to continue as more people move out to the surrounding counties. But there has not been a corresponding movement of acute hospital services; the concentration of hospitals in Central London still exists but new hospitals have not been built fast enough in the surrounding areas. As a result, there is a comparative over-provision in Central London—even when allowance is made for the specialist services provided by the teaching hospitals—and under-provision in places like Kent and Essex. The health authorities have a duty to build up the levels of provision in these areas so that people can get the general hospital treatment they need nearer to where they live.

At the same time, there are parts of the Health Service which are poorly provided for in London—a matter to which the noble Baroness, Lady Robson of Kiddington, drew attention. Services for the elderly, the mentally ill and the mentally handicapped in inner London leave much to be desired. These services, too, need to be developed and improved. Indeed, the noble Lord, Lord Richardson, drew attention to this point. I was very glad that the noble Lord, Lord Hunt of Fawley, said (I think I am quoting him correctly) that departments of general practice had been founded in five of the hospitals in London. This seems to me to be the kind of way forward which the noble Baroness, Lady Robson, would welcome, and which I am sure is welcomed by us all.

The task facing the Thames Regional Health Authorities, which have to plan the health service in London and the surrounding Home Counties, is therefore a difficult one. It is made more difficult by the fact that these regions already have more than their share of the funds available. The policy for the distribution of resources to health regions is based on the recommendations of the Resource Allocation Working Party. It aims, over a period of time, to move towards a distribution of resources based on relative need, and regions are encouraged to adopt the same approach in allocating funds to Area Health Authorities.

I am sure that noble Lords recognise the fairness of this policy in terms of the access which people throughout the country should have to health care. But, because of the low rate of growth which we are able to give the National Health Service at present, the amount of money available for development in the Thames Health Region is not as high as we would like. The health authorities have, therefore, to look to the over-provided acute services in London to solve their problems; and it is only by rationalisation of these services that the shift of resources from acute to chronic care in central London can be achieved.

These changes are essential from the health service point of view but, as I said earlier, they may pose serious problems to the medical schools. While these schools would all wish to see better facilities for non-acute patients and would wish to improve the experience their students get of such cases, their main need for teaching purposes is for acute hospital facilities.

The problem is to find a balance between these conflicting interests. One suggestion has been that provision for medical education should be moved out of inner London. There are strong arguments for distributing medical education more widely across the country. The problems of conflict between health service needs and medical education which arise in London are less apparent in the provinces, and the existence of a new teaching hospital is bound to improve services in an area which is currently poorly served; and doctors who are trained in an area are more likely to continue to work there afterwards. The new schools which were established in Nottingham, Leicester, and Southampton in the 1960s are now beginning to produce results and will, in time, develop reputations and traditions to match those of the London schools. But there is a major stumbling-block. The building of a new teaching hospital and medical school involves expenditure in the region of £60 million, and we are simply not living in a financial climate where such sums will be readily available.

Ways of reorganising existing provision must also be considered. Many of the existing schools in London have taken steps to adapt to the movement of population and services. They are increasingly using hospitals away from central London to augment the clinical facilities available to them. But there are limits to this. The medical students must still be able to continue their academic work within the medical school environment, and this will be more difficult if their practical training takes place at a distant hospital.

It may also be possible to improve the use of educational facilities within central London. Concentration in fewer schools and larger units might lead to more economic use of both health and educational resources. Such a rationalisation of existing provision need not mean that the current level of entry would have to be reduced. We are still pursuing the national target of a student entry of about 4,100—this will be achieved soon—and London's intake is an important part of that total. But decisions about the long-term future will then have to be taken and, in view of the problems in London, any reduction in the overall total might well apply to London. Certainly if the overall total were to be increased, it seems unlikely that anyone would wish to add further to London's problems by increasing its intake. But in saying this one must recognise the points that have been made in the course of the debate, particularly the point by the noble Lord, Lord Hunt of Fawley, about the human problems which arise when we are actually talking about rationalisation and reorganisation of hospitals.

I have attempted to summarise the problems facing London's medical schools and some of the solutions that have been suggested. What, then, should be done? As several noble Lords pointed out, all these matters are currently under consideration by a number of different bodies and committees, and I sympathise with the noble Lord—I think it was Lord Richardson—who said that this really was a very complicated situation.

The university itself, as the noble Lord, Lord Annan, has explained, has set up a working party, under the chairmanship of Lord Flowers, to examine the use of resources for medical and dental education in London, and to see what redeployment is necessary to maintain standards of teaching and research. The Government welcome this, and will study very carefully the implications of the working party's report.

On the health service side, the London Health Planning Consortium has been set up by the Thames Regional Health Authorities, the University Grants Committee, the University and the Department of Health and Social Security. It is a planning body which is examining these and other major strategic problems to identify the options for achieving change. One of its main tasks has been to study the imbalance between the hospital facilities required to meet, on the one hand, the needs of a reducing population and, on the other hand, undergraduate medical teaching needs. The consortium proposes to issue a consultation paper later in the year which will identify and quantify the options for resolving this imbalance in order to seek the views of the University, the University Grants Committee, the health authorities and others. The consortium has a rather different standpoint in considering these problems from Lord Flowers and his colleagues. but I am glad that the two bodies have common membership and that Lord Flowers will be able to take into account the work which the consortium has been doing.

I should like to mention two other points which have been raised and which are said to contribute to the problems facing medical education in London. The first is the question of funding the teaching hospitals. I have already referred to the method by which resources for the National Health Service are distributed. I do not think there is any disagreement about the fairness of the principle that money in the National Health Service should be distributed according to relative need, but there are arguments about the pace at which it should be done, and we must give proper consideration to the costs of medical education and specialist services. The central problem here has nothing to do with the Health Service; it is simply our poor economic performance in recent years. The National Health Service has been able to grow only very slowly. As a result, efforts to redistribute funds to deprived areas have led to a sharp brake on development and something of a squeeze on those places, such as London's teaching hospitals, which had previously been accustomed to steady expansion. Her Majesty's Government believe that a levelling up of standards and provision is what is needed, but this will be dependent on our producing greater wealth to support it.

Following on that point, the noble Lord, Lord Cottesloe, and the noble Lords, Lord Auckland and Lord Garner, all mentioned the future of the Hammersmith Hospital. The North-West Thames Regional Health Authority, which is responsible for the Hammersmith Hospital, has included in its present plans provision for a major redevelopment scheme to improve poor facilities at that hospital, and the project is programmed to start in 1985–86. I hope this will be of some help to the noble Lord, though I am sure we would all wish that resources would allow us to do more, more quickly. The noble Lord, Lord Greenhill, raised a point about the dental school attached to King's College Hospital. I regret that I have no information available this evening, but if the noble Lord. Lord Greenhill, will bear with me I will write to him on this matter when I have an answer for him.

Finally, my Lords, there is the question of the National Health Service reorganisation, which, it is said, has made life more difficult for the medical schools. The arrangements which existed before 1974, under which the teaching hospitals were administered by boards of governors directly accountable to the Secretary of State, may well have had advantages for the medical schools. The teaching hospitals did not have clear service responsibilities, and could adjust the pattern of their work more easily to fit in with the needs of medical education. But this independence caused serious problems for the then regional hospital boards, which had the statutory responsibility for the provision of service. Many of the services which were needed, including particularly the more specialised services, were outside the control of the regional hospital boards. The proper planning and co-ordination of services and the control of development in the Health Service in London—and the teaching hospitals are primarily part of the Health Service—was much more difficult to achieve. The reorganisation of the National Health Service has overcome some of these difficulties, but not all of them. The Government, however, recognise that there are many shortcomings in the reorganised Health Service which have tended to produce an unnecessarily bureaucratic structure. Once the report of the Royal Commission on the National Health Service is available, we shall be looking for ways of simplifying the system and returning operational control to the lowest possible level. The Royal Commission's report may also have a bearing on many of the other issues raised in this evening's debate.

I hope that I have said enough to make it clear that the Government are fully aware of the real problems involved in this difficult area and of the important part that London and its hospitals play in the Health Service and in medical education in the country as a whole. In view of all the developments which I have outlined, I am not unhopeful that solutions will be found; but I should not like to pretend at this stage to be able to say what they will be. I should like to give the noble Lord, Lord Annan, the reassurance that the Government will be ready to play their part in bringing about the necessary changes; but I am afraid this will not be an easy process.