§ 3.11 p.m.
§ Lord Nelson of Stafford rose to move, That this House takes note of the report of the Select Committee on Science and Technology on Priorities in Medical Research (3rd Report, 1987–88, HL Paper 54).
§ The noble Lord said: My Lords, I move this Motion as chairman of the sub-committee of the Select Committee on Science and Technology which was asked to conduct the inquiry into priorities in medical research, as particularly related to the needs of the National Health Service. This report comes forward at an opportune time when the Government are looking into the question of the operation of the National Health Service.
§ The examination we have made of this specialised but very important part of the health service should, I think, be helpful to the Government on the broader issues to which they are addressing themselves. We in the committee trust that our recommendations will be taken fully into consideration in the review and in the Government's subsequent decisions.
§ The inquiry was a very full one, as is well justified by the importance of the subject. The evidence put 274 before us was quite outstanding and covered a very wide range of interests within the medical world. I should like to pay tribute to the assistance given to us by our professional advisers, Professor Sir John Butterfield, who, we are delighted to see, was created a life peer in the Birthday Honours and Professor Walter Holland. They were indefatigable in support of our work. I must tell noble Lords that their knowledge and contacts within the medical world were invaluable to us. I have much pleasure in putting our grateful thanks to them on the record.
§ I wish to make special mention of the excellent visit we made to the main centres of medical research in the United States of America. An account of the visit appears in Appendix 5 of the report; it is well worth reading. We were particularly well received by our American hosts and given much useful help and advice in answer to the many questions we put to them. Professor Holland's excellent contacts in the United States, which were made readily available to us, proved extremely helpful in making our visit really worthwhile.
§ During our inquiry we were much impressed by the quality of the evidence put to us and by the dedication and high professional standards of the witnesses whom we had the opportunity to interview. However, the members of the committee were both depressed and deeply disturbed at the low morale and the feeling of despondency which clearly existed within the medical research community. That these conditions should be widespread in such an important sector of our National Health Service must be a matter of concern to your Lordships. The unfavourable view of UK medical research currently circulating in United States medical circles reflects this state of affairs and is referred to in paragraphs 39 to 42 of Appendix 5.
§ I believe it goes without saying that inadequate funding plays an important part in creating this atmosphere, as I am sure the Government are well aware. But there are other reasons, spelled out in the report in considerable detail because we particularly directed our attention to them. We believe that our recommendations, if adopted, could go a long way to bring about a major improvement in the current unsatisfactory and unhappy state of affairs without substantial additional expenditure.
§ As your Lordships will appreciate, priorities in medical research as related to the needs of the National Health Service are a very wide-ranging subject. Priorities related to what? Priorities between proposals submitteed by researchers? Priorities within available funds? Priorities among established health service needs? What are the health service needs and how are the priorities determined? We addressed ourselves to just these questions. Your Lordships will not be surprised that we found no precise answers. Indeed, we received no clear impression that any formal mechanism existed to establish such answers.
§ We were favourably impressed with the system operated by the Medical Research Council, the manner in which the council determines the science-led research programme and also how it establishes priorities between the many proposals put to it within the clearly inadequate funding available.275
§ Also within available funds, your committee found satisfactory and effective the working of the two dual support systems, operated on the One hand by the research councils and the UGC and on the other hand by the Department of Education and Science and the health departments. However all of us in your Lordships' Committee sensed that within the National Health Service itself there was a lack of involvement in research. We felt strongly the need to balance the Medical Research Council's science-led programme with a more dynamic, forceful and more clearly defined National Health Service need-led programme.
§ It was impressed upon us that there was a crucial missing link between the National Health Service and its needs on the one hand and the science-led academic research programmes on the other. We were also surprised that within the National Health Service—the largest organisation in this country with over 1 million employees, a third of whom are nurses—there was not a more substantial capability in the fields of public health research and operational research. It seemed to us that both these areas of investigation could make a major and important contribution to the efficiency and effectiveness of the service. We felt that a majority of these would prove to be self-financing, from the savings that could be made.
§ There were a number of other weaknesses detailed in the report. In opening this debate I shall refer briefly to three. First, we were concerned that clinical research in the teaching hospitals was being badly interrupted by the pressures of patient care arising from understaffing in the wards. It was clear to us that, as in the United States, some mechanism should be introduced to protect the clinical research workers from such pressures. Without this research programmes are delayed, research workers themselves become frustrated, and potential benefits to the health of the nation from past research work are postponed or do not materialise at all.
§ Secondly, it was impressed upon us that there was no clear or attractive career structure for research workers, either medical or scientific. There was a lack of consistency between the grades in the National Health Service and in the medical schools. There was difficulty in moving from one area to another—into research, out of research or hack again. There was no career incentive to those who undertook research. They received no apparent advantages from it for the time that they spent on it. All these factors seemed to us to be seriously affecting the important recruitment of the high grade and quality of medical and scientific research staff required for effective work.
§ Thirdly, the Committee was impressed by the important linkage between academic teaching and research as encouraged by the dual support system. However, we were concerned that this continuing low morale among research workers would inevitably affect teaching standards. The maintenance of such standards is essential to the recruitment, training and retention of the best medical and scientific staff for the future. Without such people standards within the health service must inevitably decline in the years to come.276
§ To ensure that these and other problems mentioned in the report receive adequate and continuous attention we have recommended the creation within the National Health Service of a national health research authority. That would not be another quango, but a body with a task to undertake. It would be a means by which, within the National Health Service, these problems are identified and actions are initiated where appropriate to ensure medical research is safeguarded within the service and is adequate for the needs of that service.
§ The role for this authority is spelt out in our report. It fills a gap in the administration of the National Health Service which clearly exists at the present time. Its function is not to control research but to ensure that research has its rightful place within the National Health Service, that its importance is understood at all levels within that service, and that its results are fully exploited in the interests of patient care.
§ Inevitably in such a complex field as this, a number of other recommendations arose from the inquiry. I shall particularly mention two at the present time. With the cry for more money for medical research echoing in our ears we only made one specific recommendation because these cries are often justified and speak for themselves. We made a direct recommendation for an additional £25 million of expenditure per annum for three years to be made available for the purchase and installation of new equipment. In this age of high technology effective research can only be achieved if the equipment available is adequate for the task. Without this the best people are either less effective than they should be or they go where the equipment is—inevitably that is so often overseas.
§ We believe that an early decision on such expenditure is justified by the importance of the research work and its effect on that research work. Further, such a decision would go a long way to convince doubters that the Government appreciate the value of high quality research work and that the National Health Service itself understands the contribution that it can make to a healthy national health service.
§ The other point I make is to draw your Lordships' attention to the importance to the country's medical research effort of the funding provided for medical research by the medical research charities and the pharmaceutical industry. In the year 1987–88 it is estimated that the charities will provide research funding amounting to £120 million and the pharmaceutical industry will provide funding to the level of £620 million. To put this in its context, it compares with funding from the MRC of £148 million, from the UGC of £150 million and from the DHSS itself of £18 million. These sources of private sector funds make an enormous contribution to the national medical research effort and they must be carefully husbanded. We made recommendations to ensure that the prevailing conditions are such as to give them every encouragement and also that their work is adequately co-ordinated with and supported by the state-funded programmes.277
§ To conclude, the committee was convinced that the National Health Service must become more involved in the nation's medical research programme. It plays such an important part in maintaining the high standards expected from that key national service. Our recommendations aim to achieve that without interfering with the present excellent work done in the Department of Education and Science through the Medical Research Council and the University Grants Committee.
§ I look forward to our debate on this important subject and these vital issues and in particular to the maiden speech of my noble friend Lord Johnston of Rockport. I am glad to see his name on the list of speakers and I am much encouraged by the number of noble Lords who have put their names down and the number who have intimated to me that they would have done so if there had been fewer speakers. At the conclusion of the debate, we shall welcome any comments which my noble friend the Minister feels able to make in response to what has been said. We shall expect and hope to receive in due course a full written reply from the Government.
§ Finally, I wish to impress upon the Minister that within any action the Government take on the future administration of the Health Service there is an urgent need to remove the impression that the Government do not care about medical research. There is a need to make it clear that there is an understanding and appreciation of the part that research can play and is playing in ensuring the efficiency and effectiveness of the National Health Service. I ask the Minister to convey that message to the Secretary of State. I beg to move.
§ Moved, That this House takes note of the report of the Select Committee on Science and Technology on Priorities in Medical Research (Third Report, 1987–88, HL Paper 54).—(Lord Nelson of Stafford.)
§ 3.34 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Skelmersdale)
My Lords, the House will be grateful to my noble friend Lord Nelson of Stafford and to his committee for its timely and thought-provoking report on priorities in medical research. The Government most certainly are grateful too because, as my noble friend has said, we are currently engaged on what I can only describe as a—no, not even that—the great debate on how to recast the National Health Service to fit it for the next 20 years. Sir Roy Griffiths notwithstanding, I believe this national soul-searching has not been attempted on any scale since the Beveridge Report was written.
The debate will probably be about principles and, as so often on these occasions, details, no matter how important they are, tend to get adapted to fit in with the consensus view. But this report does not do that. It treats the vital subject of medical research on its merits; a fact that I for one, speaking on behalf of the Government, appreciate. It is precisely because of that linkage that the Government do not intend to rush in with a definitive response today. I am grateful to my noble friend for not expecting that.
278 My noble friend has hinted at the present arrangements for medical research in the United Kingdom. I should like to use this opportunity to boast a little, if noble Lords will permit me, about one or two of our achievements in this field and to give my thoughts on what appears to me to be the main recommendation; that is, the call for the establishment of a national health research authority to provide what my noble friend called the crucial missing link.
Let me make it clear that the Government are committed to maintaining a strong and healthy research base, commensurate with the resources that our nation can reasonably deploy. Noble Lords—especially those who speak in this debate—will be aware of the invaluable contribution that medical researchers play in improving the health of our nation. Whether they are involved at the leading edge of basic scientific research or in evaluating ways of improving the efficiency of our hospital services, their breakthroughs, their successes and their continuing efforts are relevant to us all. Let us not underestimate or forget their contribution to our well-being.
As the report points out, the organisation of medical research in the United Kingdom has several main components. The committee identified the following: the Medical Research Council; the University Grants Committee (soon to be the Universities Funding Council), which pays for the medical school and university infrastructure; the DHSS and other health departments; the medical research charities; and the pharmaceutical and medical equipment industries. I want to concentrate on three of these components; that is, the roles of the Medical Research Council (the MRC); the DHSS as the main health department; and the National Health Service. I shall concentrate in particular on how the MRC and the DHSS link in with the NHS to meet the research demands thrown up by the need to continue to improve not only treatment and care services but also preventive services and positive health promotion.
The Medical Research Council is the main government-funded body dealing with basic and clinical medical research. It responds to the research aims and the requirements of the health departments, as well as those which are the responsibility of the Department of Education and Science. The main mechanism for co-operation between the MRC and the health departments is the concordat dating from 1981 and renewed in 1986.
Annual stocktaking meetings between senior officials of the health department and the MRC are held to enable the health department to inform the council of problems, and of their current and future needs for basic and clinical research; and for the council to bring to the health departments' attention new scientific developments that will affect health care and health services. The committee's report recommends an expansion of the annual stocktaking process and we are looking at that plan in the light of our own evaluation of the stocktaking arrangements.
Contact between my department and the MRC does not, of course, stop at this level. It pervades 279 every level of both organisations, resulting in constructive and satisfactory relations between the MRC and the health departments. I am pleased to note the committee's conclusion that the MRC is the right vehicle for funding basic and clinical research. However, the committee seemed to be less happy about the role of the DHSS. Indeed, it took exception to the description of the purpose of the department's directly managed research programmes regarding health services research. In their evidence to the committee the Government stated their belief that:The main aim of DHSS health research is to provide guidance to Ministers on ways of improving the efficiency and effectiveness of the health and personal social services, by promoting improvements in organization, operation and administration".That is to be found in Volume II, paragraph 2, at page 410 of the report. Appropriately designed studies examine ways in which services can be organised to make the best use of available resources to help individuals stay healthy, and to provide effective treatment and care when necessary.
The DHSS does not normally directly support basic or clinical research. It concentrates on health services research or, to use the terms used in the committee's report, public health and operational research. Paragraph 3.24 of the committee's report states that:Ministers need a research programme, obviously. The NHS needs a research programme also, and it is likely to be different, both in scale and kind".However, paragraph 3.25 goes on to say:The Committee do not underestimate the NHS's local interest in research. NHS managers… have freedom to commission the research they need from their own allocations".That is absolutely right. The point I wish to make here is that much of the research directly commissioned by DHSS is of benefit to the NHS. It has direct and very real implications for the planning and provision of services. Earlier on I said that I proposed to boast a little about some of our achievements. I propose to do this by giving two examples of where research directly commissioned by the DHSS has had a direct and positive impact on the NHS.
The first example of the practical value of such research is provided by the study into the costs and benefits of the heart transplant programmes at Harefield and Papworth hospitals. That research demonstrated the effectiveness of heart transplants in terms of improvement in the quality and quantity of life of the patients concerned. The results were very useful when policy decisions were required over the size and siting of possible further centres to participate in a national heart transplant programme. Indeed they led directly to the policy of supraregional funding.
Another example is a two-stage project looking at urinary tract infection. In the first stage a survey was undertaken of nursing practices in the care of patients on urinary catheter drainage. The report of that survey has been used by nurses to re-examine current nursing practices. For example, the survey recommended the use of disposable urinals for the drainage of the catheters to minimise the chances of cross-infection. The report of the second stage is expected to provide a more scientific basis for the 280 nursing care of such patients, and to contribute to the prevention of hospital acquired infections.
I could give more examples, but those two are, I think, sufficient to make the point that to a great extent the aims of directly commissioned DHSS research serve to improve the efficiency, effectiveness and quality of health services in this country. Indeed, the department's priorities for its health and personal social services research programme have been framed with the National Health Service's needs very much in mind. The department's arrangements for directly commissioned health and personal social services research were recently restructured to provide, among other things, a better focus on those areas of greatest importance. In 1987 we identified a number of priority themes for research which relate to the Government's priorities for the health and personal social services. Those themes also take account of that body of DHSS research which has already been commissioned and research undertaken by the MRC and other departments.
There are seven of those health themes. AIDS is the first one. Although most AIDS research falls to the MRC, a number of important studies in health and personal social services research fall outside the MRC's responsibility. The funding of those studies relevant to the DHSS programme is very high on our list of priorities. The DHSS is making funds available to the MRC to assist in funding research on epidemiological aspects of the problems of AIDS. That is over and above the special funding the MRC receives for research on possible vaccines and antiviral agents and the normal grant-in-aid the MRC receives from the Department of Education and Science.
The demands on, and effectiveness of, acute sector services is the next theme. We know that these demands are increasing. Research to investigate the underlying causes of pressures on the acute sector is urgently needed so that services can be made more effective in meeting the needs of patients. For example, we need to explore the reasons for variations in hospital admission rates between regions.
Next is the transition to community care and maintenance in the community, a subject that is very dear to my heart. This theme is designed to identify, describe and evaluate service activities aimed at easing the transition from institutional to community care. The theme covers both health and personal social services, and social security objectives.
The fourth theme is professional manpower. As manpower is the single most costly item of National Health Service expenditure, accounting for slightly over 70 per cent. of the total £24 billion budget, we really need research to explore the reasons why shortages occur in some disciplines and the extent to which changes in education, training and organisation might improve the position. Why for example is it easier to attract people to some specialities rather than others? Why does this change from place to place?
The fifth theme is consumer attitudes to health and personal social services and social security. The customer's views on the development and 281 deployment or services is rightly being seen as increasingly important and deserves more study. Next, we have the influence of lifestyles, especially in relation to drugs and alcohol. While there is scope for many studies in this field we have so far concentrated on research into the problems of drug abuse.
Finally there is the theme of child abuse. No explanation is needed why child abuse is a research priority. I am sure we all share the serious concern about the frequency and circumstances of child abuse, and the urgent need for research to identify how child abuse can be prevented.
We introduced the concept of priority research themes to provide a structure to guide, but not bind, the department's research efforts. That approach has proved helpful to Ministers both past and present. Of course the themes will be regularly reviewed and will change as priorities demand, as they so clearly did with concern about child abuse.
I hope that that approach has also helped researchers to consider how they can best contribute to meeting research needs. But some topics are very difficult to research. In such subjects sound proposals are not always forthcoming because of a paucity of promising ideas for research. We have recently encountered such problems with research into meningitis: a disease which can be fatal especially in children and which causes so much suffering and distress. We urgently need to know more about how and why meningitis is spread.
At our request the Medical Research Council has arranged a three day international meningitis workshop in Oxford at the end of this month, and the department has offered the Medical Research Council a specific commission to implement promising research recommendations that come from that meeting. I can report further good news in that the MRC has recently received two applications for grants to carry out research on meningitis which are likely to be funded. I am also very pleased to report that the department is about to commission a case control study of meningococcal disease in eight West Country health districts. It will be carried out by Bristol and Western Health Authority.
I have tried to set out the strong and important links between directly commissioned DHSS health research and the research needs of the NHS. However, I must also emphasise that the research needs of the NHS are many and varied, so much so that it would be inappropriate to suggest that the responsibility for formulating the NHS's research needs should rest in a single place. They should be identified and met in a variety of different ways: by the Medical Research Council; by the medical charities; directly by the DHSS or by those bodies such as the Public Health Laboratory Service which are funded by the DHSS but commission research on their own behalf; or through research organised locally by health authorities.
The important point is that those concerned should be aware of their own and others' responsibilities so that priority needs are not overlooked and research is not duplicated unnecessarily. It is, therefore, of the utmost 282 importance that adequate mechanisms exist to permit the level of co-ordination required. It is on that issue which the committee rightly focuses attention. Indeed, it is the basis for the report's central recommendation. Paragraph 9.17 of the report states that:The NHS should be brought into the mainstream of medical research. It should articulate its research needs; it should assist in meeting those needs; and it should ensure that the fruits of research are systematically transferred into service".Paragraph 9.18 goes on:For this purpose a National Health Research Authority (NHRA) should be created".Nevertheless a number of the report's recommendations would undoubtedly have financial implications—not least the concept of a national health research authority, its proposed functions, especially its role in funding research, and its relationship with other bodies involved in medical research.
That leads me to the funding of medical research. The committee said it had tried to keep its recommendations within present levels of public spending. However, as my noble friend has said, it felt impelled to make three recommendations about funding: first, a general proposal that more spending on medical research is needed; secondly, that a special allocation of around £25 million a year for three years should be made for the modernisation and re-equipment of medical research facilities; and thirdly, that wealthy individuals should be encouraged to support research by benefactions which maintain the twin traditions of medical excellence and private generosity.
The first two of those recommendations are calls for more public money to be spent on medical research—one general, one specific. I do not intend to quote endless statistics about the funding of medical research, but I think that it would be appropriate to mention just three numbers.
In 1986–87, the last year for which comparable figures are available, it is estimated that government departments and agencies directly and indirectly spent nearly £400 million on health research. In addition to that it is estimated that for the same year the pharmaceutical industry spent around £600 million on research. Also members of the Association of Medical Research Charities, to whom the Government are extremely grateful, spent over £100 million.
My purpose in quoting those figures is a very simple one. It is to show that considerable amounts of both public and private money are spent on medical research. It has become a cliche for people to say that the demand for health service spending is limitless. In much the same way the argument is put that there is never sufficient funding for medical research. The Government take the view that that is a matter of judgment. There has to be a balance between medical research spending and other ways of using resources for health. Such judgments are extremely difficult to make. I do not believe and indeed I suspect that nobody speaking today would believe that there are any right answers.
The recommendations for increased funding suggested by the committee are serious proposals and we shall treat them with the same seriousness with 283 which they were put forward. However, we have to consider them in the context of other demands for public money; not just for the health service but for other public services as well.
As the House will be aware, one of the key tenets of government policy is that individuals should have more freedom to decide how to spend their income. However, increased freedom brings with it increased responsibility. It is with that in mind that I welcome the committee's recommendation that wealthy individuals should be encouraged to support research. However, I am sure that noble Lords will not want to overlook the highly commendable efforts of research charities in this country nor the generosity of individuals both wealthy and not so wealthy who contribute to very many worthy causes. As an incentive to individuals who contribute to charities, the Government have introduced tax free payroll deduction schemes which commenced in April 1987.
I should like to conclude by congratulating my noble friend on what I can only describe as the shining galaxy that he has attracted to speak in this debate today. Like other noble Lords, I am eagerly awaiting two speeches in particular: the contribution of the most reverend Primate the Archbishop of York and the maiden speech of my noble friend Lord Johnston of Rockport. The Government will take into account their thoughts, as indeed those of all noble Lords, when we produce our carefully considered response to the Select Committee's report.
§ 3.52 p.m.
§ Lord Prys-Davies
My Lords, the Minister will have to listen to my contribution in the meantime. I am not an academic, nor am I a doctor: I am just a lay person who happens to have a special interest in the National Health Service. Whatever may be the Minister's standards, those are my only qualifications for speaking in this very important debate.
I warmly welcome the report and the two volumes of-evidence. I think that the 830 pages of evidence are invaluable, casting light as they do on the difficulties of this complex field. I am advised that if implemented the 50 recommendations drawn from that evidence would provide a firm basis for the expansion and development of medicine which is needed in our country. The committee therefore has performed an immense task that is normally entrusted, so it seems to me, to a Royal Commission.
There is widespread appreciation of the efforts of the noble Lord, Lord Nelson of Stafford, and his 13 colleagues as well as the two very distinguished specialist advisers who assisted the committee. The House is also grateful to the noble Lord. Lord Nelson, for the admirable way in which he introduced and explained the salient proposals in the report.
The background to the report is the growing concern since 1980 about the extremely serious state of medical research in the United Kingdom. One aspect of that concern was debated in your Lordships' House on the 26th November 1986. The report has also to be considered against the background of growing pressures within the NHS 284 which are leading policy-makers and managers increasingly to question the benefit and cost of what they are doing. Clearly the committee was flooded with an immense flow of evidence from a total of about 250 national organisations and distinguished individuals. The list is impressive. It includes 39 professors of medicine, 12 Royal colleges, 30 medical schools or faculties, 23 professional organisations, the pharmaceutical industry (which we accept supports the biggest field of research) and 25 national charities. Among the national charities are the major medical trusts, such as the Wellcome Trust, the Imperial Cancer Research Fund and the British Heart Foundation which have made such significant contributions to research in those areas which are popular in the public perception.
With hindsight it can now be seen that the setting up of this committee to collect the evidence and report was long overdue. So it is with hindsight; but should not the need have been dictated by foresight? If they were in touch with the researchers and the medical schools, should it not have been obvious to the department and its research advisers that there was a deep-seated unease and widespread concern among medical researchers and the teachers of medicine. The department itself should have been seeking to get at the truth. The fact that it did not do so suggests that it failed to consult adequately in these matters. Perhaps this is a point on which the Minister can comment when he comes to reply.
In an era when medical research has never been so exciting and so full of promise, the Committee, as the noble Lord, Lord Nelson, pointed out, found many grave weaknesses. The committee confirms the widely held impression that the general position is profoundly unsatisfactory and in one or two respects may even be scandalous. The report says very clearly to the Government and to the country that health research must become central and not he peripheral to the NHS. Indeed, as I read it—and it is confirmed by the contribution of the noble Lord, Lord Nelson, this afternoon the central recommendation of the committee is that the National Health Service itself must be brought into the mainstream of medical research. The report says how that can be achieved. It recommends setting up a permanent body—a national health research authority—to discharge some of the functions. That body would be within the NHS but separated from the DHSS, and there would be similar bodies for Scotland, Wales and Northern Ireland. Presumably it would be accountable to the Minister for Health.
Some of its functions have been summarised by the noble Lord. Lord Nelson, and they are to be found in Chapter 4 of the report. I simply note that it would not be its own research body but would commission projects and programmes as necessary from other bodies. It would ensure that the priorities were in the right order and related to need. It would have a very strong intelligence function to play within the NHS and it would provide advice on the training of researchers in the health service field and assist in developing a satisfactory career structure for researchers, fulfilling another need which is not currently being met. I understand that it would exist in parallel with the Medical Research Council, whose 285 reputation for science-led research is deservedly high. However, I shall listen very carefully to what its chairman, the noble Earl Lord Jellicoe, will have to say about this proposal and the possible relationship between the two bodies.
The setting up of a national health research authority outside the DHSS would be a bold and imaginative development. But there could be a snag. There could be a problem, as was acknowledged by the noble Lord, Lord Nelson, when he questioned Mr. Maxwell of the King Edward's Hospital Fund on his thought-provoking paper. I am not sure whether it can be said that Mr. Maxwell is the author, or one of the authors, of the independent research authority idea. What is the problem? It is this. Despite the merits of the proposal, it is extremely difficult to get this Government to set up a new, nominated body and to provide such a body with funds to discharge its functions. In the eyes of this Government such a body would be just another quango using limited funds to sustain another group of administrators.
If I have one criticism of the report, it is that it failed to concentrate on all the possible objections to this bold proposal of the committee. I believe that all the objections should have been brought out, discussed, and met. I happen to believe that they could be met. We happen to believe that it is extremely important that there should be such a body and that this body should be outside the DHSS.
The Minister has been boasting of the record of the DHSS. But in the light of its evidence to the committee—to be found in Volume II—and in the light of complaints that we hear from research workers up and down the country, have we any confidence in the capacity of the department to pay sufficient attention to medical research and to question assumptions? The Government are considering how to recast the NHS in order to seek a more cost-effective health system. The ministerial review provides not just an opportunity but in our view a requirement that the essential functions allocated by the committee to the proposed body should be undertaken.
I now wish to refer to the evidence of Sir David Weatherall, Professor of Clinical Medicine in Oxford, who is responsible for directing the Nuffield Department of Clinical Medicine. Sir David was the first witness to appear before the committee. It has not gone unnoticed that in Sir David Weatherall's judgment the single most important initiative which is immediately necessary is to find:enough money to create a number—perhaps a couple of hundred—of full-time research posts, preferably within the University Departments, so that one could encourage people into research careers. I think we have the best graduates corning into medicine now …and we should encourage a few hundred of those over the next year or two to believe that there is a career—a decent research career".This proposal at the invitation of the committee, was pursued further in the additional memorandum submitted, again at the request of the committee, by the Association of Clinical Professors of Medicine. As I understand it, the association would settle for 250 additional posts at a total cost of about £18 million per annum. I am not quite certain what view the committee took of this proposal but it seems to 286 me that these additional appointments, together with the radical improvements in the physical environment in which research is conducted, and which is recommended by the committee at a cost of about £25 million a year for the next three years, must be pretty high priorities. Together they would have a powerful effect on morale. Having listened to the Minister's opening address, I am not assured that the Government will be responding favourably to these recommendations.
In the debate on academic medicine in your Lordships' House 18 months ago the noble Baroness, Lady Trumpington, complained that there had been too much doom and gloom in the debate. She went on to boast about the Government's achievements. I sent a copy of the Hansard report of the debate to Professor Leslie Blumget, the former director of surgery at the famous Royal Postgraduate Medical School at Hammersmith, who, sadly, had then just opted out of academic medicine in the UK, because of the unsafisfactory conditions under which he worked, to take up an appointment at the University of Berne. His comment on the speech of the noble Baroness was sobering, and I shall quote it. He said:I was most interested in the reply of Baroness Trumpington's which did nothing to assure me that had I stayed, there would be any real change during the period of my professional lifetime".All those with an interest in medical research in this country, and all those who are interested in the NHS and are alive to its ultimate dependence on medical research, will study very carefully the Minister's opening speech and his reply at the end of the debate. I would suggest only that the achievements which he relied on in the opening speech are probably more apparent than real. We hope that in his reply he will give clear indications that the Government fully appreciate and understand the gravity of the challenge facing medical research and that they will be responding constructively before more research workers are lured by better facilities to work permanently in other countries, and before some laboratories close their doors forever.
We are grateful to the committee. We believe that it has fully discharged its duty. It has made the position crystal clear to the Government and to the general public. We can only trust that the Government will not be deaf to its considered recommendations.
§ 4.9 p.m.
My Lords, as the noble Lord, Lord Prys-Davies, has already said, the thanks of the House are due to the noble Lord, Lord Nelson of Stafford, for introducing this very important debate; and to the noble Lord and his 13 colleagues—a baker's dozen—for preparing such a thought-provoking, very carefully researched, report into a very vital subject. I cannot wholly agree with the noble Lord, Lord Prys-Davies, in saying that the report should have anticipated some of the objections to some of its proposals. I think that there will be many. But that it is the job of the Civil Service. Every civil servant is trained to find a difficulty for every solution, and I am quite sure that the Civil Service will find plenty of difficulties for these solutions. I do not think that they need any help from your Lordships' Select Committee.
287 Two themes appear to me to run through the report. They recur on page after page, sometimes with stark and alarming detail to support them. They are, first, under-funding and, secondly, low morale among those engaged in this important work. It is no surprise to anyone that under-funding should be an important aspect of the report. I believe that if one reads the report carefully one will see that the consequences of under-funding are spelled out as being extremely costly in both the short and the long term from the public funding point of view. The second theme is the low morale to be found among those who engage in this work. It was referred to in a letter to me from the noble Lord as amounting to despondency in many cases. It is a very important issue, to which I shall return.
The report speaks for itself. It would not be helpful to your Lordships' House if I repeated what is set out so eloquently in the report. Therefore I shall limit myself to raising four separate sources of anxiety which I have in this field and about which I should welcome the Minister's comments in reply. With so many speakers in the debate the Minister will have many questions to answer and all noble Lords will understand if he cannot deal with them all.
I should like to express my regret that there is not one more speaker. I know that the noble Baroness, Lady Gardner of Parkes, intended to speak but had to withdraw. Had she spoken I believe that she would have voiced one minor criticism about the report and it is one that I share. It is that the report does not give sufficient credit to the outstanding success of research in the field of dentistry. It has been a success story in the modern world because dental caries has virtually disappeared. That could have been stated in the report, but it is not a major criticism. I know that the noble Baroness would have made that point had she been present.
I should like to turn to the four anxieties to which I have referred. The first is the issue of morale. Since its foundation 10 years ago, I have been closely connected with the Association of Researchers in Medicine and Science. That body is deeply concerned, and always has been, about the lack of a wholly adequate and acceptable career structure in postgraduate and post-doctorate medical research. I received a letter from Dr. Simmonds, one of the founders of the Association, who stated:There is now a severe shortage of people willing to take graduate or post doctoral positions as contract researchers. This almost certainly relates to the great discrepancy in the terms of employment of contract researchers and their unfair treatment compared with other scientific workers".She continues:The Association of Researchers in Medicine and Science remains firm in its belief that the basic problem is not lack of money, although more would not go amiss, but the way the money is spent. We feel there is an urgent need for continuity in academic research in the United Kingdom, and believe this can only be achieved by the development of an appropriate career structure".I have been personally aware of the lack of career structure. I am aware of the difficulty in many universities of recruiting people to take on short-term post-doctorate research projects. That is so even in the university with which I have the closest 288 connection as deputy pro-chancellor; the University of Lancaster. The difficulty exists because of the terms and conditions of employment.
On behalf of the association I once led a deputation to one of the Ministers in the Department of Education and Science to discuss the problems. I ventured to enquire how many of the women employed on short-term contract—and most are employed on short term contracts carrying out important medical work and often post-doctorate research work—had ever received any kind of maternity benefits. I carried out some research into the question and the answer is none. Why is that so? It is because none of them ever qualified for those employment rights because they are never in employment long enough to have them. That makes it inevitable that many gifted and talented women graduates, who may be ideal to take on certain projects, will often turn them down in case they should become pregnant, knowing that their career prospects are such that they will receive no assistance. I believe that the whole matter needs to be examined.
I should like to turn to my second anxiety, a point which was made forcefully by the noble Lord, Lord Nelson of Stafford. It relates to the predicament of academic clinical staff who have teaching and research obligations in addition to the clinical care of patients in the hospitals to which their teaching institutions are attached. The hospital cuts—although I have no doubt that the Minister will prefer me to use the words "shortages"—are now such that the extent of the clinical work borne by such people renders many of them unable to fulfil their research duties.
I should like to give an example of the effect of that in one particular field—that of AIDS. It is understood that most of the AIDS cases in Britain requiring continuous treatment in hospitals have been treated at St. Mary's and St. Stephen's Hospitals in London. It is true that most of the clinical care of those patients has been borne by academic clinical staff. They are the very people who should have been carrying on with the research into AIDS. However, such have been their clinical burdens that they have not been able to do so.
One of the results has been that nearly all the research has been carried out in the United States. I have no objection to that because I believe that we all benefit from medical research wherever it is carried out. Yet it is a pity when we have such able medical scientists in Britain that they are not able to take as full a part as they ought in such urgent research. There is also a danger that some may leave and go to the United States not just for more money but for more continuity and long-term prospects in relation to research, and for more resources. Noble Lords will know of whole university departments that have upped sticks and decamped to another country because of the difficulties of continuity for a research programme. That is the second of my anxieties.
The third is a matter to which I referred in the recent Second Reading debate on the Health and Medicines Bill. An issue relating to Clause 7 of the Bill was brought to my attention in a letter from Sir Mark Richmond. He is the vice-chancellor of my 289 former university and he wrote to me in his capacity as chairman of the Committee of Vice-Chancellors and Principals of universities in the United Kingdom. He fears that certain aspects of Clause 7 will give the DHSS certain rights over research which has been funded by it and carried out in universities. My anxiety relates to the nature of the rights of the DHSS, to whether they are restrictive and to whether the fears of Sir Mark Richmond are justified.
The Minister has written to me explaining Clause 7(1) (f) of the Bill. I have no doubt that the letter is intended to be helpful and I am sure that it would be if I could fully understand it. I am not suggesting that it has deliberately been made slightly ambiguous here and there and I have no doubt that others who study it carefully may be able to understand it fully. I have no wish to embark on a lengthy debate on this subject, but I should like to ask the noble Lord a specific question. which I hope he will answer at the end of the debate.
I know that the DHSS will have certain rights over the commercial exploitation of certain discoveries made in universities as a result of funding by the DHSS. I should like to know whether the DHSS proposes to place any embargo or delay on the publication of a research study carried out by a talented, and probably ambitious, postgraduate student in a university. Nothing could be more sapping to the morale of an academic research worker than to spend two or three years on a research project and on completion of the work suddenly find that he is unable to publish his conclusions in the learned journals. If he is unable to do so he will feel dispirited and despondent, as the noble Lord, Lord Nelson, has said. The DHSS may have certain rights with regard to intellectual property rights, but I should like to know whether it intends to delay publication of the results of academic research studies. If it intends to do that, it will further damage the morale of some of the people upon whom we depend so very greatly.
Let me move to my fourth point, which deals with research relating to the elderly. I am interested to have received a letter from the British Medical Association on this subject. I am sure many noble Lords have received this letter. There is a quotation from a speech made by Dr. Colin Smith, who is chairman of the BMA Medical Academic Staff Committee. He was referring to the whole matter of funding of research.
The Minister has explained the different sources of funding in his excellent and very clear speech but, as Dr. Colin Smith points out, there are certain areas which are a little more glamorous and more likely to attract funding than others. He goes on to say starkly in the course of his speech,Who, for example, will fund research into geriatrics?With the changes in our population profile and the higher number of elderly people, it seems that research into geriatrics is of immense importance. Therefore I was somewhat distressed to receive a letter from Dr. Norman Vetter of the research team for the care of the elderly at the University of Wales 290 College of Medicine. At the top of his letter he tells me,The research team for the care of the elderly people is to have its DHSS funding withdrawn as a result of a review by the DHSS chief scientist's assessors and the view of the Welsh Office that our work is not a priority for research funding".Research into geriatric matters must surely be a priority for anybody's funding. I should like to hear what the Minister has to say about that particular matter, whether what is said in that letter is true and whether there can be any further thoughts at this late stage.
Those were my four points. Perhaps the Minister may be able to comment on some of them. I should like to say two things before concluding. I am immensely interested in the proposal for a national health research authority. I should like to take part in further and more detailed discussions on that matter because there are many controversial points arising out of it. I also notice that in the course of the report the committee said that it felt unable to judge strictly between different medical priorities. That is understandable. As a doctor I am perhaps a little less timid and I am prepared to judge between certain medical priorities. I would merely pick out one priority that I should like to put to the noble Lord, and that it is one that I have stressed before. I believe that with the present funding difficulties in the National Health Service, it is becoming increasingly urgent that we carry out detailed studies of the cost-effectiveness of medical procedures, he they diagnostic or therapeutic—not with a view suddenly to deciding that there are going to be no more liver transplants or anything of that kind, but so that we can know from which kind of investment we derive the maximum benefit in terms of the saving of lives and the relief of human suffering. In the past when cost-effectiveness studies have been mentioned in relation to medicine, it has been said that we are not dealing with the raw materials of industry; we are dealing with people's lives. However, if we are to use restricted resources—and effectively there will never he enough resources in the National Health Service—we must know on which areas those researches must be focused so that we can be sure that enough goes to the areas which bring the maximum return in terms of the relief of human suffering and the saving of lives.
I say no more, save that I look forward to hearing all further speeches, in particular the maiden speech of the noble Lord, Lord Johnston of Rockport. I also look forward to hearing the Minister's answers.
§ 4.25 p.m.
The Archbishop of York
My Lords, I was a little alarmed at the high expectations expressed by the Minister about what I am going to say. I hope that he will not be too disappointed.
I venture to join in this debate for two reasons. First, I speak as a one-time medical researcher, duly funded by the Medical Research Council; but that was back in those halcyon days when a researcher could do more or less whatever he liked. It is true that we had to make our own apparatus, much of it culled from crashed aircraft. Priorities had to be set by what 291 was feasible, with virtually no funds. Those days have gone, though obviously not entirely.
My second and more serious reason for speaking is that I am alarmed by the spread of predominantly utilitarian attitudes towards research. I therefore warmly welcome the report's main recommendation that medical research should be science-led.
We are all aware that the scientific community is under much pressure these days. I do not see any harm in economies, provided that they do not destroy the infrastructure on which effective research depends and provided that they do not sap initiative. I quoted my own example because I know what can he done with quite slender resources and a bit of ingenuity. However, if the drive for economy leads to a view of science whereby it constantly has to justify itself by marketable results, then we are well on the way to corrupting our science. We would threaten the very spirit of objectivity and detachment and the willingness to be proved wrong, on which scientific integrity and thus its ultimate usefulness depends.
In a fortnight's time I am due to take part in a conference on the value of useless research. It is a joke title but it is a serious topic. If there is any valid theological point to be made from these Benches on the subject of the Select Committee's report, then it must lie here. It is not simply that we cannot know in advance what is going to be useful: it is that if usefulness becomes the controlling ideal, it can eventually erode the bedrock on which science is built. That bedrock is the desire to know the truth.
It seems that the discovery of low morale, which has been so much mentioned and which is such a disturbing feature of this report, is one of the preliminary signs of the erosion of basic ideals. That is not to say that fundamental research is diminishing. In one sense there is more of it than can readily be assimilated. Scientific productivity has reached a pitch world-wide at which it is extraordinarily difficult to tell what is fundamental and what is trivial. This is why the judgments of experienced researchers are so important and why their morale and their sense of acceptance is particularly important. That is why their career structures have to be safeguarded. There is no way of setting priorities or deciding which leads are worth following up, without relying on the instincts which the good researcher develops. Therefore we must cherish them. Even then, there will be many mistakes. That is why I am sure that the committee is right in saying that we shall continue to need a variety of funding bodies so that good ideas can appeal to a variety of backers.
I have spoken up for basic research, in which I passionately believe. Now let me turn to the other end of the spectrum—namely, its clinical application. To say that basic research must have its own integrity does not mean that it has to be carried out without relating at all to clinical needs and to the kind of issues which one hopes a national health research authority would identify.
The point was raised that the whole medical fraternity has to be encouraged to be research-minded and to see itself as part of one enterprise, from those who are engaged in basic scientific 292 research through to the clinical researchers and, at the other end of the spectrum, the health service researchers and the sociologists. If the whole medical fraternity is encouraged to be research-minded and if some of this attitude could rub off onto the general public, it might help to create more realistic expectations. Every treatment is an experiment.
A few years ago the Council for Science and Society produced a report entitled Expensive Medical Techniques, the main burden of which was that some techniques and treatments were brought into regular use before their value had really been established. Sometimes the gap between research and its application is too great—and that is a problem which the committee has rightly addressed. However sometimes it is the other way round. The pressure of public expectation builds up and it becomes increasingly difficult to deny treatments which might do some good but which have not been properly validated and which might entail simply pouring money down the drain.
Research-minded doctors would sense the need to move carefully and would see the importance of not muddying the evidence by using techniques indiscriminately. A research-minded National Health Service could play its part in educating the public on what its priorities were and, therefore on what it is reasonable to expect. In fact, this other report to which I have referred, written six years ago, made a very similar case to that of the Select Committee for a body which would give real teeth to health service research. Neither that report nor the Select Committee was convinced that that was something which the NHS could do by itself. One must add that for such a body to have real teeth it will need better funding than is proposed.
I turn now to the training of medical students. I have had experience of two very different patterns: first, the traditional scientific training followed by clinical experience: and, secondly, the integrated course in which students make contact on day one of their university course. My own daughter recently completed such a course and I well remember that at the end of her first term she said, "You can do anything you like to your arm and I will treat it, but do not do anything else to any other part of your body", because they had studied the physiology, movements, anatomy and pathology of the arm and the orthopaedic treatments which one might give. It seems to be an extraordinarily effective method of teaching. This is a wild generalisation but I suspect that integrated courses make more sensitive and humane doctors whereas the traditional courses make better researchers.
I believe that the current movement is in the direction of integrated courses. Because that is so, I warm to the committee's recommendation No. 9.49 about an intercalated year in all courses for research. It seems to me that this suggestion might have given us the best of all worlds; namely, doctors who are clinically sensitive but who have the opportunity to develop a real scientific understanding and this research-mindedness, about which I have been talking, which is so important.
Perhaps I may say a few final speculative words. I hope that some thought will be given to areas of 293 research which should not be funded by commercial interests. I have in mind some of the horrifying problems which will face us with the improvement of genetic engineering techniques. We are already confronted with questions about the patenting of new techniques and life forms. It is significant that these come to us primarily as financial questions rather than moral ones. Extrapolate this to man and add the same kind of commercial interest which is now very strong within the genetic engineering field and I believe that we shall be in real trouble. There seems to be a case for having strong, centrally-funded research on this which could attract the relevant expertise in these especially sensitive areas. However, I simply add that as a footnote on which to end and I express my warm appreciation of this report.
§ 4.36 p.m.
§ Lord Johnston of Rockport
My Lords, it is with some trepidation that I rise to make this maiden speech. I have learned that one feature of a maiden speech is that it should be maidenly,—unsullied by controversy and purged of too much politics. I assure your Lordships that having spent the last 25 years holding various positions in the Conservative Party, it comes as something of a relief to step hack for a moment from party politics and I shall try to do just that.
Indeed, the subject to which I would draw your Lordships' attention is something which should not be the stuff of partisan debate for I would like to consider how government and society in Britain can rise to the challege presented to us by the suffering of so many of our fellow countrymen from painful and incurable diseases.
A good deal of public attention has been focused on the problem of AIDS, but the challenge to medical science is posed by many other conditions, some of which have been with us for many years. It was indeed the case of a particular couple whom I know that prompted these reflections.
They are both young by my standards. She is suffering from multiple sclerosis and has been in a wheel-chair for the last nine years. Her husband, who has been quite wonderful in the way he has looked after his wile, has in recent years been diagnosed as suffering from an incurable condition affecting the nervous system called Huntington's Chorea. This hereditary disease will mean that in the very near future his need of help will surpass hers, and she has to sit and watch the inevitable physical and finally mental deterioration of her husband. He now suffers from total insomnia and is fully aware of the sentence which hangs over him.
I was fortunate in being able to contact his former partners and to my great delight they took immediate action which helped relieve the couple of some of their financial burden. In that connection I should like to pay tribute to my noble friend Lord Keith of Castleacre, the chairman of the company concerned, and his colleagues.
It is of course, multiple sclerosis—or MS—which has received by far the most attention. The superb work of the MS Society is well known and the society 294 has committed almost £10 million to research since it was formed in 1953. The Association to combat Huntington's Chorea (known as Combat) provides an information service and help and support for its victims.
In 1986–87 the Medical Research Council spent just under £100,000 on research into Huntington's Chorea. One may question whether this sum is sufficient to make real progress in containing a complex and unresolved condition which results in the death of the sufferer some 10 to 15 years after onset, which is generally in middle life.
The question I put before your Lordships today is: how best can government and society press out the frontiers of our knowledge so as to ensure that we can relieve present and future victims of such suffering? Before suggesting an answer—and this is, as may well be all too apparent to your Lordships, not the answer of a medical practitioner but simply the answer of a layman with a personal interest in the matter—let me draw attention to the importance of promoting research and harnessing technology as has been shown by improvements in health care in the last eight or nine years.
So much of the political debate about the health service has centred on the sums spent, the nurses and doctors employed and the overall number of cases treated that it is all too easy to forget the huge but silent advances that the more widespread application of new techniques and methods has brought. I do not propose to enumerate all these as we have heard them referred to many times in the Chamber; suffice to say that modern technology is in some cases avoiding the need for operations altogether.
If we are to harness medical science and new technology to the relief of suffering and the cure of disease, I suggest there are certain priorities that must be applied. First—here I speak with more practical experience than hitherto for I am an industrialist, not a physician—we must create the wealth in Britain that will allow us to perform the research and provide the care that we all want to see. Any society that becomes so obsessed with the redistribution of wealth that it forgets about its creation will have less and less wealth to distribute. This is a lesson that the Prime Minister and her Government need no one to teach them.
Secondly, we have to have a framework of laws and taxes that encourage charitable donations. Voluntary effort and private funds will continue to make a major contribution in this area. It is indeed one of the achievements in which I for one take most pride that, with the introduction of tax relief in successive budgets, recorded giving to charities has doubled since 1979 even after allowing for inflation.
Thirdly, the Government themselves must play their part. Here I am pleased to note that government spending on medical research has increased from £92 million in 1979–80 to £176.4 million in 1986–87 over and above what is spent by universities. One of the problems I see is that charitable foundations and Government can do only so much, so it is to industry that I wish to turn.
The Medical Research Council receives money from large industrial groups. I feel sure that many 295 more would contribute if in some way they were able to receive the same measure of publicity given to those companies that sponsor large sporting events. Would it perhaps be an acknowledgement of their generosity if they were permitted to imprint a special insignia like the Queen's Award to Industry on all their advertisements and letter-heading indicating that they are subscribers to extra special medical research? Were it possible that funding in this way for medical research charities could be given tax relief, it might help enormously in speeding up successful research into some of these obscure diseases. Industry is already giving generously. I am informed that University College London received from industrial sources more income in 1985–86 than any other university in the United Kingdom for research grants and contracts. It totalled £3.76 million. Many industrial companies are now sponsoring "commercially relevant" research. I hope very much that this will expand. En passant, as a point of interest, the diagnostic kit manufactured by Wellcome for the AIDS programme was developed jointly by University College London and the Institute of Cancer Research.
Finally—I believe that it is in this area that the most exciting advances may be made—we need to see a really effective partnership between the public and private sectors. Already a number of projects have shown the value of this approach. For example, BUPA paid £800,000 for a lithotripter for St. Thomas' Hospital with the aim of utilising capacity for the benefit of both National Health Service and private patients, thus reducing cost burdens on each service. In Wales, as a result of the initiative taken by the previous Secretary of State, now a Member of your Lordships' House, tenders were invited for the provision of two new renal units. Private sector bids were successful. More patients are being treated and better value for money has been achieved. Why should this not happen in research?
Without appearing morbid or pessimistic, I must end by noting that it is and always will be the lot of man to suffer and to face disease and death, but it is no less the lot of man—and not just Government—to struggle against it, and I pay tribute to all those who commit their lives and resources to doing so.
§ 4.45 p.m.
§ Lord Flowers
My Lords, it is my good fortune to follow the noble Lord, Lord Johnston of Rockport. Therefore, in accordance with our ancient traditions. I congratulate him on behalf of your Lordships on his most interesting, stimulating and moving maiden speech which, if I may say so, was a model of its kind. The noble Lord brings to the House a wide knowledge of business and politics both at home and abroad. We shall hope to hear from him many times.
It has already been said that medical research is relatively well supported by charitable foundations that nowadays match the funds provided by the state. Moreover, the medical profession is well organised to seize new opportunities. One might therefore expect to find research in medicine less endangered by too little money than in most other disciplines. Not so. The committee found the present state of medical research disquieting and the prospects decidedly 296 alarming for the health of the nation. It was a conclusion that marred the otherwise unalloyed pleasure of serving under the noble Lord, Lord Nelson of Stafford, whose chairmanship was so agreeable and whose measured words today I am sure have the support of all members of the committee.
The committee prescribed a little money here and there to provide temporary relief. And those suggestions I would say are important, especially if they can be administered quickly. A sum of £25 million annually for three years is really not much to pay in order to restore the equipment base of our medical schools to something approaching international standards. However, the real malaise lies deeper and is not only a matter of money. In spite of its undoubted advantages, there can be no field of learning more at risk from mutually conflicting public policies than medicine. It is the ravages of those conflicts that we witness today.
The practice of medicine is nowadays led by basic scientific discovery, as the most reverend Primate the Archbishop of York so eloquently remarked in a most impressive speech. And the pace of that discovery is quickening. Therefore, a doctor, when he qualifies, should not only be up to date; he must also be able to sustain throughout life an interest in acquiring new knowledge and in appraising new concepts. In short, he must be acquainted with the nature and function of research. The medical teachers best able to impart that acquaintance are those—the noble Lord, Lord Winstanley, referred to them—who are themselves engaged in research as well as in the care of patients. That is why the education of doctors is nowadays confined exclusively to the universities. The medical curriculum is laid down by the General Medical Council, which means that the universities must provide teaching in all the prescribed subjects. If that teaching is also to be informed by research, it follows that there should be significant research activity in every major medical discipline—though perhaps not in every specialty—at every medical school. To have it otherwise would be to retreat to the days of the apothecary's apprentice.
However, those who fund research—the University Grants Committee, the Medical Research Council and many of the medical charities—are following an increasingly selective policy, even to the extent that many departments seem likely in the future to be able to do no significant research at all. Given the shortage of funds with which they are faced, the creation of a few major concentrations of research in chosen activities of current importance is a natural, if desperate, reaction. From the point of view of teaching, however, the inter-disciplinary research centres will inevitably open a broad ditch between departments that are active in research and those that are not. The prospect of many of our doctors being trained in medical schools unacquainted with research must, I suppose, dismay the GMC. Policies for teaching and for research are in conflict and the ultimate loser will be the patient.
There is also conflict between the policies of those who fund research. The research councils and the charities do not pay overheads. They assume that the normal infrastructure which includes consumables of 297 every kind, routine equipment and furniture, maintenance of laboratories and so on, as well as the salaries of permanent staff, are already provided by the block grant from the University Grants Committee. That is known as the dual funding system. However, it has broken down because the more successful an institution at attracting research grants, the worse off it becomes when there is insufficient provision for overheads through the block grant. Strictly speaking, it should then begin to decline additional research grants, but one of the indicators of performance on which its main UGC subvention is calculated is its success at winning research grants. Paradoxically, those judged to be the best are most at risk.
Some institutions, especially those with powerful departments in the physical sciences, engineering and business studies, are able to retrieve the position a little by charging realistic overheads on contracts with industry and commerce; but that remedy is not readily available to medicine. It must also be borne in mind that the UGC and the research councils are noticeably biased against applied subjects.
The most serious conflict of all, however, is between the policies of the DHSS and the DES. It is the DHSS which, through the National Health Service, provides for the hospitals in which medical students receive the bulk of their clinical teaching and in which most of the clinical research is performed. That is the second funding duality of which our report speaks.
The relationship between medical school and its teaching hospital—or hospitals, as nowadays is more likely—is so close that it is often difficult to unravel the activities and responsibilities of hospital and academic staff, both taking part in teaching as well as research. Various knock-for-knock conventions have grown up over the years to account in a rough fashion for the attributable costs of those overlapping functions, though precise separation is neither possible nor desirable and would probably destroy the necessary collaboration between the two sides.
The main convention, of course, has been the service increment for teaching—SIFT—through which the NHS provides additional funding for teaching hospitals. As the report acknowledges, the NHS contribution to the work of medical schools through its payment of SIFT to the teaching hospitals usually exceeds the UGC contribution to the medical schools. There is also a smaller payment by the regional health authority in respect of a teaching hospital's function as a tertiary referral centre for the region. However, those contributions, though substantial, do not take into account, at least explicitly, the fact that teaching hospitals must provide for research as well as for teaching.
Therefore, your Lordships' committee believes that SIFT should in future be allocated on the basis of the medical schools' contribution to the national training and research effort as opposed to local service priorities. We propose that it be renamed SIFTR—service increment for teaching and research. Moreover, we consider that some of the SIFT funds should be paid directly to the medical schools rather 298 than to the districts in order properly to reflect the needs of academic medicine. This would, incidentally, make simpler the accountability of academic medicine for the services that it receives.
I have referred to the policy conflict between the DHSS and the DES. It arises because the DHSS wishes, for good reason, to spread facilities and opportunities for health care more uniformly across the country whereas the DES wishes, through the UGC and the research councils, to follow a strictly selective path. This conflict sharply afflicts the teaching hospitals and our proposals for SIFT, or SIFTR, are intended to remove it.
Of course, additional money is required but not perhaps so very much. If SIFT does become SIFTR, I imagine that part would be given as the formulaic contribution towards the teaching function of the hospital and part as a selective contribution towards its research function. The addition might amount to about £50 million all told, but it is difficult to bandy about figures in this debate.
These SIFTR proposals, if adopted, would considerably ease the problems of medical research. Even so, they do not go to the heart of the problem. The health of the nation is the responsibility of the DHSS. Health care depends upon adequate medical research. The DHSS accepts very little responsibility for research. Responsibility for research lies with the DES which accepts no responsibility for health care. Put a little too starkly, that is the heart of the problem.
I must add at once that some regions are interested in fostering research and some districts are loyal supporters of their teaching hospitals. For example, Bloomsbury Health Authority is a most helpful partner of the newly assembled University College School of Medicine for which, in London, we are all very grateful. Nevertheless, it is clear that the regions, with no lead from the DHSS, do not regard the support of research as a vital matter for them and are sometimes inclined even to disrupt efficient teaching by distributing it too widely in accordance with local service needs.
Your Lordships' committee has proposed the creation of a national health research authority to sharpen the interests of the National Health Service in the provision of clinical research facilities, in the setting of priorities for clinical research and to ensure that the results of research are used in the care of patients for which the concordat referred to by the Minister is so ineffective an instrument in practice. We suggest that the authority might also be responsible for the allocation of SIFT money which, if it is to be extended to cover research, must be in the hands of a body able to take decisions about national research priorities.
The national health research authority is the centrepiece of our proposals. It will be strongly opposed, I imagine, by the DHSS which has not seen the need to be involved in research and by the regions which either share the same view or, if they do not, would not wish to give up what they might then see as a jewel in the crown. We made the proposal nevertheless, and most seriously. I hope it will be seriously considered by the Partridge Committee 299 which has been set up jointly by the DHSS and the DES to examine some of these problems.
There is another route which, if taken, would eliminate many of the present conflicts. It is to follow the practices of other countries, not least the United States, where university hospitals are entirely the property of universities, funded through them and managed by them. The chief of services in the health care sense and the head of department in the academic sense are the same person. This last arrangement is followed by the Royal Postgraduate Medical School at Hammersmith which relates to the National Health Service by means of a special health authority created to administer to its special needs. The hospital, in that case, does not belong to the school, but it is academically led as in other countries and works well. If special health authorities were created for all the medical schools they could perhaps then depend upon a national authority such as the one we have proposed.
The possibility remains, however, of following the American model more exactly, the teaching hospital actually being operated by the university. That would require a considerable upheaval in the financing of universities which, however, we have already been led to expect with the advent of the Universities Funding Council and the adoption of contract funding. If there is to be in addition a measure of privatisation of the National Health Service, the way is open, it seems to me, to consider the wholesale transfer of responsibility for the teaching hospitals from the health service to the universities. That would remove many of the sources of conflict of which I have spoken.
§ 5.1 p.m.
§ Baroness Lockwood
My Lords, as a member of the inquiry committee I welcome the opportunity for the House to debate this report. I should also like to pay tribute to the noble Lord, Lord Nelson, for his patience and thoroughness in guiding the committee through the large bulk of evidence during the course of our proceedings.
As the chairman has said, the inquiry was at the same time both stimulating and depressing. It was stimulating because of the future prospects for medical science: and it was depressing because of the low morale which we encountered. Professor Sir David Weatherall summed up the situation when he said that academic medicine had been affected by cuts in the National Health Service, by cuts in university funding and by cuts in the Research Council's support.
At paragraph 2.73 we quote his remark:It is a great shame that we are Facing this crisis at a time when the basic sciences are offering us the possibility of making the next 50 years the most exciting and productive for medical research; we must not miss this opportunity".Sir David was the first witness to appear before the committee; but much of the subsequent evidence confirmed what he had said. At paragraph 8.1 your Lordships will notice that the committee concluded that the overwhelming body of evidence indicates that medical science is under-funded. Although the cost and the financing of the health service were not 300 within our terms of reference, we went on to make a recommendation—a modest one—for a special allocation of £25 million a year for three years to modernise and re-equip our medical research facilities.
As the noble Lord, Lord Prys-Davies, indicated in his contribution, in so many cases a modest additional contribution to medical science can make such a difference. He also quoted the recommendations to the committee of Sir David Weatherall and others that we should seek an extra 200 to 250 places for medical research. Our modest proposal of £25 million a year for three years was put forward for four reasons. First, as a stimulus for bringing medical research and the health service more closely together. In this respect, I should like to underline what the noble Lord, Lord Nelson, said. One of the gaps which the committee found was that the needs of the health service were neither clearly defined nor clearly articulated because it was nobody's responsibility to do so. Nor were the needs of the health service and the possibilities in research complementary components for determining priorities in medical research; hence our central recommendation for a National Health Service research authority.
I must say to the Minister that nothing he said this afternoon in his opening remarks convinced me to the contrary. I should like to point out to him that the £18 million which the department spends directly on research represents less than 0.01 per cent. of the total expenditure on the National Health Service. If any industry were to consider spending such a small proportion of its turnover on research and development, it would be very seriously criticised by the Government.
Our second reason for making the recommendation is that new opportunities are being opened for us in medical research. This is especially so in molecular biology. Thirdly, it is important to help our universities to remain competitive. Fourthly, it is necessary in some way to improve the morale of scientific medicine, and we believe that this contribution could go some way towards it. However, the committee recognised that not all the problems are finance-based. Greater co-ordination between all the agencies involved is certainly a most important factor. Again, our central recommendation for a National Health Service research authority would contribute to that end.
We also recognised that better health may not necessarily involve more expensive treatment. The promotion of better health, the evaluation of existing clinical practice and the assessment of both new and existing techniques and procedures as well as systematic clinical audit would be part of the functions of the proposed new body. That could help to lead towards better health without increased expenditure.
As many speakers have already indicated, crucial to the nation's health is the availability of sufficient well-trained scientists and doctors and a firm scientific base for medical research. In this respect, the committee certainly had a number of concerns. We were concerned about the career structure in academic medicine. A number of factors seemed to 301 militate against the best medical students being attracted into research.
First, at undergraduate level, there has been a decline in the number of students who were funded for intercalated degrees. In the past, intercalated degrees were largely funded by the MRC who now indicate that they feel that such degrees are more for training purposes than research and therefore not their responsibility. The committee recognised, as did many people who provided evidence, that to provide an intercalated degree by an extra year of scientific study need not necessarily equip a student for a research career. However, it would give the student an opportunity to learn research techniques and to make a better choice. It would also, as the most reverend primate the Archbishop of York said, equip the doctor—if the student went into general practice—to evaluate more critically and assess the reliability of the evidence before him, or her. Therefore the committee recommended that the intercalated honours degree should be available to all medical students who opt for it. They recommend that it should be funded by local education authorities as part of the mandatory grant system.
Secondly, at postgraduate level those students who opt for training in medical research must add this to their already long training period. The deterrent in that is quite obvious and applies in many ways. It delays their entry into the profession: it prevents them from getting a foot on the promotion ladder and, the grants or pay for postgraduate research posts—which they would go into as an alternative—are low and, as has already been said, are normally now on the basis of short-term contracts. Therefore there is no security in this option, and there is certainly no career prospect.
In the past there has been some difficulty in obtaining credit by the Royal colleges for time spent on research when applying for clinical posts. The committee was both relieved and grateful to the president of the Royal College of Physicians in Edinburgh who is now Chairman of the Joint Committee on Higher Medical Training—to learn that this factor is now being taken on board.
Another factor is the temptation for the student to go straight into general practice where the immediate rewards are higher and where there is greater security. In some ways perhaps this is not a bad thing because obviously general practice would benefit from receiving a good share of the brightest people. However, the committee was concerned that the career structure appears to be so rigid that if a person moves into general practice there is little opportunity thereafter for him or her to move across into academic medicine. Thus we should like to see more flexibility in that connection.
We have already heard from the noble Lord, Lord Flowers, that the prospects presently offered by universities are not encouraging; that is, either for clinical researchers or non-clinical researchers. The Committee of Vice-Chancellors and Principals expressed serious concern at the underfunding of the dual support system. They indicated that between the years 1980–1981 and 1986–87 there had been a net 302 loss of 551 full-time wholly university-financed academic clinical staff, which represented a 21 per cent. reduction. On the other hand, the compensating increase in full-time staff funded from other sources—that is, not wholly university funded—has come largely through the growth in external research income. However, it includes many short-term contracts which, again, is a deterrent.
While the increase in external funding is to be welcomed, it can in no way replace publicly-funded sources which not only secure the medical base in the universities, but also underpin the necessary academic freedom to pursue research which is unconnected with specific projects. Indeed, in his comments the Minister referred to what is being done by the Government to meet the crisis caused by the AIDS disease. It was pointed out to the committee on many occasions that we would not be nearly so far on the road to coping with AIDS as we are had it not been for the basic research that has been done in biology over the past 10 or 15 years.
Other pressures on research, especially on clinical research, come from the National Health Service itself. As has already been pointed out, when a doctor is responsible for patient care, teaching and research, it is inevitably research that goes by the board. The problem seems to have been exacerbated to some extent by the Hayhoe Report, Achieving a Balance. We see at paragraph 3.26 that no provision for honorary contracts was made in the first Hayhoe Report. That applied both to the public sector and to the charities who were themselves not initially given honorary registrar posts. It seemed to us that no account appeared to have been taken of the research needs of the health service.
The memorandum from the Dean of Medicine, the University of Leeds, at pages 271 to 273 of Volume II of the written evidence, sets out the severe constraints put on the Leeds Medical School and on the Yorkshire region because of the shortage of senior registrars. He outlines the enforced changes in structure of academic clinical departments that are taking place as a consequence of the JPAC senior registrar policy. This is further outlined at page 274 of Volume II by a letter written by Professor Semple of University College and Middlesex School of Medicine. He estimates that:there will be a reduction of about 1,000 to 1.300 Registrars out of I total of approximately 5,000 Registrars in England and Wales".He points out that the reason for the suggested changes in the staffing structure is due to the fact that the service work load on senior and junior academic staff will be increased. And, if the service load on the clinical staff is increased, inevitably that must reduce the time and energy available for research.
The committee were most concerned that the crucial role of medical research in the health service appears to be undervalued. Therefore, we hope that the Government will take note of the committee of inquiry's report. Further, we hope that they will act upon it to ensure that the research capability of the United Kingdom in medical science is continued in the future.
§ 5.20 p.m.
§ Lord Kearton
My Lords, perhaps I may begin by paying tribute to the chairmanship of the committee by the noble Lord, Lord Nelson. It was a long, arduous and exacting inquiry. Without the noble Lord's inspired leadership we should often have been bogged down. As previous speakers who were on the committee have said, his guidance and good humour took us through a major task. We are all grateful to him. I should also like to echo the tributes paid by the noble Lord to our two specialist advisers—Sir John Butterfield and Professor Walter Holland. As a lay member, it would have been impossible to have played a constructive role in the committee's work without the guidance and help that those two expert and remarkable men gave to us. As the noble Lord said, we and the House are deeply in their debt.
The noble Lord gave a wonderful over-view of the committee's conclusions. I was somewhat disappointed by the Minister's reply. I have a great admiration, even affection, for the noble Lord, Lord Skelmersdale, whom I believe to be an extremely efficient Minister and Member of the House. However, he had to play a straight bat and stonewall.
We recommended that to make up for the lack of essential equipment in our universities and the Medical Research Council's major laboratories we needed a minimum of £25 million per annum for three years. That figure was not picked out of the air. It was the result of careful cross-examination of all the people concerned with fundamental research. If he had been able to say that the Government were taking the major issues which research raises into consideration and that they had agreed to that £25 million for three years, it would have at least shown how serious they were about research and the committee.
A government who can, on the nod, offer £100 milllion to bring Baron Thyssen's art collection to this country can surely provide the relatively trivial amount needed to keep the nation's main research effort in good heart. We hope that the noble Lord, Lord Skelmersdale, whom we so admire, will take back that message to the Minister.
The report contains two main threads—science-led research and service need. In science-led research, as the noble Baroness, Lady Lockwood, has said, molecular biology is transforming the whole approach to investigative medicine. We were the world leaders in molecular biology. It can almost be said that it was started in this country. The work has been taken up enthusiastically in other countries. We still have first-rate people, but they are inadequately funded. We found, for instance, that the New Institute at Oxford was lucky to receive £2 million to start a new institute of molecular biology. When we were at Stamford University, California we found that it was spending 60 million dollars on a new institute of molecular biology. We found that Harvard was backing a professor with 40 million dollars for an institute of molecular biology. The same was true all over America.
Our funding is trivial. The Minister made use of statistics of our total spending on research. He brought out the fact that rather more than half of it 304 is spent by the big pharmaceutical companies. As the noble Baroness, Lady Lockwood, pointed out, in their evidence to us those companies said that their whole development depended upon the fundamental work being done in the universities and medical research laboratories. The work of the pharmaceutical companies has been beneficial to the health of the people and has produced a large export surplus. They were worried, as we all were, that without continued adequate funding for basic research in our major medical institutes, that source of their inspiration and, for that matter, their source of trained men, would dry up.
The research now possible in molecular biology requires the use of increasingly expensive and highly specialised equipment. Success will give detailed insight into how the body's defence systems operate and how they can be successfully reinforced. For service need we require more effective provision for public health research and for operational research.
The Minister said that we had something to boast about. He mentioned that the DHSS was spending money in that field and gave some interesting examples. He did not say that the DHSS's total budget is £12 million. The noble Baroness brought out that point. It is a trivial figure. Whereas the research work about which he talked gives a few welcome little specks of light, what the field needs is a great searchlight of illumination with something much more adequately funded than the pettifogging ideas which so far hold sway in the DHSS.
Work in operational research and public health research will have a quick pay-off. It will greatly facilitate the efficient running of the National Health Service. Of all the things upon which we could spend money it is the area which will produce the quickest pay-off.
The main feature of our report is that we recommend the setting up within the National Health Service of a national health research authority. Its main purpose would be to bring the National Health Service into the mainstream of the medical scene, both in outlining its needs and seeing that the fruits of research are systematically transferred into results.
The science-led research would still be funded through the MRC and University Grants Committee. The service need would be funded by the National Health Service through the new national health research authority.
I should like to spend the rest of my time on one issue, which was touched upon by the noble Lord, Lord Flowers, explaining the committee's recommendations relating to the protection of the facilities for clinical research in the teaching hospitals and medical schools. Those recommendations are essentially contained in paragraphs 4.26 to 4.32, under the heading of SIFT, which as the noble Lord, Lord Flowers, said, stands for service increment for teaching, and "knock-for-knock". They are technical, but they are crucial.
The committee states that one of the most important functions of its proposed NHRA would be:to ensure …an adequate research capability for the needs of the NHS in clinical …research"—305 and—to advise on the implications for medical research of National health Service policy and practice …and where conflicts arise to ensure that the interests of research are fully taken into account".Both the medical schools and the NHS have recognised that their common interests and involvement in clinical research are so complex that the most efficient way of administering it was by the knock-for-knock system; that is, the NHS would provide the service facilities for the patients involved in the research, and the academic clinicians would provide a proportion of the patient care; and neither side would try to account in detail for their relative contributions to the common purpose, but would assume that their contribution was balanced by the benefit they gained. Clinical research, as the noble Baroness emphasized, is the means by which technology transfer of new techniques into the health service is effected; by which treatment for patients is improved; and by which causes and mechanisms of diseases can be better understood.
Knock-for-knock has worked well enough in the past, but with spending restraint the system has come under increasing strain. Clinical research is expensive. It requires levels of nursing and ancillary services which are higher than average, and it may require longer stays in hospital. Hard-pressed health authorities tend to reduce spending on the extra services needed for clinical research. Academic clinicians then put the immediate interests of their patients first, above their research interests, and they make up service shortfalls. Research is the loser.
There is very strong evidence— the committee received a great deal of evidence—that particularly in London, clinical research is being hampered because researchers are spending too much time on patient care and health authorities cannot provide adequate nursing care.
That problem is not peculiar to the United Kingdom. During our visit to the United States we learnt that every major American research centre we visited faced similar problems, which they solved in different ways and, as one might guess, with different degrees of success. To put it bluntly, research costs rocket if patient service is charged to research funds. One gets a totally false impression of how much has been spent on research. The research centre whose system most closely resembles our own is that in Boston and Harvard. The medical schools at Harvard use the local hospital system—notably the Massachusetts General Hospital—for their clinical research as our medical schools use NHS teaching hospitals. Indeed, the American researchers and administrators told us that they saw the NHS as providing potentially the ideal basis for clinical research.
The committee saw no alternative to the knock-for-knock system. It considered that it would be foolish to try to disaggregate academic expenditure from service expenditure in this field. The problem is how to improve the way it works. We believe that the proposed national health research authority would be in an ideal position to advise and assist in making the knock-for-knock system work.
306 We make a specific recommendation to ensure that those funds which are already set aside to meet the demands which academic medicine makes on the health service are used in the most efficient fashion. Incidentally, the report makes it clear that teaching and research are inextricable, a point on which the noble Lord, Lord Flowers, touched.
The SIFT (service increment for teaching) budget is designed to cover the extra cost to the NHS of running a teaching hospital rather than an ordinary hospital. This budget is allocated on the basis of a fixed payment per medical student to the district health authority in which the teaching hospital is situated. At present the allocation is approximately £30,000 per medical student. There are something over 12,000 medical students, so the total SIFT budget is very substantial—approximately £380 million.
District health authorities in teaching districts make no bones about the fact that they rely on this budget to meet their general expenses. It is not therefore applied specifically to the purpose for which it is intended—namely, to support the service needs of teaching and therefore research. Moreover the means of allocating it is rather crude. It will be obvious to your Lordships that it is likely to be more expensive to provide services in a London teaching hospital than it is in a teaching hospital in the regions. Yet at the present time the SIFT allocation is the same for each.
We understand that the SIFT budget is being reviewed. We welcome this. As part of this review, the option of paying the SIFT budget direct to medical schools should be investigated. We were aware that the complexities of NHS funding, may mean that there could be difficulties. Nevertheless I stress that, so far as we, the committee, can see, the proposal has many merits, and we would have to be convinced of its impracticability. If university medical schools had control of the SIFT budget, they would be able to say to NHS managers, "We want this ward serviced and staffed to this level, and here is the money to pay for it." The medical school would in fact buy the services for research within the NHS that it needed. I believe that would be both efficient and in line with the general trend of management thinking within the National Health Service.
It is of course true that district health authorities—who have received the SIFT payment heretofore—would lose control of money which they have been tempted to apply for their general needs. But that is a fault in the NHS system. To put it bluntly, let me say again that over the past few years the SIFT budget has not been used for the purpose for which it is intended. That, I suggest, is a situation which ought to be remedied in any case. It is not for me to make recommendations as to how district health authorities' budgets could be restructured so as to meet their general service needs. What I am proposing is a system for the proper administration of the funds already allocated for teaching and research.
In our report, the committee says that the NHRA could with advantage administer the SIFT budget, although the recommendation to pay SIFT to 307 medical schools is valuable independently of the existence of the national health research authority. Nevertheless I again stress very strongly our belief that the two recommendations strengthen each other enormously. SIFT should be administered centrally, with a degree of selectivity and accountability, rather than on a crude per capita basis. For the national health research authority to administer SIFT would be to give the authority a second real job to do, a substantial budget to allocate, and therefore real teeth. That would increase the research authority's leverage in carrying out its wider functions.
The advantage of the research authority administering the SIFT budget would be that the budget would be allocated by the body with the responsibility for maintaining the national research base needed by the National Health Service. The research authority could take a view on the relative costs of clinical research in different areas of the country. It would be able to develop means of allocating resources selectively between medical schools on the basis of teaching and research excellence. It would be a development in line with present moves to ensure the efficient spending of public moneys in research and in the National Health Service.
I must emphasise that our recommendations relating to SIFT do not mean that money would be taken out of NHS service in order to fund academic research. SIFT would continue to be used for services in hospitals. A district which had been using SIFT for the purposes it was meant for would find that the money was being spent in the same way as before. There is just one exception to this. Medical schools often use hospitals outside teaching districts for teaching purposes. Our recommendation would allow all medical schools to reimburse such hospitals for the costs they incur, and perhaps encourage greater flexibility in the use of clinical resources. At present that is the practice in only a proportion of regions.
In short, we believe the system we propose—granted the necessary period of transition in making the administrative change—will be far more flexible and far more efficient. I apologise for taking so much time on a specific recommendation, but I thought that a definite "for instance" might be helpful for the House to consider. I hope that the Government will give our recommendation on SIFT a very high priority.
§ 5.36 p.m.
§ Baroness Blackstone
My Lords, like many other speakers in this debate I welcome the report. There can be few more important areas of research than work that tries to advance our understanding of the causes and nature of disease and how it may be prevented, controlled or cured. New discoveries in medical research have transformed the lives of millions of people, not only in this country but around the world.
The UK has a long tradition in medical research of which we can be very proud. I fear that there is now a danger that our contribution will no longer be what 308 it was, for a very simple reason. Although we still have many dedicated and talented medical scientists who are capable of doing medical research at the frontiers of knowledge, they are grossly underfunded. Poor working conditions, rundown laboratories, obsolete equipment and insufficient supporting staff, whether research assistants or technicians, are almost certainly affecting their productivity. They are definitely affecting their morale.
I should perhaps declare an interest. Although there is no medicine as such at Birkbeck College where I am the Master, a number of Birkbeck staff in chemistry, crystallography, and psychology are doing interdisciplinary research in medical science. They are talented people, in a number of cases with international reputations. Whether they can maintain these reputations if the shortage of resources continues is open to question. I shall give some examples of their work in a moment. Like the most reverend Primate the Archbishop of York and my noble friend Baroness Lockwood, the point I want to emphasise is that some of the most important medical research is undertaken by those in science departments in universities applying their expertise in basic science to medical problems. Some of this work is done in collaboration with clinicians; some does not require that kind of collaboration. Where it is necessary, it is absolutely vital that the clinician should be given more time than at present to collaborate with those in basic science disciplines. As the noble Lord, Lord Winstanley, said, lack of time is preventing progress being made.
It is also very important, as other Members of your Lordships' House have already said, to prepare future clinicians properly. The proposals in the committee's report for an intercalated year and more research training for medical students will help in this respect if they are accepted. I am sure that university science departments will be more than willing to help with this. In order to make all this possible, the MRC should be given enough funds to renew, for example, its partnership award scheme, which it has had to abandon through lack of resources.
The committee correctly concludes that, for the greater part, priorities in medical research should be set by science-led initiatives, but that they should also, in specific areas such as AIDS, be set by direct research programmes.
However both proactive and reactive modes of setting priorities will require multidisciplinary activities with increasingly close co-operation between clinical researchers, molecular biologists and immunologists, all of whom are presently funded by the MRC, together with organic chemists, biochemical and medical engineers and biophysicists, who are often outside the medical research community. This multidisciplinary research activity is paralleled by a pluralistic policy of priority-setting by the research councils, the charities, the universities and the pharmaceutical industry.
A major objective must be to create a more favourable environment in which this complex matrix of activities can thrive. Work in my own 309 college exemplifies the new developments and the new pressures that on the one hand create optimism about medical science, but on the other create very considerable despondency about its reaching fruition in the present financial climate.
As the report outlines and as the noble Lord, Lord Kearton, has just said, molecular biology has in the past few years given us many clues to the causation of disease. This is a qualitative change; it is something new. The understanding can and should be exploited by rational approaches in the design of drugs, vaccines and novel proteins. Thus, for example, molecular biologists and biophysicists at Birkbeck are collaborating with immunologists at the School of Hygiene and Tropical Medicine in the design of a vaccine for hepatitis. They have collaborated with Hammersmith Hospital and with pharmaceutical companies to produce new drugs that inhibit a specific enzyme, renin, for lowering blood pressure. Chemists at Birkbeck collaborate with London hospitals in the use of nuclear magnetic resonance to scan for unusual metabolites in body fluids and with industries to produce novel metallodrugs.
We have both collaboration and jointly funded posts with the Imperial Cancer Research Fund, the Ludwig Institute for Cancer Research and the Cancer Research Campaign. Psychologists are collaborating with London hospitals in research on the effects of brain damage on patients. At present, difficulties and despondency arise mainly from the decrease in support from the research councils and the UGC. That has led to a number of problems, such as the need to rely on obsolete equipment. I very strongly endorse what the noble Lord, Lord Nelson of Stafford, said this afternoon and what was printed in the report of the Select Committee that this problem more than any other is the one that depresses many medical scientists.
Further, salaries for postdoctoral workers in universities are considerably less than those of equivalent workers abroad and those earned by workers in the charities and in industry. I give an example of one of our students who is currently completing a Ph.D in biocomputing and molecular biology who has been offered a job in Japan at a salary of £23,000 per annum. A potential young applicant for a lectureship is presently being paid £27,000 a year at the European Molecular Biology Laboratory in Heidelberg. How can we possibly compete with that when that is the salary for a professor here? Ten postdoctoral students from one of our departments left for the United States last year; they comprised 70 per cent. of the output of that department.
Recurrent funding for medical research in universities in this country is between 20 per cent. and 40 per cent. of that available in similar institutions in the United States. In those circumstances is it surprising that young scientists leave? I was interested to read in an appendix to the report that the committee went to the USA believing that American pre-eminence in medical research was the result of massive private and industrial support, only to learn that the vast majority of institutions received most of their money from public sources. Between 75 and 90 per cent. of their money came from public 310 sources—mainly from the National Institutes of Health. The Government here must surely recognise that most research in public institutions must be publicly funded. Industry will of course do a great deal of research of its own. That is fine as long as the balance does not swing too far in the direction of basic biomedical research being industry-based. Here again I strongly agree with what the most reverend Primate the Archbishop of York said on this.
Glaxo can afford to spend £500 million on a new research centre in Stevenage. I am very pleased that it is doing that, but when did we last spend equivalent sums on university biomedical research laboratories? Research publications from industry will always be constrained, at least to some extent, by commercial considerations. This has dangers for the public, particularly in the medical field.
The Select Committee must be congratulated on emphasising the seriousness of the situation. Both science-led and directed programmes require well-found laboratories and adequate support for highly motivated researchers. Success in attracting continued funding from the charities and industry must depend on a revitalisation of centrally important chemical and biological research. At the present time many of our universities find it difficult to meet their commitments to the charities, to industry and to scientists in other countries where they are collaborating with them. This collaboration with scientists abroad will become even more important with further EC and international programmes. For universities to lose the opportunity of participating in this rich period for medical research will be to damage the efficiency and the future effectiveness of both the pharmaceutical industry in this country and the National Health Service.
The demoralisation that the committee identified among medical scientists could have been prevented by a few million extra pounds per annum over the past decade. We now need considerably more than a few extra million pounds to regain our place among world leaders in medical research. The Minister said that he wanted to boast about the Government's record. No doubt there are some things to boast about, but seeing these matters from the perspective of interdisciplinary university-based medical science, there is I am afraid to say more to be worried about than to boast about. There are also some things to be ashamed about.
Perhaps there are no right answers on exactly how much money we should be spending, as the Minister said. But a visit to a small number of university departments would, I feel sure, persuade him that there is a right answer which is that more should be spent than at present. I hope that the Government will accept the recommendations of the Select Committee and provide the necessary funds.
§ 5.47 p.m.
§ Lord Swann
My Lords, I think, like every noble Lord who has spoken, that we owe a great debt of gratitude to the noble Lord, Lord Nelson of Stafford, and his committee. I am sure that its report must rank as a classic among Select Committee reports. If the Government adopt its recommendations, one cannot 311 doubt that the pace and the quality of all kinds of medical research will be enormously enhanced, as will the practice of medicine.
However, I cannot help asking myself whether the Government will follow the guidelines that the report has laid down. To judge from the response to earlier reports in this area, one can only have one's doubts. Indeed, as the report emphasises, there is a widespread feeling that the Govenment do not really care about research, even medical research. We can only wait and see whether the usual appreciative noises actually result in action.
It is hardly surprising that research morale is so low. I wish to quote from Sir Walter Bodmer, the director of the Imperial Cancer Research Fund, in his evidence to the committee. He said:It is little less than appalling that a Department with an approximately £20,000 million pound annual expenditure on the National Health Service, funds a research programme of its own at a level hardly more than £20 million.As the noble Baroness, Lady Lockwood, has, with impeccable mathematics, pointed out, that is precisely 0.1 per cent. of the cost of the National Health Service. I cannot help noticing that the Government always want to introduce industrial thinking into academic and research circles. But what sort of high-tech firm—medicine is very high-tech these days—can they have in mind that spends so minuscule a fraction of its money on research? That is not wholly fair, of course, because the Government spend £120 million or so on the Medical Research Council. That, together with the DHSS expenditure, puts the figure up to about 0.7 per cent. of the cost of the National Health Service. I suggest that that is hardly impressive when one considers that high-tech firms often spend proportionately 10, 20 or even 30 times as much.
Although I spent a good many years as a biologist researching on the fringes of medicine, I am not competent to comment in detail on many of the report's recommendations. However, I am now a trustee of the Wellcome Trust which supports research to the tune of over £40 million a year over the whole range of basic and clinical research. I therefore wish to make a few points about the role of the medical research charities. Many of them cover particular corners of research—most notably cancer, heart disease, arthritis and rheumatism, and so on—though a great many smaller charities have other concerns. Most of them depend on raising money from the public. That inevitably means that areas of research with less public appeal—old people, for instance—are scantily represented.
By contrast, the Wellcome Trust, where our seven trustees own the vast majority of shares in the international Wellcome drug company, is not constrained in that way. But, like all the others, it cannot be quite certain how its income will hold up year by year. Nevertheless, the medical research charities are a very significant force in the funding of medical research nowadays. Their total spend in 1986 amounted to about £110 million at a time when the spend of the Medical Research Council was £120 million. By now I suspect that the charities have overtaken the Medical Research Council.
312 One might suppose, that being so, that Government thinking would have wanted to see at least a measure of collaboration with the charities. Sadly, as the report notes, there seems to have been very little of that. The Advisory Board for the Research Councils—the ABRC—took no account of medical charities in its recent report on the strategy of the science base; the widely criticised attempt by the University Grants Commitee to rank the research of universities and their departments took no account of the charities and neither did the National Health Service in its manpower planning. Indeed, the charities often deplore the lack of openness of government agencies as they plan for the future. We are delighted to see that the report recognises that and we hope that it will prove a watershed in the future organisation of medical research in the United Kingdom.
When there is talk of closer collaboration and consultation between the medical charities on the one hand and the Government and government sponsored bodies on the other, in no way would we want either side to be a carbon copy of the other. Consultation on general issues, yes; on specific issues, no. That is so precisely because—the most reverend Primate referred to the matter in his speech earlier this afternoon—there is no monopoly of wisdom anywhere in this world, least of all when it comes to choosing and directing research. Indeed, there is a terrifying history of inadequacy even on the part of distinguished researchers when it comes to deciding what research will prove ultimately important and what will prove insignificant. Peer review, as it is called, is a decidedly chancy business, albeit it is the best that we can do.
There is one way and only one way of increasing the chances that the right decisions will be made. That is to have a multiplicity of independent sources of funding, so that someone somewhere gets things right. When it comes to such detailed decision-making, the more independent the funding sources, the better. Perhaps there ought to be in principle several smaller rival medical research councils. Somehow I do not see Her Majesty's Government, radical as they like to see themselves, being quite so radical as that.
A multiplicity of sources of research funding is certainly a good thing. The charities contribute to that in a big way. However, they have their problems. One is the uncertainty that necessarily overhangs the stability of their income. What the research world actually needs is the possibility of funding over longer periods free from all the uncertainties of short-term funding. Only the Government can solve that problem, though the charities are doing what they can.
Another problem, stemming from successive cuts in university funding, has been the gradual decline in what is known as the research base. Equipment, for instance, is sorely lacking. We have heard about that already this afternoon. It is highly welcome to see that the report recommends that £75 million should be provided over the next three years. Universities are desperately in need of funding, not only for equipment but also for many other overhead costs. While grants from government sponsored bodies 313 usually carry such overhead costs with them, grants from charitable sources do not unless the charity pays up. However, medical research charities were not set up for making good the deficiencies of basic government funding of universities and we see no reason why they should be. We are glad to see that the report takes a firm line on that matter and recommends that the University Grants Committee and its successor body should pay the general overhead costs associated with the funds granted by charities.
On the other hand, charities have some marked advantages over government departments and government sponsored bodies. For instance, they can pay the rate for the job rather than adhere to the characteristically stingy and out-of-date rates of pay which have already been referred to by the noble Baroness, Lady Blackstone, and which seem to be the norm in government funding.
Perhaps I may give the House one example. The Wellcome Trust this year advertised and duly appointed 50 or so new prize Ph.D studentships with a higher stipend and a greater research expenses allowance than the DES allows. The result has been quite dramatic. It is time that the DES realises that we live in a competitive world, just like industry, which is so often held up to universities by the Government as a model to be followed.
Perhaps I may mention two other features of charitable funding which I believe the Government would do well to ponder. Not long ago the Wellcome Trust held one of its periodic meetings with its grant holders. We were pleased and flattered to hear that when those grant holders had approached a research council they were given a form to fill out; when they approached the Wellcome Trust, they got a lot of friendly, helpful and continuing advice from the trust's expert senior staff who are all medically or scientifically qualified and one of whom is no less than a Fellow of the Royal Society. In short, the trust, in common with other trusts, believes that it is eminently worthwhile employing such people, notwithstanding that it costs more. We believe that that policy has paid off handsomely and I have no doubt that it should be copied by the Government.
Moreover, charities are not constrained by the fashions inspired by centralised government decision-making, one such being the idea of interdisciplinary research centres—IRCs for short, and, I believe, usually known in university circles as "erks". They have their points and in reality quite a number of them already exist in one form or another. However, because they will carry extra money from the Government, the universities and the research councils are busy inventing them regardless, or trying to show that they already have them. Of course they then run the risk that they will be short of money for the ordinary, everyday small research grants which are so crucial not least for getting younger staff started on their careers. Indeed, the Medical Research Council has recently had to announce that it is cutting funding in precisely those areas.
By way of a postscript—with a moral—I want to describe a fascinating moment in a Wellcome Trust meeting just a week ago. A sizeable application had 314 gone through the usual vetting by an expert panel and was being put to the scientific trustees for final approval. The project concerned the problem of how nerves might—and I emphasise "might" because only time will show whether it is possible—be induced to grow again into a broken spinal cord and the paralysis that presently accompanies such damage might he avoided. I need hardly remind your Lordships how important that could be when quite a number of our colleagues bravely face that awful disability.
The application was widely commended. It was deemed highly original, highly imaginative and very soundly based on a lot of extremely good earlier work by the applicant. However, the circumstances were unusual. The man in question is relatively young. He works on his own and is not part of a team. He works in a department whch is by no means highly rated in the UGC's recent invidious ranking exercise, and he is in a university which is in great financial trouble and if any universities are to be closed is a very likely candidate. In short, the trustees noted with much satisfaction that the circumstances of that applicant are the complete antithesis of the kind of centralised thinking that now weighs so heavily over our universities. Originality, my Lords, cannot be planned.
§ 6.2 p.m.
§ Lord Colwyn
My Lords, I had intended this afternoon to make some comments on dental research. However, when I tried to think of something to say I discovered that despite trying to keep up with current theories on dental disease and materials I was a little further out of touch with the very latest research than I had realised. In the regrettable absence of a brief on any aspect of current dental research I have decided to confine my few short remarks to another vital aspect of health.
There is no doubt that the noble Lord, Lord Nelson, and his committee must be congratulated on their report and on many of their recommendations. However, I feel compelled to draw your Lordships' attention to one very serious omission in the report of the Select Committee; namely the absence of any consideration of research into complementary therapeutic systems and techniques. Research in that field is both essential and urgent for public protection in view of the steadily escalating demand for increasing access to such therapies.
In 1986 one in three people used or considered the use of complementary therapies and 50 per cent. of all GPs either referred their patients to complementary therapists or took active steps to increase their own knowledge of the subject.
I do not know how different bodies were invited to give evidence to the Select Committee, but within the list of about 250 witnesses there is only one submission from an expert in complementary medicine which, I repeat, is now an important factor in medical treatment for one-third of all patients.
Fortunately, an independent research council capable of tackling that formidable task established itself in 1983 and has already made substantial further progress since it submitted evidence to the 315 Select Committee in March 1987. The work of the Research Council for Complementary Medicine has included work on the validation of the major complementary therapies which has resulted in an increase in their credibility and acceptance within the orthodox medical profession.
Research projects at the Universities of Surrey, Sheffield. Belfast and Glasgow, and work in some London teaching hospitals, have resulted in papers being published in internationally recognised medical journals. Much of that work is carried out by the orthodox fraternity, with or without the co-operation of complementary practitioners. In many cases medical academics have acted as supervisors or enablers.
In 1983, the task of the Research Council for Complementary Medicine appeared relatively simple: the encouragement of research and the raising of funds for that purpose. However, it has since become clear that research in this field presents additional problems.
Owing to the absence of a grade similar to that of registrar in their training establishments—for which the implementation of research projects, under the guidance of established professionals, is included in the job specification—the majority of complementary practitioners lack the necessary expertise and experience as well as the time, materials, facilities and finance, to undertake research projects of a quality sufficient to command international acceptance.
For that reason the RCCM now sees the necessity for a wider remit and has decided to assume an educational and advisory role. In the area of training for research, the RCCM will be initiating and advising on projects as an integral part of the curriculum. Until that is achieved, much of the research within complementary medicine will necessarily have to continue to be undertaken by the orthodox medical profession, which is not wholly satisfactory.
Already, many professional organisations and colleges are asking the RCCM for advice and guidance. This role will be extended to those organisations wishing to set up information databases. The RCCM, together with the British Library, will act as central co-ordinator of a network of research literature resources throughout the country.
The Council's first Fellow in complementary medical research—based at Glasgow University—is successfully engaged in investigating methodologies suitable for such research because in many cases the conventional methods are not always appropriate. He is half way through his three-year appointment and has made considerable contacts with overseas organisations.
The RCCM itself has links with the Bonn Government, who have recently set up a similar organisation, and with the Netherlands Government who have appealed to the RCCM for help with research training.
It is in the critique of conventional therapeutics that the movment for positive health and 316 complementary medicine finds its justification. If modern medicine were all it is claimed to be—a wonderland of miracle drugs and life saving gadgetry, holding out the promise of final victory over disease—research into alternatives would be unnecessary. But as the myth of medical effectiveness gives way to a growing awareness of the limits and dangers of pharmaceutical medicine, so more and more thinking people are taking the decision to seek safer and more effective ways of coping with illness.
The RCCM sees its work resulting in the eventual integration of various more cost-effective methods of health care—in the wider application of therapies such as acupuncture, homeopathy, medical herbalism, osteopathy and chiropractic—where appropriate, for many chronic and non-life threatening conditions and for geriatric care. This would free expensive high technology and costly drugs for those who are in urgent need of them.
I am sorry to have missed my noble friend the Minister's opening speech but I shall look forward to reading what he said in Hansard tomorrow. I hope that he will either have already agreed with me about the sad omission of any reference to the complementary therapies in the report or that he will be able to assure me, in his winding up speech, of the Government's continuing and increasing recognition and support for this essential aspect of our health care in the future.
§ 6.10 p.m.
My Lords, like other noble Lords who have already spoken, I too welcome the report. I also appreciate the lucidity and completeness of the comments made upon it by previous speakers which allow me to focus my remarks literally on one word. My comments will relate to the interests of medical students who have occupied so large a part of my thinking during my lifetime.
There can be no doubt whatever that the teaching of clinical students by those who are engaged in active research or have been well known research workers and understand the discipline is tremendously stimulating, exciting and inspiring. Without proper research facilities around a medical school it would be a very flat and dull place.
In my youth, the excitement of clinical medicine was enough to enable most of us to enjoy our days as students. I believe that there has been only one notable example of a medical student who made a research contribution that became widely known throughout the profession. It was achieved by a previous Member of your Lordships's House, the late Lord Rosenheim, who, as a student, developed a treatment for urinary infection that held sway and was in wide use for about five years until the sulfonamide drugs were introduced. Opportunities for a student to do anything in the research line were minimal, and the achievement of the late Lord Rosenheim was widely acclaimed.
As the report noted, the intercalated year—the year supported by the most reverend Primate the Archbishop of York and the noble Baroness, Lady Lockwood—has nowadays become:either standard or available at a few universities".317 That is encouraging, but the report goes further and says that:the intercalated year should ultimately be standard for all medical students".It is the word "all" with which I wish to take issue this afternoon.
Anyone who has spent over the years what can seem like aeons of time in committee trying to keep the medical curriculum to something like a reasonable size will find it very hard to accept that an extra year should be required for all—I emphasise "all"—and that a year should be added to the length of time before a young man or woman can qualify and feel that he or she is a doctor. And of course added to that, both for general practice and consultant work, even more years of training are required. It is obligatory in the case of general practice, while in the case of consultants, one simply does not reach the higher ranks without an even longer training. It seems to me that to require an extra year of all students is a very inflexible proceeding and could be damaging.
Why do I say that? I have known many doctors and general practitioners. I have had the privilege of watching them work and working with them. To my mind, there are unquestionably first-class doctors who have never had any real interest in research or research techniques. They have wanted to look after patients. They have succeeded and been extremely competent in their work. It seems to me that to discourage that in any way would result in a great loss of first-class doctors—not cientists—from practice in the National Health Service.
There are sometimes very practical reasons—not only financial reasons which can be helped by some improbable show of generosity by the state—against this intercalated year being required of all students. I can think of three doctors—men of around 45 or 50—who discovered that they were dying and struggled on in their practices, suffering not only exhaustion and pain but also the effects of the treatment to keep them alive, in order that their sons should qualify and be in a position to support themselves, their mothers or their younger brothers. Indeed, one such boy who struggled to qualify quickly while his poor father suffered became a Member of your Lordships' House. Think what an extra year would mean to such people!
Then of course there are people who long to be independent and do not find it easy to tolerate years of having junior status. They want to be independent and practise independently. As I have already said, they have to face a very long and hard trek and an extra year would be a very great burden for them to carry.
My dislike of the words "standard for all" does not mean that I believe that the intercalated year is other than admirable for many and possibly for most. As has indeed been said, even those who do not go into research in any way will be in a better position after having had that extra year to meet a need that the committee made very clear; namely, that of reducing the long delay that the committee deplored between the demonstration of some feature by research 318 workers and its application in the clinical field. It offers great advantage to everybody and not least to the patients.
There is another proposal about which I feel very happy and which I do not think has yet been mentioned, and that is the increased support that is recommended for locally-organised research schemes. They apply to those who are working in the regions and away from the great teaching centres, where at least some facilities are always available. Furthermore, the committee suggested that such a research facility should not be confined solely to hospital doctors and general practitioners but should be extended to dentists, nurses and allied disciplines. It could lead to the fruits of serendipity. It would certainly lead to a sense of satisfaction and give psychological gratification to all those people who are working in the regions of this country and who sometimes feel that from a research point of view at any rate they are in a rather Cinderella-like position.
§ 6.20 p.m.
§ Lord Rea
My Lords, as a co-opted member of your Lordships' committee, I should like to express how privilged I felt to meet so many distinguished witnesses and to visit some of the world's most prestigious research establishments. I had the good fortune to be among the small sub-group of the committee which spent a very action packed, and brilliantly organised, nine days visiting both the West and East Coast of the United States. For all these experiences, as many other members of the committee have mentioned, we owe a debt, not only to our two expert advisers and our indefatigable chairman, but also to our dedicated secretariat and tireless clerk, to whose literary skills we must owe some of the clarity of the report.
I should like to divide my remarks into three sections. I should like to make some brief remarks about the international position of British medical research today, the need for more and better coordinated public health research, and the position of research in primary care. I shall draw on some of our American experience while discussing these problems.
There is no doubt that until recently this country led the world in the quality of its medical research. The originality and soundness of British-trained scientists are respected worldwide. However, our preeminence is rapidly fading. My noble friend Lady Lockwood has quoted the words of Sir David Weatherall. In the United States very serious concern was expressed to us about the state of British biomedical science. There are many very close transatlantic working relationships in medical science. There is a tradition both of co-operation and friendly rivalry—sometimes not so friendly!
I quote from paragraph 39 of the appendix, relating to the American journey:One of the Committee's hosts went so far as to say that the history of biomedical research used to be the history of British biomedical research—but not any more".I should like to emphasise that this is not because the talent is not here in Britain. Witnesses repeatedly told us that the quality of medical and science graduates is as high and ingenious as ever, if not more so. It is 319 the opportunities and the career prospects that are lacking, as many other speakers have described. This is not a purely British phenomenon. I recently saw a letter in the Lancet of 21st May from Australia which said:If the decline in recruitment to academic medicine continues the clinical researcher might well become an endangered species.Your committee's report addresses this situation and suggests some solutions. But I consider that the topic of careers in academic and medical research is so complex that it deserves an inquiry on its own.
We found that there was a problem for young researchers in many countries. In the United States potential young researchers are attracted into the more lucrative branches of medicine because sometimes they have a huge debt to pay back—up to 100,000 dollars which they have incurred during their medical training. We do not have to face that. However, our young graduates have to buy houses and they then incur a debt of £1 00,000 if they are going to live in the South-East. They are therefore immediately attracted to looking into secure long-term careers which, as my noble friend Lady Blackstone has pointed out, are not the norm, to say the least, in medical research. One could say that market forces seem to act against research careers.
Perhaps I could say a few words about public health research and relating research to "the needs of the National Health Service", which was part of the remit of the committee. The main recommendation to set up the National Health Service research authority which would be equivalent in status to the regional health authorities and the health education authority, and so on, was not dreamt up out of the air. It followed directly from much of the evidence. That does not imply that the committee felt that basic research should be curtailed. In fact, quite the contrary. I think that the report fully recognises the primary importance of science-led research, and recommendations to strengthen the science base are made. In particular it is proposed that no funds should be transferred from the Medical Research Council to the NHSRA, as has already been pointed out by the noble Lord, Lord Nelson.
Other noble Lords have pointed out the very small proportion of the cost of the National Health Service which the DHSS spends on research. I am not sure whether it is 0.1 per cent. or 0.01 per cent., but it is a very small proportion indeed. The committee felt that decisions by management and clinicians at all levels would be made much more effective if the research base of the National Health Service were strengthened. We felt that the proposed research authority would require comparatively little extra money if it were funded, as suggested, partly by transferring the existing research budget of the DHSS, and partly by requiring a hypothecated contribution by each region, with extra funding from the regions if they wished to back particular projects.
The new authority would thus relate directly to the research needs of the health authorities because they would be paying their money into it. If it were given the task of allocating SIFT, as has been very well described by the noble Lords, Lord Flowers, and Lord Kearton, the research authority could help to 320 protect the money from erosion by service needs and could acquire a status, with regard to the clinical schools, approaching that of the Universities Funding Council which is proposed.
The committee recognised that perhaps this suggestion—the transfer of the distribution of the SIFT funds through the proposed national health research authority—was one of its more controversial recommendations. However, we felt at the present time, in particular as SIFT is under review, that it was a realistic suggestion with many advantages. These have been pointed out with great clarity by the noble Lord, Lord Kearton.
The problem with research into current practice in health services is that it is not popular either with the doctors or the administrators for obvious reasons, because their practices are under scrutiny and may be criticised. It is very difficult to rub spots off leopards. They are rather powerful creatures with sharp teeth. They may well turn round and bite you. The United States has the same problems. Very large sums of Federal money are put into basic research but very little into public health or operational research. Paradoxically some charitable trusts in the United States now fund public health research because powerful lobbies in Congress have been so effective in cutting public funding, although that is the very type of research that is most likely to improve the cost effectiveness of public funds put into health services. That has been greatly to the detriment of the health services in the United States. Perhaps it is one of several reasons for the comparatively poor health statistics of the United States, compared with the United Kingdom and other developed countries, despite its impressive biomedical research.
Finally I should like to say a few words about primary care research. The committee felt that it was a pity that the recent White Paper on primary care paid such scant attention to research. Promoting Better Health, the White Paper, envisages a major readjustment of the focus of primary care from a mainly curative, on-demand service to one involving a preventive or health-promoting approach. There is a great need for more data on what is now happening in primary care and there is a need to evaluate the effectiveness of various different approaches. Despite much interest among general practitioners, research in primary care is still poorly funded. Comparatively speaking, it is an amateur affair often relying on the dedication of part-time enthusiasts carrying out research at their own expense.
Few GPs have had much formal research experience or training. There is therefore a great need to strengthen the academic departments of general practice attached to each clinical medical school. So far the Government's expressed support for such units has not led to secure funding for research or training in research methods. Even the longest established departments have difficulty.
In oral evidence Professor Howie, Professor of General Practice in Edinburgh, which was the first Department of General Practice in the country, said (I quote from question 1400 of Vol. II of the oral evidence):In my research group …I have a health economist, a sociologist and a nurse. It has taken 5 years to get together a project that could 321 be funded during which time we could have been doing the research that we want to do and within two years I am going to have to go out and get more money to continue to keep the group together".Primary care research is often interdisciplinary and to retain behavioural scientists, economists and statisticians together on a long-term basis it requires long-term funding.
Research in primary care is much more concerned with measuring human behaviour and perhaps less with laboratory facilities. Many current health problems are related to aspects of human behaviour. Methods of influencing that behaviour are becoming of increasing importance. I suggest that in the future primary care will be in the front line of research in preventive medicine.
The committee considered that the National Health Service research authority would be more attuned to primary care research than the Universities Funding Council, the regional health authorities, the DHSS and the Medical Research Council have so far proved to be when faced with their other heavy demands.
I am looking forward to hearing the Minister's reply. I also feel that this report has come at an opportune time with the ministerial review of the National Health Service in progress. Surely changes in organisations are much more likely to be effective when based on objective research. We believe that the suggestions in the report are relevant and could lead to much more effective use of the £20 billion spent on the National Health Service. Surely the public, both as taxpayers and consumers, deserve no less.
§ 6.35 p.m.
§ Baroness McFarlane of Llandaff
My Lords, like the noble Lord, Lord Rea, I was a co-opted member of the committee and had the privilege of visiting the United States. As a consequence I should like to draw attention to and underline some of the aspects of the report which are particularly relevant to my own profession; that is nursing. As a professor of nursing I must declare an interest in the funding of nursing research, education for nursing research and career structure for nursing research.
In paragraph 1.9 we stated that medical research embraces a wide range of disciplines, including nursing and dentistry. Although the committee interpreted the word "medical" in its broad, generic sense—and asked witnesses for comments on any aspect that affected the health of the nation—it is understandable that in the oral evidence and in the report much of the discussion relates to a narrower interpretation of medical research, with focus on biomedical research and the clinical practice of doctors. That is right and proper because it attracts the major research funding. It is in those areas that the frontiers of knowledge are pushed back and are valuable to the rest of us.
Alongside that major thrust we state in paragraph 4.10 that the professions allied to medicine are marginalised in the allocation of research priorities, and hence in funding. There is no doubt that nursing research derives much from biomedical research. As the noble Lord, Lord Rea, has said, we also rely heavily on research related to behavioural sciences.
322 Two sobering facts arise from much of the research that comes through my department. They are sobering facts that are secondary findings to some of the studies. One is the lack of an adequate knowledge base enabling nurses to carry out the tasks for which they are responsible and the decisions that they must make. If nurses lack that knowledge they can retreat into routinised approaches to care. The profession has warmly welcome the announcement that Her Majesty's Government have accepted in principle the recommendations of the UKCC Project 2000. We believe that that will do much to enhance the scientific bases of nursing practice.
In other projects that come through my department the use of methods, reagents or equipment which may be positively harmful to the patient's welfare have been found. I believe that the example given by the Minister illustrates how, in nursing, better methods of care may be derived from research.
If one looks at the size of the nursing workforce, which is more than 509,000, it stands to reason that the effectiveness and efficiency of the clinical methods used in nursing have significance for the national economy. I believe that that demands a far greater input into clinical nursing research and aspects of what the committee has termed "public health and operational research" which can focus on the effectiveness of manpower deployment and utilisation in nursing.
However, funding for nursing research is a major problem. Of the 10 university departments of nursing, where one would expect to find centres linked with multidisciplinary work, very few are adequately funded from university grant funding.
They are inadequately funded for their teaching function, let alone for a research capability. The departments are small and for the most part without the critical mass of staff needed for teaching and research. Fortunately these factors are currently under review by the UGC panel on which I serve, on subjects allied to medicine.
With regard to the DHSS side of funding, the departments of nursing are in competition for scarce research funding from research councils, the DHSS, the NHS and charities. The DHSS has had an enlightened approach over the years in funding studentships for the research training of nurses. However, these have been reduced in recent years and currently three a year are awarded. It supports two nursing units; a unit in nursing practice at the University of Surrey and a unit in nursing education at the University of London. However, compared with the size of the profession, one unit in nursing practice is derisory.
I cannot help comparing that position with that which we found on our visit to the United States. At NIH we found a newly-established institute for nursing research with a funding of 25 million dollars. Shortly afterwards I visited the province of Alberta and in that case found funding of 2½ million dollars.
In these circumstances it is exceedingly difficult to put forward projects from well-trained researchers with a track record of success in grant applications and completed work, and there are positive disincentives to enter into the nursing research career. 323 Only last night as I left my department I was talking to a nursing research student. She is a nurse graduate who has spent close on 10 years in clinical practice in geriatric nursing. She is a highly experienced nurse. Her clinical acumen is valued by the National Health Service and she was promoted to be a clinical adviser for a group of geriatric wards in Manchester Royal Infirmary. She has seen the need to train as a nursing researcher, to put under the magnifying glass the kinds of advice that she is giving in the rehabilitation of the elderly. In order to do so her salary has dropped by £5,000 per annum from that of a senior clinical sister to that of a staff nurse. I believe that that is a positive disincentive to undertake nursing research.
It is for these reasons that the establishment of a national health research authority, with adequate nurse representation and the functions that we outlined in paragraph 4.6, appeals to me as being a suggestion which is pertinent to the needs of my own profession. I believe that the recommendations expressed in general terms throughout the report in respect of medical research have their applicability not only to nursing but to many of the allied health professions. We have received the response of the statutory body for nursing education in England—the English national board. It supports the report; compliments the committee on its mention of nursing research; and agrees with the necessity for multi-disciplinary approaches in many cases.
I have to apologise because I was unaware that so many speakers would be participating in this debate and I have to catch the last train to Manchester tonight. However, if possible, I hope to be able to stay and hear the summing-up.
§ 6.45 p.m.
§ Lord Perry of Walton
My Lords, at this stage of the debate nearly everything that I wanted to say has been said. I think that I am the seventh member of the Select Committee to speak. My splendid chairman, the noble Lord, Lord Nelson, and my other colleagues have said nothing with which I have disagreed, and I have listened to them all this afternoon. Therefore I shall not attempt any further detailed analysis. I should simply like to emphasise one or two points among the major ones in the report.
I can also claim, like the most reverend Primate the Archbishop of York, to be an insider, having spent 22 years of my life doing and directing medical research as a member of staff of the Medical Research Council, and then as a professor directing a Medical Research Council unit. All of that was in basic biomedical and academic clinical research. That kind of research was at that time science-led, and the Select Committee still believes it should be science-led. The Medical Research Council to a very great extent supported carefully selected people rather than putting money behind particular problems.
In medicine, however, all basic research is also strategic research. However recondite a basic research project in medicine may appear, almost any knowledge of the human body is bound to be related to the treatment of disease or to the maintenance of 324 health. The problem in basic research is not an organisational one. The Medical Research Council did a good job relying on peer judgment to determine its priorities. And I believe it still does so.
There is of course too little money. We are living through an explosive revolution in biology. Research in biology now needs inter-disciplinary teams. The lone worker is seldom able to compete. I fear that no longer can research of quality be done, as the most reverend Primate and I did, with apparatus made from parts of aeroplanes or from string and sealing wax. That kind of economy is no longer possible. Techniques are complex and apparatus is costly. That is why costs rise so fast, and that is why the extra £75 million in the next three years for equipment is so badly needed.
Worse than the shortage of funds is the feeling that was expressed by almost every witness that we met: the feeling that the DHSS and the NHS do not seem to care about research. Even if every witness is mistaken, even if the Government really do care, as the Minister assures us they do, they still have a major job on their hands to try to dispel that very real impression, even if it is a wrong impression. It is not enough simply to say that we are spending more and more money on research. Something more must be found if the collapse in morale is to be countered. We thought that that was the main cause of that collapse in morale.
I was however very impressed by the suggestion of the most reverend Primate that the emphasis by the funding organisation on the utility of research rather than on the search for truth was a contributory factor, and I hope that this suggestion will also be considered by the Government.
Perhaps I may turn to the service-needs research. This is a very different problem. It is not organisationally sound like basic research. It has no supporting structure like the Medical Research Council or the UFC, but is nevertheless of increasing importance. It is necessarily problem based not science based; indeed, as people have said, throwing money at scientific problems seldom produces solutions, but throwing money at administrative problems can produce solutions. There is an enormous range of problems which is not being tackled. A few are being investigated with the wholly inadequate funds available to the DHSS and some were mentioned by the Minister. Others needing attention were raised by the noble Lord, Lord Winstanley.
The Select Committee felt very strongly that there must be a co-ordinating body of the NHS to provide the drive, and indeed the money, to lead to this kind of study which could certainly help efficiency and lead to economies in the health service. That was the fundamental reason for the committee's suggestion of a formation of a national health research authority. It is my belief that the creation of such a new authority would, in itself, be a contribution to improving the state of morale in medical research.
§ 6.51 p.m.
§ Lord Sherfield
My Lords, I rise to support the recommendation of this report and in doing so I 325 follow the noble Lord, Lord Kearton, in paying tribute to the chairmanship of the noble Lord, Lord Nelson of Stafford, who guided the committee so ably through an unusually heavy weight of evidence. Apart from an inquiry into occupational health and hygiene, this was the first time that the Select Committee had ventured directly into the medical field. I believe that whatever the Government may make of the recommendations, it was a timely move since it coincided with the current in-depth review of the National Health Service. The report was certainly intended to be a helpful contribution to that review.
It was my intention to deal mainly with the issue named by the committee as public health research, as defined in paragraph 1.8 of this report. That covers research into health education and health promotion as well as the provision of services and:by drawing on a range of disciplines, including epidemiology, the behavioural sciences, statistics and economies seeks to establish strategies to promote health and provide optimal health services".As that question has also been addressed by the noble Lord, Lord Rea, I shall try to be brief. The committee found that public health and operational research— and the noble Lord, Lord Kearton, stressed this—have been inadequately supported in the United Kingdom, identifying as a main reason the virtual absence of a research capability in the National Health Service itself.
This weakness is a principal reason for the recommendation that a national health research authority should be established in the health service. As I have said before, and as the noble Lord, Lord Winstanley, implied in his remarks, the committee knows that recommendations about the organisation and machinery of government tend to be resented by the Civil Service and possibly by some Ministers and are usually ignored or rejected. Therefore, it was no surprise that the Minister's first reaction to that proposal this afternoon was distinctly tepid. He seemed to think that the co-ordination of existing bodies would suffice. Of course, that is quite contrary to the evidence on which the committee based its principal recommendation. It found that there was a need for restructuring, and restructuring requires some diversion of existing funds and some new money. The repetition of the monotonous statement that there is no new money for anything has put a real damper on the debate this afternoon.
I still earnestly hope, though I fear that the hope may be vain, that in this case the Government will study the central recommendation of the committee with an open mind, particularly as the organisation of the National Health Service, as it has developed, is admittedly unsatisfactory and under close scrutiny. In the committee's view it is especially important that the review of the National Health Service should have, as one of its premises, the need to bring the National Health Service into the mainstream of medical research.
The significance of this area of public health research has been brought home to me not only by the evidence which we received, but also by a recent book published in the USA by a distinguished Californian physician, Dr. Leonard Sagan, entitled The Health of Nations. Drawing on the most recent 326 research work and statistics in the USA and this country, the book deals with two main questions: why since 1840 in industrial societies there have been such dramatic improvements in human health with an increase in the average lifespan of as much as 40 years; and secondly, why in the United States the decline in US mortality rates has not kept pace with other industrial countries, and why in recent years there has been an actual increase in mortality and disability rates in spite of the fact that the United States has a medical system second to none and the highest per capita expenditure on medical care in the world after Sweden.
American life expectancy now trails after 18 other nations. Yet it had the fastest decline in mortality rates in the world between 1900 and 1960. The decline slowed in the 1970s and 1980s and has now almost stopped. The implication is that life expectancy, mortality and disability are related much less to advances in medical science and practice, environmental factors, diet and so on, as is commonly supposed, and much more to socio-economic factors such as parental care and levels of education.
If the general health of the United States is declining due to such factors as divided homes and illiteracy, drug addiction and other changes in social behaviour, should we not be inquiring whether a similar trend is not prevalent in our own society? In fact, we know that such trends are prevalent here, though perhaps to a lesser extent than across the Atlantic.
Medical science has done wonders in relieving pain, distress and misery but has perhaps had less effect on life expectancy. There seems to be evidence that this has been the case over a long period of time: for example, at the outset the decline in deaths from infectious diseases began before the appearance of innoculations and antidotes. I can only sketch in the most general terms the general thrust of this argument, which is probably familiar to noble Lords with special knowledge of these matters, but which was new to me and rather striking.
I should like to relate this theme to the report under consideration. There is some work going on in this general area of the economic and social aspects of health and health care provisions, to which we draw attention in paragraph 1.17 of the report. That is mainly under the auspices of the Economic and Social Research Council and we had, for example, oral evidence from the Centre of Health Economics at York University. However, quite apart from the adequacy of the provisions for such research, this work is mostly far removed from the National Health Service itself, whereas it should surely be a matter of direct concern and interest to it.
The proposed national health research authority would have the task of ensuring that all aspects of operational and public health research were properly covered, while as we recommend, the Medical Research Council should continue to take the lead in biomedical research.
The general point is touched upon in paragraphs 8 and 9 of the extremely valuable account of the members of the committee who visited the United States. It reports: 327By at least one significant public health indication—life expectancy—the general health of the USA and the UK is about the same. Nor can the USA's poor showing in relation to its vastly higher expenditure be explained by higher rates of disease among its underprivileged communities. The connection between health spending, and particularly research spending, and the health status of the population is a complex question and one which is not yet understood.It is my contention that we in this country should make a much greater effort to understand it than we are doing at present. This can be done only with the direct participation of the National Health Service, and it would help to make the delivery of services by the health service more effective.
I have one further point to make, which was also addressed by the noble Lord, Lord Kearton. In paragraph 3.21 the committee draws attention to the effect of the operations of the Resource Allocation Working Party on some centres of medical research excellence, particularly in the London area. While there is no doubt a case for spreading resources more evenly through the country, it is in the centres of excellence that advances in medical treatment and technology usually take place and on which the international reputation of this country in medical science largely depends. In some cases these centres are now starved of resources and even threatened with closure. I ask the Minister: are not the Government concerned about these developments, and are they taking any steps to mitigate the effects?
§ 7.2 p.m.
§ Lord Houghton of Sowerby
My Lords, sitting through a debate of this length one feels that your Lordships' Chamber is more a place for meditation than for listening or self-expression. While listening to the speeches of four noble Lords who are members of the Select Committee, with a speech by a fifth member still to come, I have been wondering what the hell I am doing in this debate. What do I have to say that will be relevant to the expertise in medical research of which we have been hearing? Anybody making a guess about what I intend to do is probably right: I shall raise the need for research into research. The need for research into research has to do with animals in research. Your Lordships now have a clue to why I have remained in the Chamber since 10 minutes past three.
First, I hope that the noble Lord, Lord Nelson of Stafford, will feel that this thanksgiving service has given him the satisfaction and reward that he needs for a perfectly thankless task of the kind undertaken by all chairmen of committees of your Lordships' House. One is given a vote of thanks and if one is lucky the Government will do little; if one is given the customary treatment, they will do nothing at all.
I am very surprised that neither the report nor those noble Lords who have spoken mentioned the restraints and restrictions that the new regime in medical research imposes on the use of living animals under the Animals (Scientific Procedures) Act 1986. The most significant change in the law on the use of animals in laboratories since the 1870 Act when Queen Victoria lobbied this House in her war against the sovereign state of science, and made some inroads 328 in the matter of controlling the degree of pain that animals should suffer in the hands of researchers in our laboratories. It has taken 100 years to secure that degree of control and accountability by the Home Secretary of what goes on in our laboratories.
What goes on in our laboratories is something that the television cameras never dare show to the public any more than they dare show what goes on in our slaughterhouses. They know that the public would be sick and that there would be an outcry at what goes on to cure the ills and follies of mankind by the use of living animals—living tissue, living creatures, the raw material of medical research; yet not a word has been said about it.
We hear about "resources"—that is the "in" word, meaning mostly money—or "funding", another euphemism for more money. What about the "planning permission" to use animals in laboratories for experimental and research purposes? We—many people—are apparently indifferent to that. If one touches the embryo of the human species, then one is in trouble: the bishops will crowd in and the moralists will come. In the case of a proposed community charge, the hoards will come in and shuffle through the Chamber as if they were tourists being shown round the place. When animals are suffering by the million every year under the protection of the law, it is licensed cruelty and licensed suffering. Because it is animals, we think that it does not matter. The headlines ask, "Are not chimps God's creatures too?". They may be, but one thing is certain: man will pursue the chimps to the point of extinction if he needs them for experimental purposes to cure the consequences of his own mode of life. That is the simple truth.
What does the 1986 Act say? What does it put into the hands of the Home Secretary? Before researches can embark on the use of living animals, more than a personal licence is required: a project licence—not just a personal is required. This is the new concept—the basis of use of animals under the new legislation. Section 5(4) says:In determining whether and on what terms to grant a project licence the Secretary of State shall weigh the likely adverse effect on the animals concerned against the benefit likely to accrue as a result of the programme to be specified in the licence".Does that mean anything? If not, there is trouble to come at the next general election. If it means something, there is trouble to come in the laboratories because some people will be refused permission to do what they want to do. The Minister made clear in debates on the 1986 legislation that the keynote was to reduce the number of animals involved in research. That will be the logo and propaganda at the next general election if people do not see a reduction in the number.
What else does the Act say? Section 5(5) says:The Secretary of State shall not grant a project licence unless he is satisfied that the applicant has given adequate consideration to the feasibility of achieving the purpose of the programme to be specified in the licence by means not involving the use of protected animals".In Section 20 provision is made to set up an animal procedures committee to overlook the implementation of the new regime. It says:The Committee may promote research relevant to its functions and may obtain advice or assistance from other persons with knowledge or experience.329 This is the new regime. This is the new discipline. This is the new control. This is the new accountability to Parliament for the first time for 150 years. The Home Secretary has never been accountable to Parliament in the past for what goes on in our laboratories. His sole concern has been to limit the amount of pain that animals suffer. The Victorians were not concerned with the dignity of animal life. They were concerned with pain. Pain was their obsession. They did not like to feel it. They did not want it to be inflicted on other species.
What are we doing about this? For one thing, we are working through the system. Before very long results must be evident otherwise those of us who stood up for this legislation in 1986 and put our heads on the line will be in trouble. Some of us collaborated with the Home Secretary at the time to get a consensus Bill through both Houses—and we did, but we wanted it to mean something. We were under a guarantee that it should mean something; but that means administration and it has to be evident.
The Home Office, through the Procedures Committee, has embarked on a measure of research of its own into alternatives. One of the avenues for the reduction in numbers must surely be to find alternatives to the use of living animals in some branches of research. A sum of £60,000 has been put up for this year. We were told that the Treasury had allocated £100,000 but in the end it was decided to give £60,000. The Home Office embarked on an advertising campaign inviting all those who might be involved in research work to submit applications for grants to promote the work they were doing. Over 100 applications were received. That £60,000 has to be divided between them. Some very good ideas will have to be excluded. What will happen to them? Some of the best ideas cannot be funded out of £60,000—not for three years hence. That sum is a drop in the ocean. One might say that it is almost Boys' Brigade research, it is so small and so financially insignificant.
The Germans, of course, are acting on a much larger scale. They are financing research into replacements, which can be by information retrieval, the breakdown in the barriers of confidentiality, by data banks, and so on. I have high hopes that the European Community will help to jockey us on. We need a European system. We need to break down the barriers between nations that are all seeking to do the same thing. I am doing my best to persuade some of our largest users of animals to confer on the extent to which private funding from industry—I have come round to funding—can help in the work of finding alternatives.
This is not charitable money. It is commercial money. The industry must reduce the numbers otherwise they will be stopped from using animals, at least to the extent it believes to be desirable or necessary. If the numbers are not reduced, all the critics, all the sceptics that we encountered when we put our heads on the line to get this legislation through, will say, "We told you so; it will make no difference". It must make a difference, otherwise this will be a political issue at the next general election. I 330 hope it will not be, but if it is I hope to be involved in it.
I am sorry to have delayed the House for 12 minutes on my harangue on this subject but since nobody else has mentioned it I am perhaps entitled to a few extra minutes. I am not getting at the Government and certainly not at anybody in particular; I am speaking for the record. I hope people will listen to or read what is being said. Something must be done to get the numbers down and the Act provides the Home Secretary with the responsibility and the means of achieving that. He must honour what was undertaken at the time the Bill was going through Parliament.
That is the long and the short of the story. I hope that those who are concerned with the manufacture and distribution of products which are developed by the extensive use of animals will bear in mind that they depend on public goodwill and public support. They depend upon consumers for their prosperity and their trade. I do not want to utter any warnings, though something should be said this afternoon to give life to the proceedings. Those concerned should bear in mind that there could be a public reaction to failure to achieve what we set out to do in 1986. The whole of the animal welfare movement is waiting to see what happens. Nobody must be misled into thinking that this is a period of indifference.
I now give way to my noble friend Lord Hunter of Newington with many apologies for having stood in his way for this length of time.
§ 7.16 p.m.
§ Lord Hunter of Newington
My Lords, I add my tribute to the noble Lord, Lord Nelson, the chairman of our committee. Noble Lords will not be surprised that, having barely taken a deep breath, he is now studying outer space. It is a measure of his versatility in these matters. We were all sad when our committee completed its work. We learned so much from the witnesses and from one another. I should like to say, if it is appropriate, that I learnt a great deal from the noble Lord, Lord Houghton of Sowerby, when we sat together on the Infant Life Preservation Bill. I look forward to discussing the matters that he raised at a more appropriate time.
This is an important debate, as has been said. It is important not only with regard to the proposals of the Select Committee but important also in relation to the machinery which the Government have created and recently reinforced on the central consideration of proposals of this kind. One is very mindful of the past. After the war there was a great deal of talk about science and government and a number of important proposals were made regarding the utilisation of science and technology in government.
The Fulton Report in 1968 set down a basic principle which was-intended to ensure that the Civil Service should keep up with the changing world. The report stated:One basic guiding principle should, in our view, govern the future development of the Civil Service. It applies to any organisation and is simple to the point of banality but the root of much of our criticism is that it has not been observed. The principle is: look at the job first. The Civil Service must continuously review the tasks it is called upon to perform and the possible ways it might perform them. It should then think out what new skills and kind of need and how these can be found, trained and deployed.331 Importantly, the report recommended also a further study of hiving off functions as a means of ensuring accountability in management—a popular concept nowadays.
Not a great deal was done. In 1975 the noble Lord, Lord Allen of Abbeydale, who had retired as permanent secretary to the Home Office in 1973, openly expressed growing doubts about the relationship of the senior Civil Service with the input of science and technology. I quote:The service must clearly hear its share of the responsibilities for the failures (as well as the successes) of government since the Second World War and for its contribution to the policies followed by this country in a period which has seen such a decline in its role in the world.The service was certainly slow to begin reforming itself after the War to reflect changes in society and the role of Government".As the 1970s progressed, it became evident that there was need for newer and younger blood within the Civil Service. The most sharply worded critique was delivered by Sir John Hoskyns in 1982, within months of his departure from Mrs. Thatcher's Downing Street policy unit. He said:It is a paradox that when government was arguably at its most effective, during the war, it was full of motivated outsiders: while, ever since, we have mistakenly assumed that government can do almost as much in peacetime as in war, but without fresh infusions of outside vigour and talent".The Rothschild proposals in the mid-1970s concerned the customer-contractor principle between departments of government and those earring out R&D. The Select Committee has taken a great deal of evidence about this matter and it would support the Rothschild principle as part of the essential function of modern departments.
The most important consequence of the report of the Select Committee on Science and Government, six years ago, was the introduction of the annual review of government funded R&D. The Select Committee report of the noble Lord, Lord Sherfield, on civil research and development recognised that the central machinery required strengthening. As a result the Government have made significant changes. There will be ministerial consideration under the Prime Minister's leadership, and:The Government will determine in the context of the annual public expenditure survey their priorities for the contribution which science and technology can make to the national economic success and departmental expenditure provision will take account of these priorities".Moreover, we are told that the Science and Technology Assessment Office will assist this work and that the office will build up a picture of the relevant contributions of the different R&D expenditures in the economy.
The recommendations of your Lordships' Select Committee are in line with the Fulton Report and also in line with the Efficiency Unit Report, Improving Management in Government—the next steps, by Sir Donald Ibbs. The whole focus in government spending has been on expenditure, not on the results obtained with the resources expended. This must change. The public are now demanding to know what are the results of the expenditure of NHS money. They are bored with "billions". They want to know what the money has achieved.
332 The proposals for a National Health Service research authority fit well into this concept. It would be there substantially to support regional health authorities in their task of making themselves more efficient and cost effective. It should be financed by the department and also by the authorities. I do not believe that this proposal will in any way interfere with the important role of the MRC in basic strategic and clinical research. Its presence and function could surely make the concordat meetings between the MRC and the Department of Health even more relevant.
It is difficult to overestimate the value of such a unit in its educational role on regional health authority members and officers and in changing and permeating the thinking of the people who run the health service. There is no clash either with the department's many important roles and the conduct of departmental research under the Rothschild principle.
Related to the problem of getting an effective organisation is the fact that the department is at present too big and too diverse to be managed as a single entity. Such is the size and complexity of a health department, with its recently reaffirmed commitment to public health and the inevitable relationships with local government, and in particular following the Griffiths Report, that there is now an area where a new and effective administration is required. One hopes that the whole question of an independent department of health will be carefully looked at by the NHS review body.
The proposals of the Select Committee would not in any way hinder such a reorganisation. In fact they would facilitate the necessary changes. The NHS R&D unit could help to mould the recreated department to its new purposes. This report on medical research, which is before the House and the Government, comes, as has been said, at a very special time. The Government have accepted the Select Committee's advice about strengthening the central machinery to overlook science and technology through ACOST. The Government, under the chairmanship of the Prime Minister, are reviewing the role and function of the National Health Service, and the Ibbs Report suggests important changes in the Civil Service. This is all in tune with the Select Committee's recommendations. We look forward to hearing the Government's proposals, perhaps reflected strongly in the public expenditure Estimates in October.
It is no exaggeration to say that the whole country awaits the review—patients and everyone else—albeit for different reasons. Surely we can now embark on an evolutionary path in science development, including medical science, as the President of the Royal Society, Sir George Porter, has so often suggested.
Sir Douglas Hague said in 1985:The problems facing Britain in the late 1980s and the early 1990s are so severe that the luxury of failing to use the country's intellectual capital simply cannot be afforded. It also requires Ministers and senior officials humble enough and brave enough to submit their panaceas and prejudices to gifted, difficult and sometimes quirky people whose greatest virtue is that they are not, in Whitehall's terms, house trained. They were needed in 1939. They are needed now".333 It is up to the Government, and we look forward to the Minister's reply.
§ 7.27 p.m.
§ Lord Peston
My Lords, as a non-member of your Lordships' Select Committee, I wish to join with other noble Lords in welcoming this excellent report. The noble Lord, Lord Swami, referred to it as a classic of its kind, and I am sure that he is right. I should like to add my congratulations to the committee on the evidence, which is a gold mine for those who are interested in the subject. We shall go over it on many more occasions.
Having said that, I should like to apologise for starting my speech with a topic not discussed in the report. I refer to the economics of the matter. I do not disagree with the warning of the most reverend Primate the Archbishop of York about what I would call naive utilitarianism as a basis for looking at research. However, in dealing with the present Government, rather more sophisticated philosophical approaches to these matters seem to pass over their heads, whereas they seem to respond to economic arguments.
One of the most important points about medical research is its enormous economic significance. The new genetic engineering techniques, the developments which will explode from molecular biology and so on will be the basis for one or more of the great new industries that will dominate the next century, those high value-added industries on which our country's economic future will depend. I hope that our successors, and my successors as economists, in the years 2030 and 2040 who may wring their hands about what they will perhaps call Britain's chronic economic decline and ask why, will not—if that should happen and we hope it does not—have to say, "Well, of course, there was this brilliant report produced by their Lordships some 50 years ago that told us exactly what we ought to be doing and where we ought to be going". I hope that will not happen. Further, I hope that the Minister will not repeat yet again the cliché "We have to produce the wealth before we can spend it", because in this area that would be precisely the wrong argument. The research we are talking about, in the main, will be the basis of the wealth of this country in the future. That is why there are good economic grounds for supporting what the report says. That is also why the Government ought to take it even more seriously than they would do on intellectual grounds, so to speak.
As many noble Lords have pointed out, if we are to move forward in this area there must be more public funding; but that public funding must be seen as an investment. That is the nature of what we are talking about. Further, it is an investment which will yield large returns. However, as my noble friends and other noble Lords, including the noble Baronesses, Lady Lockwood and Lady Blackstone and the noble Lords, Lord Kearton and Lord Sherfield, have pointed out—we are not talking about ludicrously large sums of money. Indeed, if I were—although I hesitate to do so—to dream of criticising the committee I should say that it was talking in much 334 too small numbers. The prospects here are much better than that. The likely returns to investment in this type of research are very large and therefore no one should be ashamed of talking about the £25 million extra required for equipment, or even much larger sums for training, and so on.
Secondly, I should like to emphasise certain aspects that other noble Lords have referred to and to which the Committee also referred; namely, the many complementaries in this connection. Or, as the noble Lord, Lord Flowers, said, the dualities. One talks not only about the enormous importance of basic science in this matter but also about the importance of needs and practice research. I regard the latter as complementary. I do not regard them as the basis for a controversy as to this or that; I consider that the two go together.
Similarly, to emphasise my normal approach to the mixed economy, whether one is discussing public sector financing or private sector financing, again one regards those as complementary. They may be slightly at odds at the margin but, overall, each one enhances the other. If we are discussing private industry, the universities and the research units, yet again the essential view to take on such matters is to emphasise the inter-relationships, the complementarities and the dualities rather than suggesting that somehow one must choose one or the other.
Finally, in terms of criteria, it must be said that on the one hand we have the social ends and on the other we have market forces. My own belief in the mixed economy is that those two concepts go together. Therefore the problem is to get the balance right rather than saying, "Well it is either this or that and the two can't go together". Thus, on criteria, it seems to me that there is an approach—which I favour—that sees the different criteria as fitting together. There therefore does not seem to be any need for enormous controversy in the area.
I turn now to the issue of new disciplines that the committee mentioned and to my worry about their funding. The committee referred especially to an interest of mine; that is, nursing research. I notice that the noble Baroness Lady McFarlane of Llandaff, has just left in order to catch her train so she will have to read my complimentary remarks in Hansard. It must be said that she made an excellent speech on nursing research. This is a good example of low-level research. It is not the most fundamental work that one can do but it can be enormously useful. Indeed, I should like to congratulate the DHSS upon the good work they have done in supporting the research. I was a member of the so-called Small Grants Committee, which, I must say to the Minister, his department rather foolishly abolished. It was an extremely useful committee when I was a member of it. It was there that I learnt about nursing research and the values that it can create. It is interesting to note that in the report Professor Rosemary Crow—who used to sit with me on the committee—brings out the point that in many of the new discipline areas the researchers do not have a great deal of research experience. If they are competing against the high-powered researchers who find favour with the MRC, of course they do not have 335 a hope. They are not especially experienced in organising their applications or how to organise their research. However. I am delighted that Professor Crow's evidence about the need to help people to carry out research in such areas was noted. When I come to speak about the NHRA, I shall explain why that would have a role in this area.
Another aspect of research and new disciplines, and so on, is the worry that I have about what is fashionable. I was especially concerned with one aspect of the matter—which is research into the care of the elderly—referred to by the noble Lord, Lord Winstanley. He mentioned a letter from the research team for the care of the elderly at the University of Wales College of Medicine. I have now read the letter and I too am extremely concerned about the matter. I do not expect the Minister to say much about that at the moment, but, if he writes to the noble Lord, Lord Winstanley, I hope that he will send a copy of the letter to me. I must say that I should be somewhat surprised if research into the care of the elderly was unfashionable. Of course I have not quite reached the stage where it is vital for me, but, nevertheless, I hope it becomes fashionable in good time.
Another slight area of criticism I have about the committee is that I was somewhat worried—again. I am not certain whether this is a matter of fashion—that they had paid less attention than I should have liked to the question of research into mental illness, schizophrenia and mental handicap. It is a tremendously important area and, as I shall argue in a minute, it is one where we at least have some hope. Personally I should have given slightly more emphasis to the matter than the report does. However, it is, as we all agree, a matter of judgment.
I come now to an area which has already been mentioned and in which I must declare an interest. It is pharmacy and the pharmaceutical industry. I am a member of the council of what is now called The Royal Pharmaceutical Society of Great Britain, which is separate from the pharmaceutical industry. However, it is the pharmaceutical industry that I should like to comment upon. The industry is most important, as has already been emphasised, in terms of the amount of money it spends on research. Moreover, it is almost unique in the amount it spends on public relations while yet giving itself an extraordinarily unattractive public image. I must say that I do not know how it manages to do that. However, I do not think that the poor public image that it has given itself should cause us to underestimate the enormous contribution that pharmaceutical industry research makes to actual improvements in patient care, through the discovery of new medicines, in relation to some conditions which were previously life threatening and certainly to those that previously required surgery.
Of course I recognise the importance of the pharmaceutical industry, but what is interesting about it—as other noble Lords have said—is how much the industry depends on an intellectual foundation of basic science. Again, it is a clear-cut example of the combination of fundamental science, so to speak, in universities and research institutes on the one hand and industrial research—to make 336 money, but, we hope, with the by-product of actually improving health—on the other. The aforementioned brings out the point that, in emphasising the importance of the industry, we may well have the balance wrong; that is, that the industry itself spends a great deal of money on research, but we are not spending enough complementarily on the related fundamental science.
I return now to the issue of mental illness and similar areas where, I understand, we are on the verge of possible great breakthroughs. For example, we are enhancing our understanding of brain chemistry and it may well be that in many of those areas new drugs will emerge which will be enormously helpful. We are not saying that chemotherapy is the only way to deal with mental illness, we are saying that we need a combination of chemotherapy and social support which, again, go together. However, the chemotherapy is important.
I gather that there is also great hope of a breakthrough in the area of tranquillisers, which would be most important. Nevertheless, I am well aware from my knowledge of pharmacy that it is almost impossible to invent anything that no one can become addicted to. Therefore, if one is worried about addiction, it seems to me that the propensity to become addicted is independent of the nature of the thing that you are getting yourself addicted to. Nonetheless, it is an important area of research.
However, having said all that, I like to say a word or two in praise of the Government when I can. I was pleased to read in yesterday's edition of the Independent an article about a new Government-linked scheme which will link research programmes in industry and in the universities with those of the Government. In this instance the linkage was in terms of selective delivery and targeting. Indeed, it is a good example of what we can do. Nevertheless, the point I would make, as I always do, is that it is a good example of what we ought to do. Further, there ought to be many more such schemes on a much grander scale.
Let me repeat the point on the economics of, say, the pharmacy industry that we live in a world of tough international competition. It is all very well to say, as one noble Lord did, that it does not matter where the research is done in terms of receiving the benefit in health care. It matters an enormous amount where the research is done in terms of our country's economic progress or its academic standing. Without being too much of a nationalist, I am bound to say that I want the research done in this country and I want the industry to be in this country. I believe that that industry wants to be in this country, but it wants the back-up from the Government. It is vital for us to bear that point in mind.
Another point, which is not so much on international economic competition as on research and which I have made before, is that we are also engaged in international research competition. I know that scientists like to think of themselves as being a great international community. It is a great international community, but it also has a slightly cut-throat angle to it. I should like to see the great discoveries made here rather than elsewhere.
337 Many noble Lords, including the noble Lord, Lord Swann, and the noble Baroness, Lady Blackstone, have referred to the pluralism of support. I support that concept. Nothing would worry me more than for us to find ourselves with a sole source of funding, because, as most noble Lords and those of us who have been involved as researchers or donors of money are aware, the propensity to make mistakes is enormous. We therefore have to have many sources to which we can go. I am broad-minded. I hope some of those sources will be in the public sector and some in the private sector.
I congratulate the noble Lord, Lord Johnston of Rockport, on his maiden speech. I am with him on the desirability of getting money from industrial sources (sponsorship). As someone who has worked at it, I can tell him that it is easier to do research than to obtain money from industry. If he knows of anyone who wishes to sponsor a senior research fellowship in health economics, I am certain that I can persuade the research fellow to wear an appropriate badge, as tennis players do, in exchange for the money. I agree with him that it is hard to obtain.
I come finally to the NHRA, which is an extremely good and constructive idea. Its role would be to bring the NHS into the mainstream of medical research. My experience of the MRC—I sat on one of its subcommittees dealing with the NHS—is that it is marvellous on fundamental, great science. It does great work. By economic standards, it spends enormous sums of money. It regards a £1 million project as a day-do-day matter. That is the sort of money that it needs. I do not believe that the MRC is the body to deal with what one might call the needs and practice element of NHS research, the element that involves the behavioural and social sciences and all that.
The body that could do that work would be the NHRA, your Lordships' recommended committee. We strongly support that recommendation. We join the plea that many others have made for a positive response from the Government on that point.
As an academic I like debates, but on the whole I think that the most suitable place for them is back at the university. I come to your Lordships' House, normally not successfully, in the hope that I shall occasionally persuade the Government to move into action. There is nothing much in talk for us academics. We want to hear the Government announce, "We are now going to do something about this matter".
I do not rise to the bait in the Minister's remarks about the future of the NHS, except to tell him that I am an extreme reactionary on this matter. I believe that the NHS is excellent. All it needs is more tax-based finance. It does not need givings and lotteries and other flim-flam ideas. However, we shall come to debate the future of the NHS in due course, I hope. Both in the practice and at the basic science end, the NHS will depend upon a proper research foundation. The committee is guiding the Government in the right direction. I hope that, when he replies, the 338 Minister will offer us at least some hope of positive action by the Government.
§ 7.45 p.m.
§ Lord Skelmersdale
My Lords, as I said some four and a half hours ago, it is a measure of how important the House considers the subject of medical research that so many noble Lords have spoken. Although I asked questions about the role and format of the new authority suggested by the Select Committee and did not intend—I can tell the noble Lord, Lord Sherfield—to do more than that, I was impressed by the fact that, whether or not your Lordships were members of the Select Committee, to a Peer, your Lordships told me that the new research authority was the right way ahead for the National Health Service. I find that extremely impressive advice.
The noble Lord, Lord Prys-Davies, started by asking whether the department was out of touch with the medical research community. I do not believe that it is, because, as the report points out, there is indirectly commissioned DHSS research, about which I will say more in a minute. The department cannot do that commissioning without an interaction between the National Health Service and individual researchers about research needs. There is much contact through many channels.
One of the reasons why the Government established the NHS management board was to improve communications between the centre and the National Health Service. Also, as I mentioned earlier, the department's directly commissioned research priorities have been framed with NHS needs in mind. In addition, the department's research and advisory groups include representatives of the different professional groups within the NHS and social services which can provide an insight into NHS research needs.
However, in my opening speech I used my experience of meningitis research to illustrate a factor which undoubtedly exists for whoever seeks to administer research in this country. Successive governments have relied substantially on the scientific community to determine the highest priority for research. We have no plans to depart from that practice. Indeed, as I understand it, today's debate did not suggest that we should. I believe that it is important to ensure that research funds are not spread too thinly over too many areas to be effective.
We need therefore to maintain a balance between identifying areas of promise upon which to concentrate funds and maintaining a capability to respond to grand new ideas emerging from individuals or groups within the community. Through their committees and boards, the research councils are already active in identifying areas of promise, and the new centre for the exploitation of science and technology, with the intriguing name of CEST, set up in Manchester, and the new advisory committee on science and technology (ACOST) will also have a role to play in that process. At the same time, councils will continue to fund the best ideas emerging from responsive mode research grant applications.
One of the thoughts that the Government will be taking away from the debate is how that process fits 339 in with the committee's call for a research career. I understand that in industry it is fairly standard practice for those who have been in research to move into management. I am not sure that that is appropriate in medicine; but I accept that researchers should be re-employed in appropriate disciplines when their period or periods of research are over, and not necessarily in the health service.
Most doctors undertaking research in the service do so as part of their job either within an academic department of medicine or as part of their NHS commitment. Their main career path therefore relates to their chosen specialty. Some doctors take time away from their chosen clinical specialty to pursue research for one or more years. This may or may not enhance their career prospects within the health service but it provides them, I believe, with a broader knowledge base for the practice of medicine. All training posts which include academic and research posts with the honorary registrar and senior registrar contracts are now controlled by the Joint Planning Advisory Committee whose members include representatives of the Medical Research Council, the Association of Medical Research Charities and the Committee of Vice-Chancellors and Principals, to ensure a balance between likely career opportunities, both in the health service and in the academic sector, with total numbers of doctors in training.
Obviously there is a number of research posts for non-medical professionals within the National Health Service and in academic departments or units associated with health care or health care research. The main career prospects here lie within the individual's professional field and to a limited degree with departments of health services research.
The noble Lord, Lord Winstanley, asked about the publication of academic research studies and whether the Government intended to delay this unreasonably, and whether Clause 7(1)(f) of the Health and Medicines Bill is intended to be read that way. The answer is a categoric, no. The clause is about income generation and income generation alone. The specific power is being sought in the Bill to confirm, for the avoidance of doubt, that the Secretary of State is empowered to engage in income generating activities and that is all.
Several noble Lords referred to research into geriatrics. I think my noble friend Lord Johnston, in a most interesting maiden speech, was one who did so. I hope I shall not be misunderstood if I say in passing that I am sure that the House will agree with me that it would do us good to hear him again both soon and often.
The DHSS is commissioning, through the MRC, a study into the health of the elderly. We are likely to spend up to £100,000 on the project in this financial year. There are, and will continue to be many research projects financed by the taxpayers on the care of elderly people, including work at the University of Wales. But it is right that we should spread this money to best effect both in terms of scientific quality and the value of the research to 340 health and personal social services. Our present advice is that Dr. Vetter's unit has failed to make the contribution expected. But having heard the concern expressed by your Lordships tonight, I shall of course look further into this matter.
My noble friend Lord Johnston talked about the spending on Huntington's chorea. Although the amount of research specifically devoted to this disease by the MRC is not great, there are many—how shall I put it?—lines of attack, perhaps, into research that has led to a better understanding of normal and disordered functions which could be of relevance to Huntington's chorea and related diseases. From what my noble friend said, he will appreciate, as the noble Lord, Lord Peston, certainly did, the £3 million research and development programme in selective drug delivery and targeting, highlighted in the Independent on 14th June. It is part of the Government's link scheme, having the aim of increasing the benefits to the United Kingdom economy from Government-funded research.
We welcome particularly the involvement of the pharmaceutical industry in this collaborative venture. The proposals to exploit the new drug technologies now available are imaginative and exciting. These proposals hold out promise of greater success in the fight against major diseases of our times.
There has been some confusion over the funding of medical research which, I must confess, I sought to defuse in my opening speech. I shall of course refer noble Lords who have mentioned this subject to the speech of the noble Lord, Lord Swann. But even he, I am afraid, only had what I can regard as a partial solution to this conundrum. In 1987–88 it is estimated that the DHSS spent £17.2 million on directly managed research programmes. Here, of course, I do not part company with what the noble Baroness, Lady Lockwood, suggested. But additionally, non-departmental public bodies funded by the DHSS—for example the Public Health Laboratory Service or the Central Blood Laboratory, where I was yesterday—are estimated to have spent £18.9 million. The locally organised research scheme spent an estimated £11 million, or slightly over. So the total DHSS spend comes to £48.3 million.
Apart from the DHSS programmes in particular, medical research which was supported and funded by the Government in 1987–88 comes to a further £382 million which of course includes the amount referred to by the noble Lord, Lord Swann, for the Medical Research Council. That gives a total of just on £400 million, to which I referred in my opening speech.
The noble Lord, Lord Flowers, suggested that regional health authorities do not encourage research. I am sure he will remember that the DHSS set up the locally organised research scheme some years ago which enables health authorities to fund local research projects into good practice and to encourage critical inquiry and evaluation by all disciplines of local services and subjects which call for local rather than national investigation. These are schemes administered by regions through local research committees. In 1986–87, as I have said, around £11 million was spent on this.
341 The noble Lord, Lord Richardson, asked why the locally organised research scheme was only open to clinicians. I am advised that it is open to many professional disciplines involved in health care. There has been an increasing number of awards given to these professional groups in recent years. In guidance issued to health authorities earlier this year, these groups were encouraged to open this scheme more widely to workers in all branches of the health professions.
I think that the noble Lord, Lord Flowers, was the first of the university—I cannot even pronounce the word!—academicians to raise the difficulty of covering overheads on the research grant and the possible consequences not only for charities but for the universities themselves. I can understand his interest in this. I can tell him that it is a problem which the Advisory Board for the Research Councils recognised in its report as strategy for the science base. It recommended that adjustments should be made in the respective responsibilities of the research councils and the UGC, in order that more of the costs of specific projects should be met by councils. The Government are considering this proposal among the others recommended by the ABRC.
I agree with the noble Lord, Lord Kearton, when I say that I appreciate that teaching hospitals have extra costs compared with non-teaching hospitals. Of course SIFT (service increment for teaching) is one way of ensuring that these costs are met. The review of SIFT should ensure that its distribution more nearly matches the need. The idea that SIFT should explicitly recognise research needs and that it should be paid direct to medical schools will of course be considered in our response to this report.
Several noble Lords and perhaps the noble Baroness, Lady Blackstone, in particular, spoke of the problem of UK researchers moving abroad in search of better facilities. I wonder whether this is not more apparent than real. Before the noble Baroness jumps down my throat, perhaps I had better explain. I am sure for a start that noble Lords are not against the international movement of researchers. In many ways such interchanges benefit research enormously. But I recognise that in recent years the belief has grown that the United Kingdom may be losing researchers in large numbers, although data were not easy to come by. That is why the Royal Society undertook a study on this subject which it published last year. That showed that the fears about migration abroad were much exaggerated. However, the Government are not complacent. They recognise that there is a need to maintain a number of first-class and internationally competitive research facilities in the United Kingdom. The microbiology, which was referred to by several noble Lords, illustrates that point. This is one of the outcomes—
§ Lord Flowers
My Lords, does the noble Lord agree that the report of the Royal Society showed that in terms of numbers only perhaps the problem of scientists leaving this country had been a little exaggerated, but that when one takes quality into account it is an entirely different story?
§ Lord Skelmersdale
My Lords, the noble Lord not for the first time has pre-empted me. I was about to 342 point to the reason why I said that the Government are not complacent in this area. Noble Lords themselves have referred to the morale of researchers. Whether the problem is apparent or whether it is real does not terribly matter. In either event it affects the morale of the researchers themselves and that cannot be a good thing. I was about to say that that was one of the outcomes we expect from following a policy of selectivity and concentration of research resources, but I say again that we shall have to watch it.
My noble friend Lord Colwyn, not to my very great surprise, referred to complementary medicine and research into that. He asked whether the Government were ignoring it. We are not ignoring it. The Medical Research Council provides half the funds to support a Fellow, who is currently employed by the Research Council for Complementary Medicine, to develop the methodology needed for evaluating the effectiveness of complementary medicine—a procedure that my noble friend said was badly needed.
The noble Baroness, Lady Lockwood, referred to general practitioners and research. Some of what I have said already would be pertinent to that answer, but I add that doctors who specialise in general practice are also able to undertake academic work within academic departments. There is an increasing number of academic departments of general practice throughout the country where general practitioners can learn research techniques and undertake research and teaching in addition to providing clinical care. One of the things that the Government are perforce looking at in the course of what I have called the "great review" is what contracts consultants, doctors and others employed in the wider health service actually have. It may be that in this respect improvements could be made. General practice research has a high priority within the department's research programmes. A number of research units have been set up based on university departments of general practice, and existing general research units have been encouraged to train general practitioners in research methodology and to assist and advise others who wish to undertake research within their practice. In 1987–88 just over £318,500 was spent by the DHSS directly on primary care research.
The noble Lord, Lord Hunter of Newington, rather shocked me. The one thing that I have been terribly careful to avoid saying over the past year is that people who are working in the National Health Service should be equated to civil servants. I think that they would be absolutely furious at that, and I am sure that civil servants would not be best pleased either. I should think that the honours are probably even in that respect. The noble Lord made the suggestion that an agency as envisaged in this report should follow the lines of the Ibbs Report, The Next Steps. But I must advise him that those are specifically targeted at Civil Service departments and would not, in my view, be appropriate in this context. That should not be taken as saying that the Government have set their heart firmly against the proposed research agency. Apart from that, I listened with great interest to the speech of the noble Lord, Lord Hunter, and I found an enormous amount with which I could agree.
343 The noble Lord, Lord Peston, talked about or rather embroidered what I had said earlier about priorities. I want to assure him that although those are our major priorities of the moment they are by no means exclusive, because clearly new subjects for research will come along from time to time which, quite rightly, need to be fitted in. That is why I spoke rather longer than perhaps I might have done in this particular context on the subject of child abuse because this was clearly a new subject which needed to be looked at very urgently.
Further than that, the Medical Research Council will consider research proposals on their specific merits, although of course due regard is taken of the health department's priorities as expressed at the annual stocktaking meeting between the council and the health departments. Meningitis is a case in point.
I cannot remember which noble Lord said that the concordat was a disgrace, but I think that whoever it was spoke rather more strongly than was necessary. However, I did admit that there is a certain amount of tightening up to be done in the annual stocktaking. I finish by once again thanking my noble friend Lord Nelson and his committee for their timely and thought-provoking report. Medical research makes an invaluable contribution to the health of our nation. We need to maintain and, where possible, improve that contribution. I take away with me from this debate a number of informative insights into how such improvements could be achieved.
I did not intend my opening speech to be a tepid response. I still feel a little sore about that remark of the noble Lord, Lord Sherfield. I hope that I have explained what I was about then, and that I have managed to answer some of your Lordships' questions now.
§ 8.7 p.m.
§ Lord Nelson of Stafford
My Lords, we have had an excellent and long debate which I think is quite right for a subject of this importance. I shall not delay your Lordships long in winding up. However, I wish first to thank all the noble Lords who have taken part in the debate and who have made it such an interesting discussion. I particularly wish to say how glad I was to hear the maiden speech of the noble Lord, Lord Johnston of Rockport, which was such an excellent contribution to the debate.
Reference was made by a number of speakers to items upon which we did not touch in the Select Committee's report. As I said earlier, this is a very wide-ranging subject and we had to be a little selective or noble Lords would never have received the report at all. We did leave out one or two subjects to which reference has been made. I mention in particular the question of human embryos and the use of animals, which was referred to by the noble Lord, Lord Houghton of Sowerby. His speech showed that that was a subject on its own. I think that will be shown in the record which he was very anxious to establish. In fact both of those matters have been treated as subjects on their own before and have been reviewed. Therefore we did not take them into our studies on this occasion.
344 The noble Lord, Lord Peston, also referred to two matters which I should like to touch upon. One was the absence of any reference to ageing and mental health. I assure the noble Lord that that came very much into our evidence. We received and accepted all the evidence on it, and we felt that this was a very good example of the system we propose for articulating needs. That is just a way in which the point that the noble Lord made should be identified and would arise under the system which we propose.
I was also glad that the noble Lord referred to the question of proposals for an additional role for the Medical Research Council. We considered that matter very carefully. For the reason which the noble Lord touched upon we decided that the council was not the place for that work. The council does excellent work, as many noble Lords have said this afternoon, particularly in the science-based research programme. However, we are anxious to see such work done inside the National Health Service. That was one of the matters which worried me in the Minister's reply. So many of the bodies to which he referred which are looking at research programmes are outside the National Health Service. We wish to see a body which is inside that service, which will reflect the needs of the service and which will coordinate with the bodies working outside the service and pull the whole matter together. That was why we felt that that work should not be allocated to the Medical Research Council, excellent as it is.
The Minister replied to many of the detailed points which were made by speakers in the debate and I thank him for those on behalf of us all. One of the points to which he replied was made by the noble Lord, Lord Flowers. It related to local research efforts supported by regional authorities. Perhaps I may reinforce what the noble Lord said. He did not say that that research was not being done by the regional authorities; he said that the impression that was conveyed was that it was very mixed. Some authorities were doing it—and he referred to one which was helpful—but others were not. When they were asked why they were not doing research, they said that they did not have any money for that sort of thing and that they could not afford it. One of the tasks which we have in mind for the national research authority within the National Health Service is to see that the local research effort is stimulated, sponsored, co-ordinated and protected against the pressures of funding from elsewhere. We have that very much in mind.
I hope that the contributions which have been made this afternoon have emphasised the problem which exists in this area and strongly reinforced the proposals which we have made. I hope that the Minister will be convinced of the seriousness of the problem and of the opportunity for improving research spending within the National Health Service and making it more effective and productive. I also hope that the Minister is convinced that research can and should play a greater part within the National Health Service and particularly in the fields of public health research and operational research. I agree with the noble Lord, Lord Peston, who said that there is a strong, economic impetus. Large sums of money 345 are involved and large sums can be gained. Research can play a major part in achieving that.
I know that the Government will be looking at our proposals. I welcome the Minister's undertaking to give them careful consideration and I look forward to his reply in due course. I hope that he and his colleagues will see that what we have proposed is a way of taking the research effort on to a new plane so that it can play a bigger part in the needs of the National Health Service. I hope that in their own review the Government will not let the opportunity pass of making changes reflecting our recommendations. The opportunity is unique and it should not be put to one side. It should never be said that research does not matter. It matters and it should be taken into account in the review. I beg the Minister not to let that opportunity pass. I commend the Motion to the House.
§ On Question, Motion agreed to.