Academic Medicine and the NHS

HL Deb 26 November 1986 vol 482 cc590-621

5.53 p.m.

Lord Prys-Davies rose to call attention to the state of academic medicine and its effect on the National Health Service; and to move for Papers.

The noble Lord said: My Lords, I rise this evening to draw attention to a matter of great concern for the future of medicine in our country and the future of the National Health Service. That future lies to a considerable extent in the hands of the teachers of medicine. The medical schools and the teaching hospitals associated with them are vital to the National Health Service. If our society wants to maintain and improve service to patients, our medical schools must be able to produce the number and quality of doctors that the service requires, to promote postgraduate education, and to enable them to work in an environment which will allow outstanding doctors to pursue their teaching and research so as to extend the frontiers of medical knowledge.

It is no accident that the teaching hospitals have been centres of excellence within the NHS since its founding and indeed for generations prior thereto. They have been dynamic institutions, leading their cities and their regions in medicine, setting high standards of patient care and building up academic departments which have acquired prestige both at home and abroad. I think we can properly regard our medical schools as national assets.

It must therefore be a matter of grave concern that eminent men and members of distinguished institutions, who know what they are talking about and who do not express themselves in exaggerated terms, are now expressing publicly alarm and apprehension at the difficulties which have confronted the medical schools in the United Kingdom for the past six or seven years and which will continue to plague them unless government policies are reversed.

To illustrate the nature and extent of the concern let me give your Lordships a few examples. Mr. Maurice Shock, the chairman of the prestigious Committee of Vice-Chancellors and Principals, reviewing the state of medical education in the United Kingdom, warned in June last that, everything built up since the war is in danger of being dismantled unheedingly". None of his predecessors has been moved to utter such a warning.

The British Medical Association felt itself compelled last summer to convene two seminars to consider the magnitude of the crisis in academic medicine. We are grateful to the BMA for the lead that it has taken. Sir Christopher Booth, the distinguished director of the Clinical Research Centre and this year's president of the BMA, in his presidential address last June drew attention to the crisis facing clinical research in an era of research which had never been so challenging and the benefits so rewarding.

The National Association of Health Authorities, in its 1986 review of university funding and the NHS, found that the threat of further revenue cuts: hangs heavily over the medical schools and the teaching hospitals". It called for concerted action by the two departments concerned, the Department of Education and Science and the Department of Health and Social Security.

The General Medical Council last May warned that if standards of medical education are further endangered the degrees granted by some medical schools may no longer be eligible for registration under the Medical Act. Never before, to my knowledge, has the GMC been moved to utter such a warning. Each of the examples which I have given is, I believe, a cause for grave concern. Taken together with other examples which I could have given they demonstrate that academic medicine in the United Kingdom is under very considerable pressure. I believe they tell us that something is radically wrong. The real problem is money and possibly also the Government's attitude towards scientific inquiry.

There are three main financial features at the root of the difficulties. First, from 1981 to 1986 there has been a total real decline of about 20 per cent. in UGC funding for the medical schools. On top of that, unless government policies are reversed there will be a further reduction in the real value of the UGC fund of 4 per cent. per annum over the next five years. Secondly, there has been a reduction in the resources reaching the teaching hospitals from their local NHS authorities. The NHS district authority has been under pressure to live within its cash limits and has found it necessary to close or partially close wards, to close or partially close theatres, permanently or temporarily, and also to bring about staff reductions in a way that affects the teaching hospitals. Even enlightened authorities, knowing full well that the NHS depends to a considerable extent on the contribution from the medical schools and their teaching hospitals, have had to reduce their financial commitments to their teaching hospitals.

There is a third feature. I refer to the treatment given to academic clinical staff. The question of salary and conditions of service for clinical academic staff will be discussed in detail later in the debate by the noble Lord, Lord Hunter of Newington, who is the acknowledged expert in your Lordships' House on this complicated subject. But as a layman I should like to make one point. It appears to me that clinical academic staff, notwithstanding their enormous contribution to the NHS—and I take this opportunity of paying great tribute to the small band of teachers of medicine, who have very little political power—have fulfilled their duties magnificently. But they are at a disadvantage in terms of remuneration in relation to their colleagues in the NHS.

For example, NHS staff can earn additional money by domiciliary visits or by private practice. That difference has been accentuated by the Secretary of State's decision to allow NHS staff the opportunity of increasing, within certain limits, their private practice income. However, I stress that dedicated, highly talented people will stay within the academic environment even if they are at a financial disadvantage, provided they have sufficient facilities to pursue their teaching and their research. But there is evidence of frustration that such facilities are growing fewer.

I now return to the main theme. Some medical schools have weathered the problems and the difficulties of the past five years more successfully than others. They have done so by increasing their income from new sources, such as from charitable bodies which are associated with the more popular sectors of medical research, or from commercial exploitation of their own inventions. However, all the medical schools in the land have been driven to make economies. Even those schools which have been more successful than others in adjusting to the reduction in funding from the UGC by attracting alternative financial support have serious doubts about their continued ability to expand the fund-raising base ad infinitum. All the medical schools view the future with concern.

As about 70 per cent. of medical school expenditure is on staffing there have been inescapable staff losses over the past five years. This has occurred across all disciplines. None has escaped. Since 1980 there has been a loss of 434 medical academic posts, 175 technical posts and 43 secretarial and clerical posts in clinical academic departments in Great Britain. I am advised that those figures are equivalent to the loss of one complete medical school. Furthermore, in order to save money, posts have been downgraded, Chairs have been lost and the filling of vacancies has been delayed.

Equally worrying is the fact that at least 11 senior clinical posts are vacant due to the lack of suitable applicants. I suggest that those vacancies are an indication of ebbing confidence in the future of academic medicine. I have been reminded by Sir John Butterfield, the Master of Downing College, Cambridge, that, while the pressures within the medical schools have been increasing, there has been no compensating reduction in the responsibilities that senior staff in our medical schools shoulder in the NHS, from the top to the bottom. At present they assist the DHSS at every level, from that of the chief medical officer and the chief scientist to the regional and the district committees. They make a major contribution to management of the NHS which is largely unrecognised.

Nor has there been any compensating reduction in the teaching commitment and in the intake of medical students. Indeed, the number of medical students is determined as a matter of central policy by the Government; and that number has not been reduced. We should be interested to learn whether the Government intend to maintain the 1986 level of student intake.

The point should also be made that a medical school cannot remove a subject or a discipline from the curriculum because medicine has to be taught to meet the strict requirements of the General Medical Council; and I have already referred to the concern of the GMC that some of the medical schools may be in difficulty in meeting standards.

Therefore, we arrive at this worrying situation. The quantity of teaching has remained constant but its quality is under pressure. Given the job losses to which I have referred, the inevitable increase in work load on the remaining staff, the inevitable worsening of the staff-student ratio and the increasing time and energy devoted by clinical academic staff to finding external financial resources to meet the shortfall, it is not unfair to ask for how long the quality of teaching can be maintained.

For their part the Government are quite relaxed. Indeed, it is disturbing that they should be so relaxed. Last February they concluded that the effects of the cuts up to April 1984 were no more than—and this is the Government's word—marginal. They announced that the UGC cuts had had little effect upon patient services because only 5 per cent. of hospital patient care is provided by clinical academic staff.

That may be so nationally, but it is a deceptive figure. In the districts which the teaching hospitals serve the 5 per cent. figure on which the Government rely does not even approximate to the true position. In the health districts served by teaching hospitals the percentage of hospital patient care provided by clinical academic staff is more than 10 per cent., more than 20 per cent., or more than 30 per cent., and for some specific disorders it may be 100 per cent.

I have already referred to evidence which points to difficulties in recruiting clinical academic staff, which must be a subject of concern, especially when I remind your Lordships that there may be difficulties in paying them salaries equivalent to their NHS colleagues from hard pressed university funds. But in addition there is also evidence that academic medicine in the United Kingdom is beginning to lose outstanding teachers because of the problems within the medical schools, the inadequate research facilities and the deficits in the National Health Service. In combination these factors create pressures which regrettably drive overseas some highly talented men, pioneers and research workers. This is the subject of an article called "The Brain Drain" published in this month's BMA News Review.

One such person who has left the United Kingdom is Professor Leslie Blumgart, the former director of surgery at the Royal Postgraduate Medical School at Hammersmith Hospital, which is the biggest academic surgical unit in the country. A few months ago Professor Blumgart gave up his post at Hammersmith to take up an appointment at the University of Berne. His departure has been described as a major loss to students and to NHS patients. When I asked Professor Blumgart why he had opted out of academic medicine in the United Kingdom, he replied in writing, and I shall quote a few sentences from his letter: In short, I decided to leave the UK because of continued frustration in being denied the opportunity to develop my interests and my Department. The tedious and repetitive cuts had in my opinion reduced my Department to a non-viable academic level. The recent tendencies to cut support have led to a considerable lack of morale. I personally would never have left the UK had I felt that I could continue to develop in an academic sense". No government can with safety disregard the words of Professor Leslie Blumgart.

Our medical schools are now beginning to experience at one and the same time difficulties in recruiting clinical academic staff and the loss of some talented teachers and researchers. Surely herein lies firm evidence that there is something radically wrong with government policies toward academic medicine. It can be argued that initially government policies may have facilitated rationalisation where that was necessary, but today those policies are threatening to destroy academic medicine as we know it.

Since the Autumn Statement announced by the Chancellor, with its commitment to higher public expenditure during the next two years, the Government no longer have an excuse for continuing the squeeze on resources to be made available to the medical schools and the teaching hospitals. But I am advised that it is feared that the additional funds that will be available to the medical schools for their clinical work as a result of the Autumn Statement will he very small indeed, and that they will nowhere meet the concerns which I am sure will be expressed this evening in your Lordships' House.

As I draw to my conclusion I ask very briefly four questions. I have given the Minister warning of these questions because we are anxious to have the Government's considered reply to them. First, will the Government stop the reduction in the UGC funding available to the medical schools? Secondly, will they ensure that special arrangements are made for the maintenance of teaching hospitals, bearing in mind their prime role in teaching future generations of doctors? Thirdly, will the Government provide new money for research in unpopular areas of development such as mental illness and for the application of clinical genetics? Fourthly, will they ensure that additional funding is incorporated in the UGC recurrent grant to take account of the higher base line for salary increases?

We are not asking impossible tasks of the Government. They are not impossible tasks. If the Government are unable to respond constructively, the decade of the 1980s will surely turn out for medical education and the NHS to be a decade of parsimony, frustration and a denial of the spirit of science.

6.17 p.m.

Lord Kilmarnock

My Lords, by mutual agreement with my noble friend Lord Hooson and with the leave of your Lordships, I shall speak now and the noble Lord, Lord Hooson, will speak in my place on the list of speakers. I am sure that we are all very grateful to the noble Lord, Lord Prys-Davies, for introducing this important topic for debate. He has given us an admirable exposition of the current situation and all the facts are available in the very useful briefs which have been issued by the BMA, the National Association of Health Authorities and the Committee of Vice-Chancellors and Principals, so I shall not go into them in any detail.

I think it is important at the outset to be clear that we are not talking about some abstruse or remote discipline, and the only minor quarrel that I have with the noble Lord's Motion is the phrase "academic medicine" which may give that impression. I should have preferred to see the term "medical schools" in the Motion because it is the actual places in the front line about which we are really talking. In doing so, we should never forget that those who are passing through them now will still be practising in the year 2025, and that in today's fast moving world they need to be equipped for a lifetime of continuing renewal and self-education. That will not happen where resources are inadequate and morale is low, nor will the breakthroughs in vaccines and cures that we all want to see.

In the past, the high morale, traditions and quality of care in our teaching hospitals have earned them a reputation second to none in the world but, more importantly, these high standards have provided the NHS with the doctors it needs at a very reasonable cost compared with other countries, to say nothing of innovations in health care through clinical research. This has been achieved through the hitherto fruitful partnership between the universities and the NHS, based on a dual support mechanism funded partly by the UGC and partly by the DHSS.

Clinical academics and NHS doctors share teaching, patient care and management tasks. They are not always in the same proportion; for example, London, with its eight medical schools producing one-third of the country's doctors, receives considerably more funding from the NHS than from the UGC. In other places, the precise balance is different.

The system therefore rests on a subtle and complex symbiosis. That is expressed in the so-called knock-for-knock arrangement—a gentleman's agreement—whereby neither side charges the other for shared and often inseparable costs. Within that framework, university consultants perform clinical functions while NHS doctors teach students. As I have indicated, they do the bulk of the teaching in London.

That informal partnership, a fine example of British pragmatism, has come under increasing strain in recent years, as the noble Lord said, and is now in danger of falling apart. The reason, as he told us, is the squeeze on academic medicine which goes back to 1973, although it was not until 1981 that the system began to suffer from serious, financial malnutrition. The swingeing cuts in higher education have naturally affected the university side more than the NHS side of the partnership.

In general, across the board, there has been a 15 per cent. decline in clinical academic staff, and 17 per cent. if medical and dental staff are taken together. Dentists have a special problem because the clinical academic dental service is relatively much larger than the general medical equivalent and consequently does an even higher proportion of NHS work, as the noble Baroness is well aware.

I see the noble Lord, Lord Colwyn, sitting here. I hope that he will participate in the debate and perhaps speak in the gap. Then, at the same time, there has been a reduction of some 20 per cent. in the available scientific support, through the reduction in technical numbers, which is not helpful in a hi-tech area requiring plenty of laboratory hack-up.

The Government may say that it is unfortunate that we have had to lose a few boffins but the NHS is still ticking over nicely. That is not the case, particularly in the newly developed specialties where much of the clinical service is performed by academics. The noble Lord drew attention to the global figure which has been given of 5 per cent. That is entirely misleading; for example, in paediatrics. 25 per cent. of all neonatal consultants, 20 per cent. of children's cancer consultants, 40 per cent. of all children's endocrine consultants and 25 per cent. of all children's respiratory consultants are university employees. I believe that comparable proportions apply in pathology. The academic input is therefore crucial to the maintenance and further development of those services.

It is true that some academic clinical posts have been taken over and refinanced by the NHS, but the number of such posts is only four out of the 90 losses over the past two academic years, according to the tables provided by the BMA. Furthermore, although the NHS may have suffered proportionately less than the university sector, the effects of the resource allocation working party have definitely been to move money away from the London teaching hospitals. It may be thought that a shifting of resources from the Thames regions would benefit other parts of the country, for example, Sheffield; but again we cannot win, because the regions have tended to shift RAWP money out of the big cities, where the teaching hospitals are, so that provincial teaching hospitals have also suffered and thus medical schools find themselves in a double hind, if I may put it that way.

The UGC has clearly done its best to fund its side of the equation, but it faces one insuperable difficulty, which is that medical academic stipends increase faster than non-clinical academic salaries. That is because an additional stipend is paid to bring the academics approximately into line with their shoulder-to-shoulder NHS colleagues with whom they work a 46-week year and with whom they share management and clinical responsibilities. That additional burden on the university grants system is wished on the UGC by awards made by the Doctors and Dentists Pay Tribunal over which the UGC has no influence. In some years, it is true, the Treasury has met the difference, but it has never varied the base line, so the problem constantly reappears.

It is proper that comparability should be the aim. We cannot have widely differing pay structures for people working shoulder to shoulder in the same team. But if that requirement of equity is to be met within the UGC's funds, it means that it will be able to fund only a diminishing number of academic posts. That is the current situation, as I understand it.

I should like to put my first question to the Government. Within the university system, medical schools arc clearly unique because of the NHS interface. Is there not therefore a case for earmarked funding for the medical school component of the UGC's total grant to take account of those special circumstances? Alternatively, and perhaps going further, may we not have an entirely new system whereby the SIFT money for teaching hospitals from the NHS and the additional stipends, merit and distinction awards and units of medical time and so forth are rolled together into one budget and taken right out of the UGC mainstream? That would have the advantage of simplicity in that all those additional payments could be consolidated into one monthly salary cheque, thus avoiding multiple paymasters and reducing the unnecessary frictions which bedevil the relationship between clinical and non-clinical salaries.

This may be the appropriate place to suggest that something needs to be done, not just about funding but about the liaison between the DES/UGC on the one hand, and the DHSS on the other. My understanding is that the DES medical desk is manned by one half-time post and that the DHSS has one observer on the UGC's medical sub-committee. That may have been adequate in palmier days, but has the time not come for a high powered joint board to ensure the maximum effectiveness of all teaching hospital moneys, from whatever source, and to operate a simple, common payroll? Something like that would obviously be necessary if a new funding system were to be accepted. Does the noble Baroness agree that that would provide a superior supervising body?

I follow that query with a warning. The noble Lord, Lord Prys-Davies, has given us a number of warnings. Here is another. Although medical academic stipends attract extra payment for extra duties, there are still financial disincentives to a career in this field. There is continuing uncertainty about true parity with NHS colleagues. There are poorer fringe benefits compared to the NHS such as removal expenses, and night on-call payments, which may provide one-third of a young doctor's salary, are not available to all research doctors, particularly if they are funded by the Medical Research Council or by research charities. In those circumstances, many of the best graduates now go into general practice rather than face uncertainty over their rewards and the research opportunities open to them.

I am delighted that general practice has improved its standards and status within the NHS, but we are talking about the brightest graduates of the medical schools, whose talents can be of enormous importance to research and development, who put up projects worthy of support by the MRC, who provide the Government's Chief Medical Officer and our representatives on the World Health Organisation. They are people of the highest calibre. They are the people who are being positively discouraged from that career and on whom, if they opt for it, there is an increasing temptation to take on private practice. The long-standing principle that university employees in medicine do not pursue private practice for personal gain is already beginning to be eroded. In many parts of the world, as I am sure the noble Baroness will be aware, senior staff are absent from medical schools and teaching hospitals from lunchtime onwards. That is bad for teaching and appalling for research. Do the Government want to see that become the norm in the United Kingdom?

That brings me to research. One of the most important functions of the medical academic is to carry out research. In a squeeze which is the first of his functions to be sacrificed? We cannot cut back on teaching because a statutory duty is placed on the GMC to ensure an adequate supply of teachers, as the noble Lord, Lord Prys-Davies, pointed out. There is no scope for cuts there, except perhaps in quality. Duty to the patient is sacrosanct. Neither of those duties can be postponed, so inevitably research is either deferred or not undertaken.

What sort of research is this? Why is it important? It is important because much of it leads to applications at the sharp end of medicine. It includes the incidence and cause of disease, diagnostics, prevention and epidemiological studies. Financial openings in private practice do not follow national needs or research possibilities. For example, there is little private work in immunology, infectious diseases, neonatal care or nutrition, all of which offer major research opportunities to meet national needs. There is plenty of private practice in hip replacement, hernia surgery, coronary artery disease and so on, but it is wasteful for a talented clinical investigator to spend time in many of the areas that are most financially rewarding in private practice.

Then there is the pharmaceutical industry. This is an area of economic activity in which Britain can still compete internationally, for example, Wellcome's recent penetration of Japan and its development of the antibody test for AIDS. A strong pharmaceutical industry ultimately depends upon strong medical schools. At present the recruitment of clinical academics into the industry is good. But this is reflecting the shake-out of staff in the medical schools who cannot progress in the face of current cuts. It is likely that the present poor recruitment into clinical academic departments—there are now only half as many applicants per post compared to the equivalent NHS posts—will in future starve the pharmaceutical industry in its recruitment of able clinical advisers. More generally, there will not be an atmosphere of innovation and change in health care in the United Kingdom. No academic departments, no new developments!

I conclude by summarising my queries and suggestions. Do the Government accept that the contribution made by clinical academics to the NHS is an essential one? Do they understand and will they take on board the particular problem of academic dentists? Do they agree with me and with the noble Lord, Lord Prys-Davies, that it would be a disaster if the most promising clinical investigators drift off into private practice or are forced into moonlighting to make ends meet? Do they attach importance to clinical research? Are they alarmed by the actual decline of its effectiveness, as analysed in the UGC's letter of May this year? Do they accept that there is a link between the performance of the pharmaceutical industry and the health of academic medicine? If the answer to all, or most of, those questions is yes—I hardly see how it can be otherwise—can we have a commitment this evening that the disproportionately damaging squeeze on academic medicine will be halted and reversed? Will the noble Baroness bring to the attention of her colleagues the suggestion that there should be a new liaison body to canalise this money as fairly and effectively as possible? My Lords, I look forward with eagerness to the noble Baroness's reply.

6.33 p.m.

The Lord Bishop of Hereford

My Lords, unlike the noble Lord, Lord Kilmarnock, I am glad that the word "academic" has been included in the debate. Your Lordships will realise that the debate on the relationship between academic university clinical departments and their National Health Service colleagues is yet another reflection of a curious national characteristic. It would seem that we always underestimate the value of academic expertise, scientific inquiry and research carried on in our universities and other institutions. We have an inbred suspicion that in academic research we are not getting value for money. It always seems that we are giving our support and making available our financial resources to what is seen to be of benefit to our society in the short term and giving only lip service to the importance of those engaged in work and research that will be of benefit in the long term. Where financial resources are limited, it is the former rather than the latter that receive the lion's share of the resources available.

The growth of academic university clinical departments is typical of the way in which similar developments in other fields have taken place in our universities since the war. At the inception of the National Health Service, there were very few truly academic departments within our teaching hospitals. Where professors were appointed, they were generally senior physicians or surgeons and the title was purely an honorary one. It was not until the 1950s that the universities set up departments in medicine and surgery modelled on the American pattern. These units rapidly became centres of excellence leading the way in the clinical treatment of such conditions as cardiovascular research and others that have already been mentioned.

As is always the case, there was, I believe, a friendly rivalry between the NHS clinical and the academic clinical staff. But the overriding attitude has always been one of mutual respect for those engaged in clinical work and those engaged in research. Although initially academic staff had been trained within the NHS, over the years, I understand, it has become possible for academic staff members to progress through the university system. But in most places training in medicine or surgery has been shared between the two. Most lecturers have spent a long time in the NHS before joining the university and many of the teaching hospital NHS consultant appointments come from those who have worked as juniors on the academic side. All in all, there is a large amount of cross-flow and cross-fertilisation between the academic and the clinical sides. One is complementary to the other, and if one suffers both in the end must suffer.

The foundation of other academic departments in the 1960s and the 1970s, particularly in psychiatry and in health care of the elderly, led to the raising of standards practised in the areas where the Chairs had been made. It is always a point of interest that where an academic Chair has been created for a particular discipline, it has attracted to that area those who wanted to specialise in that discipline. This has brought about a greatly increased standard of medical care to that area.

There are, however, problems arising from the dual system of funding. University departments are funded from the University Grants Committee. But quite a large proportion of their income comes from the National Health Service health authority in appreciation of the clinical academic work undertaken in universities. Both the University Grants Committee and the NHS health authority have, however, different rules. Inevitably, this causes friction.

It is at this point that I become more personal. In my dealings with medical students and academic staff, I find that this is the area in which there is most frustration and cause for concern. For many years, the sub-consultant staff level of university staff did not receive extra duty payments or extra units of medical time added to their salary. They were disadvantaged by many thousands of pounds. It is only comparatively recently that this has been corrected. But the inbuilt frustration, when one group within a profession feels at a disadvantage compared to another group, is always disturbing. Apart from the frustration this leads also to feelings of inadequacy and to a lowering of morale.

For instance, as already stated, the successful candidate for an academic appointment does not receive any significant removal expenses. This may seem to us a trivial point. But his National Health Service counterpart does receive expenses. Those who are at consultant level as senior lecturers in academic departments are at a considerable disadvantage compared to their NHS colleagues. They receive no payment for domiciliary consultation. Nor do they receive a mileage allowance for such visits. There is also confusion about the granting and financing of service leave. All of us, I believe, know that in-service training for all professions is nowadays essential.

By far the most financially disadvantageous part of being an academic senior lecturer consultant is his inability to retain fees from private practice. Most academic departments do not bar their consultants from undertaking private practice. But they expect to receive, if not all, at least the greater part of such fees for department funds. In all disciplines, but particularly surgery, this is a considerable financial disincentive to anyone taking up a senior lectureship at consultant level. What, however, has caused anxiety and great distress among all sections of clinical and academic staff has been the reluctance of the University Grants Committee to implement pay awards for clinical staff at the same time as this has taken place for their NHS colleagues. This has been especially felt during the past year.

In conclusion, clinical academic staff form an important part of our health care team. They are responsible for much of the clinical work, most of the research work and most of the teaching. It is unfair and, I believe, felt to be unfair that they should suffer financially. This financial disincentive has made recruitment of good-calibre candidates for the consultant ranks in academic staff difficult to achieve. In addition, such financial disincentive encourages, as we have already heard, many of our best potential candidates to seek appointments overseas, which in the long term will greatly impoverish the standard of medical and scientific research and academic excellence that has been built up over the years since the war.

6.40 p.m.

Lord Richardson

My Lords, as a doctor, I think I can claim to be particularly grateful to the noble Lord, Lord Prys-Davies, for putting down this Motion and particularly for the clear way in which he has asked questions. Already your Lordships have made clear the invaluable and essential services to medicine as a whole that are given by the academic staff of hospitals. Already I think it is possible to make a statement about the questions implied in the Motion. What is the state of academic medicine? It is near to desperation and the morale barometer is falling to hurricane levels. The effect on the NHS is a very present and increasing threat to efficiency and a certain threat in the future to standards. The reasons for that have already been clearly stressed: the threat to teaching and to research.

The noble Lord, Lord Flowers, the Vice-Chancellor of London University, deeply regrets that he is unable to be with your Lordships tonight. He has to fulfil his vice-chancellor duties at the university on an occasion that has been determined as to its date months ago. However, he has asked me if I would put to your Lordships the points that he himself would wish to make, and I have therefore been briefed by London University. But that does not mean that what I have to say applies only to London University. It applies to university hospitals and universities throughout the country.

About a year ago, London University found it necessary to write to the chairman of the education committee of the General Medical Council to say that the university considered the time had come when the attention of the Government should be drawn to the fact that, unless the process of apparently endless attrition in funding was halted, it would not be possible to maintain acceptable standards in medical education in this country. Coming from the university responsible for teaching over a quarter of our medical and dental students and embracing the largest and most comprehensive collection of medical academic institutions in this country, that was indeed a serious warning. That warning referred to finance. That point has already been clearly made.

However, there is another factor of great importance. It is the lack of co-ordination between the DES with the UGC, on the one hand, and, on the other, the DHSS and the NHS. The first has as its essential interest, and rightly, the concentration of resources on places of excellence and with persons who can achieve that excellence. However, the DHSS has a different objective, with which we can all have the greatest sympathy. It is concerned with dispersal of available funds on an egalitarian principle. That was shown most explicitly 10 years ago when the Resource Allocation Working Party made its report. That has been the cornerstone of the funding by the DHSS ever since.

RAWP—which is short for that mouthful regarding resource allocation—has as its principle the proper and fair distribution of resources throughout the country. I wish to make it quite clear that the noble Lord, Lord Flowers, and I are in no way against the principle; far from it. We are in favour of it. But it has now been carried to an extent that is extremely damaging. The RAWP principle has been introduced by the regions and applied sub-regionally. That is particularly damaging to academic medicine. It is right that NHS resources should be taken as near as possible to the patient, but the academic resources—with the large, complicated and expensive institution in which they have to be based—cannot be moved around to follow the resources. It is with the sub-regional RAWP deprivations of the medical schools where the great anxiety lies and the difficulties develop. It is essential that the university hospitals should be protected, and that has already been fully stressed.

The imbalance of the weighting against academic medicine will lead to the loss of new knowledge and poor training of doctors. The benefits from RAWP were designed to help the patient. But the results of sub-regional RAWP may well be serious curtailments of services to patients. The NHS staff are reduced in number and, as the numbers go down, the academic staff have to step in to look after the patients beyond the 60 per cent. of their time that is the average given by academic staff to NHS clinical work. The academic element therefore is squeezed on two sides. It is squeezed because the UGC can give it only a reduced amount of money. It is also squeezed because the NHS has to reduce its funding of staff and thus the academics have to take on clinical duties. Naturally what goes are teaching and research, the life blood of medicine.

That is already happening. The University of London and the Health Planning Consortium in 1979 to 1981 achieved a coherent plan for restructuring medical education in London and the health care delivery of it. Many of those plans are already being frustrated and others are in jeopardy. One example, the Bloomsbury Health Authority was specially formed in 1982 by taking bits off other authorities so that there could be a unified medical university education programme comprising the Middlesex Hospital and three post-graduate institutions, with University College Hospital. That is due to come to its final fruition next year.

However, the authority has already lost 332 beds since 1982, and has had a total manpower cut of 17 per cent., equivalent to 1,500 staff, between March 1983 and November 1985. That has already happened, but, furthermore, between 1984 and 1993 at least 86 consultants and 117 junior doctors will be lost. In a desperate attempt to balance the books, this newly formed authority, created to support and maximise that complex of hospitals, has lost 160 beds, equivalent to eight or nine wards. This sort of thing is happening not only in that region; it is happening throughout the whole of the London area and doubtless elsewhere in this country.

In August of this year St. Thomas's and Guy's Hospitals had to stop all cold, non-emergency admissions for a month, an incredible thought to anybody with my medical background. However, the Chancellor of the Exchequer in his Autumn Statement said that the four Thames regions would receive £30 million more to compensate for some of the RAWP effects, thus recognising the special difficulties created.

Can the noble Baroness assure us that those sums will, if not entirely, at any rate in large part, go to where RAWP has fallen most heavily, namely, on the centres of academic medicine? The delivery of academic medicine and its management are extremely complicated. It is no straight, simple matter. There are eight different types of organisation involved. The universities, the UGC, the DES, the NHS and the regulating councils, such as the GMC and the Dental Council, and the research organisations are all bodies which affect profoundly the influence and value of academic medicine. Surely a mechanism should be arranged by which their efforts can be properly coordinated and maximised.

The difficulties do not relate solely to academic medicine. There is trouble in the other direction, towards the NHS. For example, St. Bartholomew's Hospital has already lost six senior lecturer posts and one lecturer post. How about that for stimulating the morale of the skilled people produced in one of our great medical centres?

What we need is co-ordination as well as financial support. If those two requirements are fully recognised by the Government, it may be possible in a period that is not too oppressively long to re-establish what was for years in existence, the magnificence of the teaching hospitals of this country.

6.56 p.m.

Lord Hunter of Newington

My Lords, first may I add my congratulations to those expressed to the noble Lord, Lord Prys-Davies, for a quite magnificent introduction to this debate. I should like briefly to consider how long it took to create what is in danger of being destroyed. As has been said, at the end of World War II research in medicine had suffered substantially in this country because of the stresses and commitments of the war situation. The consequences were that we were substantially behind the United States in many respects.

What happened was that almost at the same time as the National Health Service was established the University Grants Committee earmarked money over a quinquennium for the first development of university academic, clinical departments. These departments are often "embedded" in the hospital, creating a unique opportunity for research and development, not only by the academic staff but through providing research facilities for the hospital clinical staff.

In today's jargon of definitions these departments are largely concerned with strategic research and not with basic research—although of course inevitably involved to some degree with research and development, R and D—and applying new knowledge to the medical situation. Their work is supported, as has been said, by the University Grants Committee and the National Health Service, and funds are available for specific programmes from the Medical Research Council as well as private foundations. In fact, they have a range of funds available to them which are not available to other disciplines.

A great deal had to be achieved during the first 20 years of this development to make the new situation possible and work well. By agreement, for example, the consultant full-time academic clinical staff were paid the same salaries as the hospital staff, and consultants became eligible for distinction awards paid entirely by the National Health Service. In the development of the new teaching hospitals, where the departments were "embedded", the question of capital costs had to be decided between two spending departments. This was done by the Pater formula. The UGC issued guidelines to universities about the sharing of recurrent costs, and the Department of Health gave guidelines, or instructions, to the health authorities.

After much discussion about two contracts it was agreed that there would be one contract for academic staff and one contract for hospital staff, though both taught students, undergraduate and post-graduate, and both did clinical work. As has been said, this was under the "knock-for-knock" principle. But of course there is a considerable grey area where each is doing similar work. Attempts at a division of costs—one of the wisest decisions I know—were abandoned. Obviously heating in the patient area is required 24 hours a day, whereas heating in the university department is required perhaps for 10 hours a day. Equipment might come from UGC funds or health authority funds. So at any one time a National Health Service consultant might be doing research work with equipment and facilties provided by the UGC, and on another occasion academic staff might be doing research work with equipment and facilties provided by the NHS.

This complicated situation developed over about 20 years, and then there was this glorious honeymoon period, if I may call it that, that we had in the 1970s, when it began to show more than promise; it showed results. What was created were departments vital to the future of British universities and medicine and vital to the future of the National Health Service. I was privileged to be the chairman of the committee concerned with academic clinical salaries from 1976 to 1981. There were no difficulties. Very often we were invited and given hospitality by the British Medical Association, but there were no difficulties during that period.

However, in 1981 the universities began to find it difficult to create the "well-founded" department with equipment and staff. This has been referred to. The Medical Research Council found it more difficult to meet all the first-class research proposals it received. It complained bitterly to the AVRC about this. The National Health Service, as we all know, was soon in difficulties as well.

During 1980–81 the deans agreed to approach the universities to preserve medical posts because of the contractual obligations and responsibilities which the universities felt towards the NHS, but at the end of the first year this, too, had to be abandoned. University non-medical staff, particularly in science and engineering, began to realise that there were substantial resources available to medical research which were not available to other disciplines. As I have mentioned, in addition to the Medical Research Council there were substantial funds for medical research—several hundred million pounds a year—available from the wealthy foundations.

In the last few years the UGC has become increasingly concerned with the effectiveness of the dual support system, and obviously they and the health departments are becoming increasingly concerned about the "knock-for-knock" principle. They have been unable to reach agreement about clinical salaries. Both realise that these difficulties will continue to grow as the level of government funding declines. One wonders sometimes, almost in desperation, whether the whole system should be dismantled and medical staff have two contracts.

In September 1984 the University Grants Committee gave the Secretary of State its advice on future developments in a document entitled The Strategy for Higher Education into the 1990s. It declared the UGC's intention to develop a more systematic and selective approach to allocating funds for research. This was university-wide, of course, but it applied to the medical faculty. The UGC strategy has been endorsed by the Government, and it is to be given effect in the allocation of recurrent grants up to 1990. The University Grants Committee now says that it will be considering resources separately under the headings of teaching, research and resources for special factors. It says that this is not the same as allocating one sum of money for teaching and another sum for research. But what does it mean? In fact, I believe that the non-payment of NHS clinical salaries to academic staff is only the tip of the iceberg as regards the difficulties, which will multiply unless something is done about this situation.

What one must ask the Minister is: How does this complicated new University Grants Committee's untried system fit in with the already complicated agreements between the Department of Education and Science and the Department of Health and Social Security about the funding of clinical departments! These arrangements were arrived at in the days of plenty. Can they be continued when we are not financially so well off? The complexity of this makes the mind boggle. One wonders, even in desperation, whether the report of the Croham Committee, which is looking at the future function and role of the University Grants Committee, will be able to contribute to this situation.

I think it would be almost impossible to examine this problem in detail and to allocate costs between the universities and the health authorities. I must confess one wonders whether in this grey area, which to the financial expert looks rather lax, there is not a great temptation to the new health service managers to get into it. I am sad to say that there is some evidence that they are doing so.

It is absolutely essential that if a new system is to be introduced because of shortage of resources that system must be understood and accepted by those who wish to make their careers in academic medicine. If this matter is not clarified there will be two consequences: one is that the good people will go to work somewhere else, and the other is that the National Health Service, on which all the people of this country depend, will falter and become less efficient in the future.

7.7 p.m.

Lord Congleton

My Lords, it is a pleasure to follow the two immensely distinguished medical Peers who have spoken this evening. I should like to commence by offering my thanks to the noble Lord, Lord Prys-Davies, for bring this matter forward. If I may, without seeming patronising or indeed impertinent, I congratulate him on the way he presented this debate.

It must be surprising to some of your Lordships that I should be standing here daring to offer a contribution on a matter with which I have had no connection at all. I am not a professional medical person, I am not qualified, I am not an academic nor am I a member of a health authority. Your Lordships may think it an impertinence that, with such credentials, or lack of them, I should stand here this evening to participate in this debate. However, I am assured by my family and those around me that I am frequently given to bouts of hypochondria, and I have had the benefit of the patient care which is available in the area in which I live, which falls within the Wessex Regional Health Authority's domain in the south of England.

Further than that, for the past three years my time has been greatly occupied in support of the medical faculty of the University of Southampton, trying to bring in resources to support the programmes of research that they undertake there. It seems to me that Southampton's case is peculiarly suitable to use as a model for the difficulties that have been described in this debate so far. Southampton University's medical faculty—we call it Wessex Medical School—came into being as a result of a joint application from the then Wessex Regional Hospital Board and the university itself to the Royal Commission on Medical Education. From its early beginnings it has always placed great importance on the regional aspect of its work in the three functions that it performs: teaching, research and patient care. There is this regional aspect in all that it does. That is thought to be important, and it is peculiar. There is no other regional health authority or medical school in that situation.

My work with the faculty as a layman has brought me closely into contact with the leaders of the faculty, the leaders of the university and the leaders of health authority. These are distinguished and dedicated people, not given to outbursts of hysteria. They are despondent; probably they are more than that. They are not despairing, but they are very despondent at the turn of events that is occurring with regard to academic medicine and the National Health Service.

I understand, even as a layman, that operationally academic medicine and the National Health Service arc inextricably bound together. The operation of the National Health Service is totally dependent on the supply of doctors from medical schools. Indeed, for the vast majority of young doctors the National Health Service is the only potential employer. The greater part of medical research is done by academic members of medical schools and teaching hospitals. I find it bizarre (and I think that other noble Lords who have spoken this evening have hinted that they, too, think it bizarre) that the funding for these two totally distinct agencies—the medical schools and the National Health Service—should come from different directions.

The extent and quality of the service given to the National Health Service by academic medicine apparently depends on factors largely out of the control of the National health Service. I want to go into that a little. It has already been mentioned by more than one noble Lord this evening. As I say, it is so bizarre that it is worthy of another mention.

The clinical academic medical people receive their salaries through the medium of the University Grants Committee's allocation to the university. My understanding is that, in certain universities, the block grant from the UGC is the subject of a debate in the senate. It is outside the control of the National Health Service, anyhow. When the UGC grant is diminished, as it has been (and this is fact) then there is an effect on the clinicians. It must be so. It will affect their work as teachers. It will affect their work as researchers and it will affect their work in the hospital when they are doing their patient care side of their tripartite existence.

Over all those things, the National Health Service apparently has no say at all. There are other difficulties in reverse, as it were. I ask the noble Baroness to please consider this matter. We have heard about the disparity of the funding and the difficulties that arise. Whether it is necessary to take the whole thing under the wing of one authority, I do not know. It could be so. It is not for me to suggest solutions here this evening. But a solution is needed somewhere and it will be for those who are closely involved and who really understand the problems, in concert with the Government, to come forward with solutions to these difficulties.

There have been reductions in the staffing in the medical teaching institutions. We know that; it is a fact. I think the noble Lord, Lord Prys-Davies, referred to it. Twenty per cent. in five years, I think, was the figure mentioned; and it continues.

This is giving rise to grave disquiet among the leaders of our medical teaching institutions and to the teaching hospitals and the regional health authorities. I have here a list of the reductions in staffing that have been made this year—agreed savings for 1986–87 in the Faculty of Medicine in Southampton. It is late and I shall not read it all to your Lordships. What I shall do, if I may, is quote from the concluding paragraph of the report, which supports the figures themselves. Presumably it is written by the dean.

It reads: It is clear that the measures now being taken will damage the ability of this relatively new Medical School to fulfil its role in training future doctors and nurses, undertaking research and providing an essential clinical service. Similar reductions for a further three years would make it impossible for the Faculty to meet its commitments. This would significantly reduce the clinical service to the public … severely limit important clinical research; and risk the loss of [official] approval for the medical and nursing training courses". It concludes: Such an outcome is unthinkable". These are serious words, grave words, about what is clearly a very serious situation.

I now turn very briefly to the situation with regard to clinical research, which really has been my main preoccupation in that, not being a medical person, I have been trying to find funds to support Southampton in its curious situation. When the National Health Service was set up, as I understand it a deal was struck between the state (that is, the National Health Service) on the one hand and the older medical teaching establishments whereby they were enabled to hang on to their reserves of wealth which quite properly and wisely they had husbanded over the years and in some cases centuries. There were endowments, and they were entitled to hang on to those to support the programmes of research that were carried on within their department.

Southampton Medical School was set up post-NHS, I think, in the late 1960s, and the first intake of undergraduates arrived in 1971. There were no endowments. It was quite simple: there were no endowments. The work that I and colleagues have been engaged on for the past three years—indeed, it has been going on for longer than that: for nearly 10 years now—is stimulating, exasperating, and every now and then rewarding. These research workers are dedicated, distinguished, splendid people in every way. We have to support them. I recognise the value of having a medical teaching institution in the area in which I live because I know (I see it around me) that the bringing forward of a medical school in Southampton has raised the standard of patient care, of health care, in the area. There is no doubt about that.

I know the value of having an institution there. I shall benefit, perhaps. I shall be better looked after and everybody around me will be better looked after. That is good news. The research situation with no endowments is particularly difficult. A noble Lord referred to the great grant-giving institutions with their great wealth that is available. Lead me to it! We find that there is intense competition for research grants. Applications are pouring in to the grant-giving foundations and trusts, to commerce and to industrial concerns all the time. I suppose I should not use the two words "savage" and "charity" in the same sentence. Let me say that the competition for these things is intense. It borders on savage at times and there is this difficulty in getting the money coming in.

When the noble Baroness replies, perhaps she can take away with her the thought of the generosity that Southampton Medical School has received at the hands of the Channel Islands. The states of Jersey and Guernsey, in recognition of what they see as a debt they owe to the general hospital in Southampton, two years ago made gifts totalling a quarter of a million pounds purely for research purposes. This was over and above any reciprocal arrangement there may be with the NHS over here and their own arrangement in the Channel Islands. We are deeply grateful to them.

Could the Government perhaps follow suit in some way? It is not all about money but it is mostly about money. Many of us have touched on the questions of reorganisation and the difficulties of funding, having one department involved with the University Grants Committee and another department involved with the NHS, and so on. That is reorganisation and it does not really mean money in the sense that I think we all know that other things mean money. I shall go on supporting the medical faculty in Southampton, not for purely selfish purposes. They are splendid people, and they deserve to be encouraged, enthused and kept going in every possible way.

It is very difficult for enthusiasm, vigour and dedication to flourish in an unfavourable environment, is it not? What happens? Sometimes it withers. The stronger spirits, I suspect, say "Enough is enough" and they take away their dedication, their enthusiasm and their great skills and they set up shop somewhere else. We must see to it that there is not a prolonged brain drain—I think that is the expression—and we really must try to keep these people in this country.

Lord Annan

My Lords, before the noble Lord sits down, would he agree that the essential difference between a medical school such as Southampton, in the provinces, and the London medical schools is that the medical school in Southampton is gravely hampered by the cuts which have been imposed by the University Grants Committee but that a medical school in London is hampered not only by those cuts but also by the process of the resources allocation working party, which made recommendations (carried out by the Government) to transfer funds from London to the provinces? Therefore in London the medical schools get a double cut: they are RAWP-ed by one hand of the Government and raped by the other hand of the Government.

Lord Congleton

My Lords, I cannot answer the noble Lord's question. I know only what goes on in Southampton and it would be quite wrong and indeed stupid for me to comment on what goes on elsewhere. I am sorry, but I cannot help him.

7.21 p.m.

Lord Hooson

My Lords, like the noble Lord, Lord Congleton, I have no academic or medical qualification justifying my taking part in this debate and, unlike him, I have no close connection with a university teaching hospital or a university with such a hospital attached to it. However, I do not think I need any such justification to take part in this debate. The noble Lord, Lord Prys-Davies, is not only to be congratulated on drawing the attention of the House to this very important matter but also, through this debate, alerting the public—as it were, the potential patients of the national Health Service—who are eventually going to suffer from the crisis that is obviously affecting the medical schools at the present time.

The crisis is put starkly in the briefing notes which emanated from the Committee of Vice-Chancellors and Principals: In the 1950s and 1960s the university lectureship was keenly sought after as a stepping stone to the most desirable senior positions in British medicine. This is no longer so: now there are 'fewer than half the candidates for the average lectureship or senior lectureship in university medicine, compared with the corresponding Health Service post'.". It seems to me that that puts forward not only the symptom but the effect of the crisis in university medicine at the moment. Of course the loss of attraction of academic medical life (because that is what it amounts to) carries for every sensible person an eventual cost which the whole country will pay. That is why it is so important to analyse why this is happening. First, there has been the redistribution of real resources, whereby money that normally would have gone to university teaching hospitals has been transferred to district hospitals by the National Health Service itself.

Reference has been made to the gradual breakdown of the flexible "knock for knock" arrangements as financial stringency has obliged the National Health Service authorities to look more to their own. Then, of course, within the universities we have had the cutting down of university grants—and again I quote from the notes of the vice-chancellors' committee— By the end of the decade universities will have experienced a real decline in their income of 20 per cent. since 1980—and more likely to be around 30 per cent. In these circumstances it is not possible for universities to go on giving their medical schools special protection.". I have no doubt they seek to do that, just as they seek to do it in the University of Southampton. We do not have to enter into the debate as to whether the provincial teaching hospitals or the London teaching hospitals are suffering the most. They are all suffering. Surely we are not here to decide where the loss falls heaviest, but to decide on what is to be done about the crisis.

If I may move to a second reason, and a very important reason, it is the Government's own attitude. They have given the impression—and I think it correctly represents their attitude—that they only back applied research as against pure research. The profit motive—that alleged means by which even people in medical research are said to be able to earn their own living—has become dominant. And there is a price to pay for all this. There has been an increasing lack of basic and original research, in which our country had formerly been pre-eminent. There is an increasing tendency, I am told, no doubt under Government strictures and constraints, to concentrate on proven and accepted fields of research. But we are in danger of being left behind as pioneers in medical research, for which this country had a very great reputation. In the ultimate—and this is the important thing which has to be spelt out for the public at large, the eventual patients of the National Health Service—the National Health Service doctor depends on the high academic discipline of the teaching hospitals.

There has been a general failure to recognise that without the highest output always coming from our teaching hospitals, the National Health Service would rapidly deteriorate. Innovation is surely constantly necessary in the field of research, and the contribution made by medical research percolates down to the National Health Service as a whole. I have no doubt whatever that if you are in an area where there is a teaching hospital the benefits of that hospital percolate down very quickly to the surrounding area. I would not have thought there could be any doubt at all about that.

The trend can be seen in the greater difficulty now of recruiting staff to teaching posts. The quotation with which I began my speech referred to fairly senior posts, but of course there is also a gradual decline because there is less pay and the rewards of prestige and the opportunities for research are less attractive and so they do not make up for the lack of pay.

One of the consequences of under-funding of university hospitals, it seems to me, is that they have to look around for means of earning money. They run courses for students and doctors from developing countries in order to benefit from the fees that are paid. No doubt there is much to be said for that, but again we pay for it in different ways. Medical staff have to spend time teaching and they are left with less time for research, because they are persuaded by the constraints to look for means of earning money, as very many other disciplines in the universities are doing at present. And of course we pay for this. There is perhaps a gradual lowering of academic standards.

Then there is the Government policy towards the payment of fees by overseas students, which has also led to considerable changes. I was given figures recently which showed that many of the brightest medical students from Malaysia, who a decade ago would have come to this country, now go to Australia and the United States for their training; whereas the United Kingdom used to be the most important centre of training for them. This tendency, I believe, is reflected in other Commonwealth countries. I think the eventual result for this country is fairly obvious for all to see.

In order to appreciate the changes which have taken place in medicine, it is quite significant to look at the plight of the pre-clinical teachers. I am told that these days they rarely have a medical degree because their rate of pay is gauged not by reference to the pay levels of NHS consultants or anything like that, but by the pay levels of academic teachers generally, such as the teachers of history, English and so on. The result is that it is increasingly difficult to recruit qualified medicos for this work.

All in all, it is quite obvious to a layman like myself that there is a real crisis building up within the teaching hospitals, and if it is not resolved quickly and properly it could have a devastating effect long-term, not only on the National Health Service but on medical standards generally in this country. I have two simple layman's questions to put to the Minister who will be replying. First, does she accept that there is a crisis? Secondly, what do the Government intend to do about it?

7.30 p.m.

Lord Pitt of Hampstead

My Lords, I, too, must congratulate and thank my noble friend Lord Prys-Davies, for introducing this debate, and also for the way in which he introduced it. For my part, I want to concentrate on the role of the clinical academic staff and the important contributions they make to the universities and the NHS. I must first explain that when I talk about clinical academic staff, I actually mean medical staff, although, of course, the term refers to dentists as well. But I shall say something about the dentists later on.

In 1968, the National Board for Prices and Incomes established the principle that, since university and NHS jobs are interchangeable, it follows that the salaries of medically qualified university clinical teachers must he linked to, and move simultaneously with, the salaries of full-time hospital doctors and dentists". In this debate we are not just talking about the salaries of clinical academic staff, but, as this quote illustrates, the recognition of the interchangeability of the work of doctors who are in the NHS and those who are within university departments.

The role of these university doctors is often misunderstood, though not by the speakers who have spoken so far tonight. Clinical academic staff are employed by the universities and not the National Health Service. They are employed to teach undergraduate medical students in their clinical years and to undertake research. Nineteen universities have medical schools, 13 of which also have dental schools. However, unlike their non-clinical university academic colleagues, university doctors also have, at no cost to the NHS, a continuing commitment to provide National Health Service clinical care.

As we have heard from my noble friend Lord Prys-Davies, there has been a reduction in the number of clinical teachers, but as the whole of the curriculum has to be taught to the students to meet the General Medical Council's requirements, we are all concerned that the standard of teaching may deteriorate since the staff-to-student ratio has decreased alarmingly. The number of medical student entrants to universities is set by the Department of Health and Social Security and remains constant until changed by the department. Therefore, we have the same number of students being taught by fewer staff. Students, as we have been told before by my noble friend Lord Prys-Davies, need to be motivated for a lifetime of continuing self-education fit for practising medicine well into the next century. It follows, therefore, that those who teach them must be among the most able in the profession. If they are not, the outlook for the standards of medical education and for future medical care must be bleak.

The principle that clinical teaching must go hand in hand with the assumption of clinical responsibility has led to a close relationship between medical teaching and the NHS. In addition to carrying out treatment necessary for training students, clinical teachers with their specialised training and experience provide treatment for patients and consultant services quite outside their teaching responsibilities, and perform administrative duties in connection with the running of the hospital as well as the school. As a consequence, whole-time university staff play a major role in running hospitals as part of the National Health Service, and it must be emphasised that these services continue throughout the university vacations. In fact, clinical academic staff are contracted to work 60 per cent. of their time in treating patients, not in hospitals countrywide, but in the teaching districts which serve the large teaching hospitals. So any statement as to the percentage of service given by those must be based on those districts.

The Government estimate that clinical staff provide 5 per cent. of hospital care, but this varies from one area to the other, and from one subject to the other. In some districts and some specialties, it can be as much as 40 per cent. The National Association of Health Authorities estimate that in areas with teaching hospitals and in special health authorities the average percentage is more likely to be 25 to 30 per cent. For example, neuro-surgery and pathology services at the London Hospital in Whitechapel are carried out solely by academics, and all the units at Hammersmith Hospital are headed by either university or Medical Research Council staff. This shows the extent of the contribution they make to the National Health Service. It follows, therefore, that any reduction in numbers of clinical staff can cause major problems in the delivery of patient care.

NHS doctors do substantial amounts of undergraduate teaching under the "knock for knock" system, which we have spoken of earlier in the debate, but as we have heard this "knock for knock" system is now under threat. There is evidence that both the universities and the NHS, in their separate ways, are beginning to look at it and to look from their side of it. There is a danger that what has worked very well, as the noble Lord, Lord Hunter, pointed out, over these years, might now be under serious threat.

I want to move to another area. I have referred to the fact that one of the important roles of clinical academic staff is to undertake research; they do it like all university teachers undertake research. The University Grants Committee provides the funds for the research base—that is, the cost of overheads and well-founded laboratories—whereas the Medical Research Council will provide grants for projects and, in some university departments, research staff and entire units.

Less money is forthcoming from both these sources, because not only are the universities having their grants reduced, but the MRC is also having its grant reduced. The researchers are having to spend more time looking towards the voluntary organisations for funding. Of course, they do not all have the help of people like the noble Lord, Lord Congleton. Many of them have to do it themselves. This may well be right for projects involving diseases which attract publicity, such as cancer and heart disease, but in areas such as mental illness and in what is commonly known as long-term basic research there is not the same interest. Because of reductions in the number of clinical academic staff over the years, those remaining have to spend more of their time in teaching and in providing NHS services. Inevitably it is research that will suffer.

All this serves to make entry into clinical academic medicine less attractive to doctors. Medical graduates are increasingly turning away from teaching hospital medicine to non-teaching medicine, either in hospital or in general practice. We must recognise what that means. It means that the seed corn is being lost, and it will have an effect on future generations.

Unlike many other university teachers, clinical academic staff have a 24-hour commitment to their patients. They have to be available for emergencies and for night and weekend cover. Many doctors feel they may just as well work for the NHS on a full-time basis, which is in any case better paid.

I am sure that your Lordships appreciate that clinical academic staff have an important role in the education of our future doctors, as well as their continuing contribution to the National Health Service. They train the new doctors; they carry out research; at the same time they treat patients under the National Health Service. However, in all three fields they are at present adversely affected. The University Grants Committee is pressed for funds, and therefore reduces its grants. The Medical Research Council is also pressed for funds, and it also has similar difficulties in making the appropriate grants for research.

We then have the closing of wards, and it seems that no one realises that when wards are closed it affects not only medical treatment for the less urgent cases but also affects medical teaching. There are fewer patients available for students to be taught on, and they are affected in that way as well. The final straw is the difficulty such staff experience in obtaining salary increases which they are awarded along with NHS staff and which universities have difficulty in paying because of the failure of the Government to provide funds. The prospect of an increasing gulf between National Health Service salaries and academic salaries is not an encouragement to enter the academic side of the profession.

Perhaps I may quote from an article in The Lancet of May 1986. This article was mentioned by one of the other speakers in this debate, but I should like to quote again from it. it says: The most able young clinicians will not go into academic medicine if broad comparability of remuneration is not maintained with their NHS counterparts". We already have evidence regarding this matter. In the 1950s and 1960s university lectureships were keenly sought after as a stepping stone to the most desirable senior positions in British medicine. This is no longer so. There are now fewer than half the candidates for the average lectureship or senior lectureship in university medicine compared with corresponding National Health Service positions.

Perhaps I may say a few words about general practice in medical schools. In this field Edinburgh University was in the van, as it so often is. The first department of general practice was established in Edinburgh University in 1957. Now most medical schools have at least one general practitioner appointed to a university post with responsibility for teaching the discipline and undertaking research. Here, too, we find financial difficulties. Some university departments in general practice have sole responsibility for running an NHS practice. Other departments have linked practices in that academic clinical staff undertake clinical work in NHS practices principally staffed by service general practitioners. Funding has always been a problem as there has been no precedent for the financing of general practice departments within universities.

Departments of general practice are funded through the UGC or charitable trusts, or by local arrangements with family practitioner committees to maximise levels of reimbursement for patient care. The NHS contributes a service investment for teaching to cover the additional cost of teaching medical students in clinical academic departments based in teaching hospitals. However, there is no equivalent NHS support system available for undergraduate general practice teaching. I gather that negotiations have been going on for six years to get that particular question settled. It seems that it will be done only if there is some initiative on the part of the Minister. I hope that when the Minister replies she will tell me that her right honourable friend is taking this point on board.

At the beginning of my speech I pointed out that the term "clinical academic staff" refers to dentists as well as to medical staff. Although many of the considerations for medicine apply equally to dentistry, there are important differences. Many of these differences centre on the fact that there is no equivalent of the district general hospital and there is no dental hospital which does not have associated with it a dental school. Consequently the clinical academic service is relatively much larger than the medical equivalent when compared to the dental and medical hospital services respectively.

In other words, there are relatively more medical academics per patient than in the case of medical schools. The NHS therefore relies more heavily on clinical academic staff in dentistry than it does in medicine. The reason is that there is much less support for dental schools than for medical schools, and that academic dentistry provides clinical services not available elsewhere in the National Health Service. There is a high teaching load on dental clinical academics, especially those supervising undergraduates. When they qualify, dentists must have done things under supervision, and that means that the dental academic has to supervise students far more than is the case with medical students.

It will therefore be seen that there is a stress in academic medicine that applies equally to academic dentistry. This stress is largely the result of Government policy. I am not suggesting that it is a deliberate consequence which the Government intended: it is a consequence of the fact that the Government have not given proper thought to the policy. What I hope we shall get as a result of this debate is a more serious consideration of these issues in the framing of policy. For example, the Government are at this moment looking at RAWP. In doing so I hope they will take into account not only the conditions of the population in various areas, which is one of the factors we have always asked them to take into account, but also the importance to medical teaching of sufficient patients being available for the students to be taught on and a sufficient allocation of resources to the medical schools so that basic research can be carried out.

I shall be listening with great interest to the reply from the Minister, and in particular to her replies to the various questions that have been put to her by the noble Lords, Lord Prys-Davies, Lord Richardson and others.

7.51 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Baroness Trumpington)

My Lords, to listen to the noble Lord, Lord Prys-Davies, and indeed to other noble Lords, one might be tempted to think that all around us is doom and gloom. Not so, my Lords. Indeed to pick up the challenge of the noble Lord, Lord Hooson, I do not accept that the situation is one of crisis. What the debate has demonstrated is the importance, among other things, of maintaining and enhancing the partnership between academic medicine and the National Health Service.

As noble Lords have said, the medical schools are training the men and women who will take our health service into the next century, adapting to rapid advances in medical science and to changing approaches towards patient care. But more than that, clinical academics make an important contribution to services to patients in our teaching districts; and our medical schools have played an essential part in bringing about and carrying through advances in medical science and treatment methods. Before I go on, along with the right reverend Prelate the Bishop of Hereford and other noble Lords, I should like to pay tribute to those men and women involved in academic medicine and to say how much the Government value their contribution to the future well-being of this country.

Turning to the NHS side of the partnership, this also plays its part. Many NHS consultants and staff in teaching districts play an important role in teaching and supervising students. Moreover, my right honourable friend the Secretary of State for Social Services carries out to the full the obligation placed on him by Section 51 of the National Health Service Act 1977 to provide the clinical facilities required by medical schools for teaching and research. The right reverend Prelate the Bishop of Hereford referred to the strains in the knock-for-knock arrangements, and he mentioned this partnership. It is unique to higher education and brings enormous benefit to patient services and to education. The Government are committed to its maintenance.

The noble Lords, Lord Hunter, Lord Hooson and Lord Pitt, asked how complex UGC grants policy can be fitted in with complex NHS funding policies, and the noble Lord, Lord Hunter, and other noble Lords referred to the Croham Committee. I welcome the acceptance of the noble Lord, Lord Hunter, that the knock-for-knock arrangements for funding cannot sensibly be disbanded. But given the two sources of funding, NHS and UGC, there is a clear need for coordination at all levels. The DHSS, the DES and the UGC are developing closer contacts in this field and the health departments have assessors on the UGC medical sub-committee. The Government will of course give careful consideration to the findings of the Croham Committee, which is examining the future role and funding of the UGC.

Much has been said during the debate about the financial problems being faced by the medical schools. I am well aware from meetings I have had as far apart as Manchester, Gloucester and Southampton that a great deal of worry is being felt by doctors, the General Medical Council, the National Association of Health Authorities and others as a result of constraints on university funding. The noble Lord, Lord Congleton, is far too modest. I have had the great good fortune to see some of the fruits of his work during my visit to Southampton and I gladly endorse his remarks about the generosity of the Channel Islands.

As your Lordships will be aware, my right honourable friend the Secretary of State for Education and Science has now agreed with the University Grants Committee and the Committee of Vice-Chancellors and Principals on a major programme of work towards greater efficiency and effectiveness in the university sector. On this basis the noble Lords, Lord Prys-Davies and Lord Richardson, will wish to note that my right honourable friend announced on 6th November an increase in cash terms of £95 million (or 7.2 per cent.) in recurrent grant to the universities for the financial year 1987–88 compared with 1986–87. For later years, future grant levels will depend on the progress made on this programme.

The medical schools can expect to benefit from this substantial extra money, but they will equally be expected to contribute their share to the continuing search for greater efficiency and effectiveness. My right honourable friend the Secretary of State for Education and Science asked the UGC to give careful consideration to the level of funding it provides for medical education and the guidance it gives to universities in the light of the concern that has been expressed.

In answer to a point raised by the noble Lord, Lord Hunter, the UGC's new system for allocating funds to universities which the noble Lord mentioned is a laudable attempt to distribute the large amounts of public money concerned in a more rational and systematic way. That can be only to the benefit of the university system as a whole and to the medical schools within it.

The noble Lord, Lord Prys-Davies, was good enough to give me advance notice of some of the points which he was going to raise in this debate. I am most grateful to him. I have dealt with the first. Turning to his second point—the need for special arrangements to maintain teaching hospitals—the Government recognise that those districts which sustain teaching and associated hospitals incur extra costs in providing clinical facilities in support of medical education. To ensure that those are met without jeopardising services to patients, regions receive a special allowance, the service increment for teaching, known as SIFT. This allowance, which is calculated on a per student basis, has been continually uprated during the lifetime of this Government in line with inflation. For the financial year 1986–87, the Government have earmarked £274 million for that purpose. In addition, there are arrangements for giving considerable central support—up to 35 per cent. of the total cost—to new hospital developments associated with medical schools.

As noble Lords will be aware, the Government are committed to a policy of equal access to patient services across the country. That means that some regions and some districts, including some teaching districts, formerly with above average provision have had cuts in the rate of growth of resources. It was in order to ease such regions and districts over the resulting difficulties that my right honourable friend the Secretary of State for Social Services announced on 6th November a special fund of £30 million available over the next two years. Again, in reply to the noble Lord, Lord Richardson, this fund over the next two years will go to those regional authorities with less than national average growth in health service expenditure. Teaching hospitals, like other services, should benefit from this and it should help reduce the incidence of the very problems to which the noble Lord, Lord Prys-Davies, referred; namely, bed and ward closures.

Before turning to the third point of the noble Lord, Lord Prys-Davies, about research, I fear I must disagree with the right reverend Prelate the Bishop of Hereford, who I think implied that the Government only paid lip service to research. My right honourable friend the Secretary of State for Education and Science announced on 6th November an extra £24 million for the science budget, from which the Medical Research Council may benefit. Earlier reduction in MRC grants to medical schools have been partly offset by provision of extra science budget money for the council this year and next. As for the research areas mentioned by noble Lords, popularity does not influence the allocation of MRC funds. Quality of research proposals and scientific tractability are the determining factors.

One area where more research is being done is Alzehimet's disease. About a quarter of a million people suffer from this mental illness, which affects one person in 20 aged over 65 and as many as one person in four in their eighties. On the application of clinical genetics, the MRC is planning a new centre of molecular medicine at Oxford which will work in this very important area.

The noble Lords, Lord Prys-Davies, Lord Congleton and Lord Kilmarnock, asked whether the UGC will be given additional grant to pay for the higher salaries of clinical academics. Presumably they had in mind the higher cost of applying to clinical academics the DDRB awards for NHS hospital doctors. The Government have accepted that clinical academics' pay should in principle be linked to NHS doctors' pay. The additional money being provided for universities next year will help to ease the general pressure.

More specifically, the Government have agreed to compensate the universities for the extra cost involved for the current year in compensating universities with medical schools for the difference between the clinical and non-clinical pay awards. My right honourable friend the Secretary of State for Education and Science met the Committee of Vice-Chancellors and Principals recently and explained the government position fully. In the light of that, the clinical academic staff salaries committee has now agreed to apply to clinical academics the DDRB settlement for the current year.

The delay this year, referred to by the right reverend Prelate the Bishop of Hereford, is not the fault of the Government. We made it clear that the universities would be compensated as soon as the non-clinical pay settlement was concluded and the cost of the difference could be calculated. The non-clinical settlement has still not been concluded.

Turning to other points raised by your Lordships, the noble Lord, Lord Prys-Davies, asked whether the Government intend to maintain the medical school students' intake. Decisions on the level of the medical school intake are taken in the light of regular reviews of future needs for medical manpower. The most recent review, that of the First Advisory Committee on Medical Manpower Planning, was published in March 1985. The decision was made at that time to maintain the previous level of intake.

A second advisory committee has been established under the auspices of the health departments. The medical profession and the interests of academic medicine are represented. The committee is expected to report to Ministers in about a year's time and we shall need to consider its conclusions before any decision on this matter is made.

The point raised by the noble Lord, Lord Kilmarnock, about DES-DHSS liaison is answered by my agreeing that close liaison between those two departments is essential when medical education depends for its funding on the combined policies of the DES on the universities and the DHSS on the NHS. Co-ordination machinery between the departments has always existed and is currently being strengthened.

Lord Kilmarnock

My Lords, may I ask the Minister whether she will pass on my suggestion that academic funds and SIFT funds should be canalised through a new co-ordinating committee? I have thrown that in perhaps rather late in the day, but I wonder whether she would bring it to the attention of her right honourable friend.

Baroness Trumpington

My Lords, I certainly shall bring that suggestion to the attention of my right honourable friend.

To continue, co-ordinating machinery between the departments has always existed and is currently being strengthened, and the health departments also have direct contact with the UGC through assessorship of its medical sub-committee. The point about earmarking UGC funds—although I shall still bring the main point to the attention of my right honourable friend—is that the Government are encouraging universities to be more efficient in the management of their affairs. This would not be helped by a policy that would greatly reduce their financial flexibility. Medical schools account for between one-fifth and one-third of departmental expenditure by their parent universities. As I said earlier, my right honourable friend the Secretary of State for Education and Science has asked the UGC to give careful consideration to the level of funding provided for medical education.

In the course of this debate the noble Lord, Lord Prys-Davies, expressed concern about the effect of the reduction in clinical academic staff on services to patients. I should like to put that in true perspective, if I may. There has certainly been an overall decline in recent years in the number of clinical academic staff wholly funded by the universities. I acknowledge that the effects of this are particularly grave for the medical schools because of the high turnover of staff, the need to cover a full curriculum and the requirements of patient care. Evidence of problems with recruitment are also a cause for concern.

Alongside this, however, I must point out that there has been a considerable increase in clinical academic staff funded from other sources. Between 1981 and 1985 the total number of full-time academic staff in the university medical schools increased by 2.5 per cent. Within that period the total number of full-time clinical academic staff increased by 7.5 per cent. We must therefore keep the reports of staff reductions in perspective.

Moreover, expenditure on hospital and community health services has risen since 1978–79 by 21 per cent. in real terms. Figures such as these reflect the extent of this Government's commitment to the health service. They show that any reduction in the numbers of university-funded clinical academic staff have not prevented a significant overall increase in the level of provision of NHS services.

In my travels I have had the rewarding experience of seeing incredible new techniques and discoveries. I have met brilliant men involved in teaching others. As I have said, I am well aware of their concerns. We welcome the responsible way in which representatives of the professions, of the health authorities and of the universities have sought to draw attention to their anxieties. We do listen and we have taken careful note of the GMC's warnings about standards. I repeat that there is no crisis, but the situation does mean that co-operation and good management are vital ingredients which will ensure that high levels of patient care and academic medicine are maintained and enhanced. We have a world-wide reputation for the finest doctors and the finest patient care. We are dedicated to upholding those standards of excellence.

Earl Jellicoe

My Lords, before my noble friend finally resumes her seat after a very able and persuasive answer, may I put one question to her? She referred to the increase—the very welcome increase—in funding that was recently announced for the research councils. I think it is £24 million. In so far as the Medical Research Council will be the beneficiary of that, as chairman of the council I am very grateful. It will be a small beneficiary.

However, does my noble friend agree that by far the larger amount of that increased funding—I think the figure is £80 million but I am open to correction—will go to cover the extra commitment of the Science and Education Research Council to take account of the increased money which it will have to make available to cover its subscription to international organisations such as CERN resulting from the fall in the exchange rate of the pound?

Baroness Trumpington

My Lords, I think I should prefer to write to my noble friend in answer to his question. I found what he had to say a little confusing. I would rather he did not repeat or try to clarify his question now. I shall write to him.

Earl Jellicoe

My Lords, I think I can assure my noble friend that my facts are correct.

8.13 p.m.

Lord Prys-Davies

My Lords, I thank your Lordships for the debate and I am most grateful to all noble Lords who have taken part in it. Their contributions and analyses have sometimes been based on immense knowledge and experience of the teaching hospitals. On other occasions they have been based on experience and understanding of the role of the medical schools in our community.

I hope and trust that the teachers of medicine will derive some comfort from the debate. It is at least evidence of a concern in your Lordships' House about their conditions and terms of service. I also agree with the noble Lord, Lord Hooson, that the debate will, it is to be hoped, alert members of the general public to the difficulties in which the medical schools find themselves and to the fact that the schools should not be taken for granted.

I regret that I did not find the Minister's replies reassuring. We shall read and study her speech with care. However, it is my impression that her response has not been satisfactory because there is no indication from the Government that they are prepared to direct new finances on the scale that is required to strengthen and revive academic medicine.

However, I am indeed grateful to your Lordships for your contributions to the debate, and I beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.