§ 3.9 p.m.
§ Lord Walton of Detchant rose to move, That this House take note of the Report of the Science and Technology Committee on Medical Research and the NHS Reforms [3rd Report, 1994–95, HL Paper 12].
§ The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper.
§ At the outset, I pay a very warm tribute to our Clerk, Andrew Makower, whose dedication, expertise and drafting skills were in every way exceptional. Since he moved on to pastures new, the flag of Sub-Committee I has been ably carried by Philippa Tudor.
§ The United Kingdom is among the world's leaders in biomedical research and UK scientists are at the forefront of rapid developments in diagnosis and treatment. In 1988, the Science and Technology Committee of this House reported that the NHS was too passive in its partnership with research, in that it neither set a research agendum nor was successful in getting research findings into practice.
§ In 1991, the Government responded by appointing a director of research and development for the NHS in England, Professor Michael Peckham, now Sir Michael Peckham. He launched the NHS R&D strategy, the first of its kind in the world. The NHS then began to identify its research needs, to commission research to meet them, to disseminate the findings and get them into practice; and, importantly, to improve its own research practice by training staff, including groups not traditionally thought of as research leaders, such as nurses, therapists and managers.
§ The strategy aims to foster a knowledge-based service as well as evidence-based medical practice. Similar developments have been launched in Scotland, Wales and Northern Ireland. Happily, in recent years, through this initiative and through the efforts of the Medical Research Council, health services research and operational research, which analyse the nation's health needs and the means of delivering health services, have expanded. Research and development are neither luxuries nor optional extras. They constitute a fundamental and crucial component of our health services, upon which the lifeblood of medical and social advance depend. That research is backed by substantial resources provided by the research councils, the pharmaceutical industry, the taxpayer, the universities and the medical charities and is crucially dependent upon the NHS for access to patients and data. In return, it offers NHS patients the benefit of the latest advances and of care by leading practitioners. As have often said, today's development in basic medical science brings tomorrow's practical development in patient care.
§ In 1992 and 1993 concern began to grow that medical and dental research was under threat from the NHS reforms. Market forces were applying pressure upon staff time and the resources needed to conduct research and research training. The principle of uncosted mutual support—Knock-for-knock—which formerly governed 892 relationships between medical and dental schools on the one hand and the NHS on the other was breaking down, and devolved decision-making was hampering multi-centre research and the strategic planning of training. Hence, while it was clear that the initiatives of Sir Michael Peckham and his colleagues were succeeding, there was much anxiety about the future.
§ The Government responded appropriately by setting up the NHS R&D task force under Professor Culyer, a health economist from York. The Culyer Report was published in September 1994 and recommended a unified NHS budget for research and its support, controlled by Professor Peckham and funded by a levy on purchasers (health authorities and GP fund holders), through which research would be supported explicitly and accountably. The Government accepted those recommendations and they are being implemented. The new system should begin operation from 1st April 1997.
§ The report of your Lordships' Select Committee, based upon the sub-committee inquiry which I was privileged to chair, was published on 15th June. I and my colleagues are grateful to the Government for their response, published in September. We are glad that the fundamental principles set out in our report and recommendations have been generally endorsed and accepted. Time will not allow me to detail all the important points that we made; but perhaps I may highlight some of the most vital.
§ First, we are glad that the Government have agreed to stand by their wish to see 1.5 per cent. of the total NHS budget devoted to R&D. In their document published last month, guidance is given to health authorities and trusts about the means by which NHS activity and costs associated with research and development will be identified so that the levy will come into force from April 1997. The R&D strategy relies crucially on the regional directors of R&D, who act as bridge-builders between researchers and NHS purchasers and providers. We are glad that the Government accept the need for a mechanism to bring together researchers and NHS managers to discuss requirements, opportunities and conflicts of interests, and a means of connecting the research community with GP fund holders, whose role as purchasers is of growing significance. We look forward to learning more about the studies that are now being undertaken by various working parties and implementation groups, through whose work these and other proposed developments should become a reality. We are glad too that the Government accept our advice about getting research into practice. We welcome the Effectiveness Bulletins produced by the NHS Centre for Reviews and Dissemination in York, as well as the work of the Cochrane Centre in Oxford. But those activities must be accompanied by continuing professional education; and the informed and innovative practitioner must remain free to override evidence if it is either incomplete in the context of the case or out of date.
§ In our report we deplored the wall of accounting which had begun to divide healthcare from research. The cost of separating the scientist from the clinician is likely to be increasingly high, both in transaction costs 893 and in the creative interactions which will not take place at all because busy people will find it difficult to tolerate the artificiality of costing and accounting for them.
§ We are glad that the Culyer task force produced a set of principles commanding general assent in order to overcome those difficulties. It is indeed crucial that a stream of research facilities funding be identified from the levy to support NHS institutions with a major commitment to research, including all university-related centres of healthcare delivery. That will replace the research element of SIFT(R) (the service increment for teaching (and research)) which in the past has supported very largely teaching hospitals. Also it will replace non-SIFT(R), which supports research in some non-teaching hospitals) as well as the central support formerly enjoyed by the eight postgraduate hospitals in London. Research facilities funding will in due course he allocated selectively through a research assessment exercise. We are glad that the Government agree that that must be integrated as closely as possible with the similar exercise regularly undertaken by the higher education funding councils, thus avoiding costly duplication of effort. The R&D stream will clearly require a component to fund activities planned centrally by the director of R&D and his regional directors. It is equally clear that funds must be made available to the regional directors to operate schemes of responsive funding for research projects at local level, like the old locally operated research schemes, which often helped young doctors, scientists and others to take their first research steps.
§ Plainly too a separate funding stream must be identified to underpin research in primary care, general practice and community settings and be available also to support research and development undertaken by nurses and other healthcare professionals. Clearly, however, the most substantial component of R&D money will provide the excess service support and the infrastructure needed in our hospitals to create the environment in which biomedical research, which is so important and vital a feature of our NHS, can continue to flourish and indeed develop.
§ We have suggested that some such funding or alternatively special new regional reserves may be used to fund tertiary referrals to centres of excellence. Those have declined sharply under the internal market, which has applied pressure to purchasers not to refer, thus hampering major research projects in both rare and common diseases and often meaning that patients have received less expert treatment. We are glad that the Government accept the need to educate purchasers about how research nurtures developments in patient care and about the importance of patient flows to research. Major academic centres must be permitted to use facilities funds to set competitive prices so as to attract referrals.
§ The Government's R&D initiative proved very successful, not least in relation to the programmes of health services research and operational research which have been introduced, some nationally and some led from individual regions. The Medical Research Council also supported much excellent health services research. When our report expressed potential concern about mission drift by the MRC, that was construed by some 894 as suggesting that the committee felt that the MRC should no longer be involved in health services research. Nothing is further from the truth.
§ Our intention was to indicate that further expansion of MRC programmes in this field would carry the potential risk of duplicating work being done through the NHS R&D initiative. The committee was concerned that a higher proportion of MRC funds might in future be devoted to that field at a time when many excellent biomedical research projects simply cannot be funded, despite being highly rated by the MRC on scientific grounds. However, I must stress that we regard health services research as being of fundamental importance to the future of the NHS. We learnt with some dismay that some central initiatives, established under the NHS R&D programme, may be under threat and we trust that that fear proves unfounded.
§ While much detail remains to be clarified by the bodies established by government to implement the Culyer recommendations and those of the Select Committee, we are confident that the research programmes now emerging and those envisaged for the future, both nationally and locally, will do much to nurture improvements in clinical care and ensure that the United Kingdom remains in the forefront of better health services research and biomedical research. Without the appropriate infrastructure, the latter would wither and die.
§ Our one major recommendation which the Government did not feel able to accept was our wish to see a major inquiry undertaken into the future of academic clinical medicine, which we believe is in crisis. From all parts of the United Kingdom we learn of falling morale and diminished recruitment. The figures published in the Government's response were, frankly, puzzling, as all clinical academic departments in the United Kingdom seem to have suffered from freezing of vacancies and disestablishment of posts. While the NHS has come to the rescue by funding many important academic appointments, a development which is to be greatly welcomed, we gave the reasons—which we thought compelling—why we believe that clinical academic medicine is under serious threat.
§ Among the many problems of which we have been made aware is the fact that holders of clinical academic posts who have always been closely involved in patient care and in the provision of NHS services, are under increasing pressure from managers to accept an enhanced clinical load. Only two weeks ago the Senate of the Royal Colleges of Surgeons in the UK expressed its concerns publicly, quoting examples of the many difficulties which now beset those seeking training for a career in academic surgery. It quoted many examples, such as the fact that two chairs of cardiothoracic surgery now established have failed to attract any suitable applicants. Only this morning I learnt from the Committee of Vice-Chancellors and Principals that in early 1995, 54 established clinical chairs in universities with medical schools were vacant; 20 had been vacant for more than 12 months.
§ While Her Majesty's Government rejected our proposal that a major inquiry should be launched, I am glad to say that the Committee of Vice-Chancellors and 895 Principals is now setting up such an inquiry under the chairmanship of Sir Rex Richards, former vice-chancellor of Oxford University and with, I hope, funding from a charitable body. I and my colleagues on the committee are convinced that the problems facing clinical academic medicine bode ill for the future of clinical teaching and research and therefore for the future of medicine.
§ Finally, while I am commenting upon the crucial role of the universities in this regard, perhaps I may inquire as to why regulations relating to the appointment of university nominees to the new health authorities promised in March have not yet emerged? What effect will reductions in capital spending, announced in last month's Budget, have upon the proposed reorganisation of London and other medical schools and their associated hospitals? How will the much needed expansion in medical student numbers be financed?
§ Those points are all vitally important to academic medicine. We trust that the CVCP inquiry will proceed with all reasonable speed. we trust also that when that body reports, the Government may then accept that such an investigation was much needed and will be prepared to take account of its findings. I beg to move.
§ Moved, That this House takes note of the report of the Science and Technology Committee on Medical Research and the NHS Reforms [3rd Report, 1994–95, H.L. Paper 12].—(Lord Walton of Detchant.)
§ 3.26 p.m.
§ Lord Prys-Davies
My Lords, I thank the committee, especially its chairman, the noble Lord, Lord Walton of Detchant, for its labour and report. Together with the two volumes of evidence, it is a substantive report. I am also grateful to the noble Lord for his affirmative and positive opening speech this afternoon. Clearly I speak as a layman. Nevertheless, I believe that research work needs the support of lay people in the United Kingdom. Speaking as a layman, it is appropriate that I give the House an assurance that I shall be brief; I give that promise.
I wish to raise two points of detail which are not unrelated to the main thrust of the report. First, I want to add words of support for the recommendations in paragraphs 4.52 and 5.29 of the report. Those are recommendations that the attractions and appeal of academic posts should be enhanced. The noble Lord, Lord Walton, spoke of that towards the end of his speech.
When I read the report I strongly supported the setting up of an immediate inquiry to find ways and means of enhancing the prospects of clinical careers in medical schools. I am sure that many noble Lords will be aware of bright young doctors who have much to offer to clinical teaching and research. But as the committee points out, they are understandably attracted away from the medical schools by the greater financial rewards of consultancy posts in the NHS combined with the possibility of the fees to be gained from private practice.
896 It seems to me, and to those with whom I consulted, that the existing salary arrangements act as a disincentive to work in medical schools. If the brightest people desert medical education, the consequences over time must be serious. Indeed, the evidence received by the committee suggests that that is already a serious problem. That too was underlined by the noble Lord, Lord Walton, this afternoon. I am sorry, therefore, that the Government did not respond positively to the call for an immediate inquiry. But I am gratified to learn that the inquiry is in hand.
I turn to my second point and trust that the House will bear with me. I want to ask about the research undertaken in Wales. I am glad to see that the noble Lord, Lord Thomas of Gwydir, a former Secretary of State responsible for health matters in Wales, is in his place. Having served in the Welsh hospital service many years ago, I have maintained a special interest in medical research being undertaken in regions generally and in Wales in particular. I wish to make two comments on that aspect. I accept, of course, that research is no respecter of boundaries.
Nevertheless, I believe it is important that medical and health service research should be undertaken in Scotland, Wales and Northern Ireland as well as in London and the regions of England. Of course I accept that the areas of the research need to be defined, mapped out and resourced in conjunction with the programmes of other institutions further afield; otherwise there could be a waste of valuable resources. I am glad that the need for regional or local research, as it was called, was underlined by a number of witnesses when they appeared before the committee. Indeed, it has been underlined this afternoon by the chairman, the noble Lord, Lord Walton.
Nothing that I say today about the position in Wales detracts in any way from my appreciation of the contribution of the University of Wales College of Medicine, the only medical school in Wales, and the research work which it is undertaking. I am also well aware of the work which has been undertaken by the Medical Research Council in Wales. I am also conscious of the contribution of the Welsh medical charity, Tenovus. Nevertheless, regrettably, it seems to me that the Welsh Office did not submit any evidence to the Select Committee, and that omission in itself may be evidence that there are problems. I am afraid that there is reason for thinking that medical and health service research paid for out of the public purse is not supported as it ought to be by the Welsh Office. Indeed, there is evidence in the report and in the two volumes of evidence for that apprehension.
First, it appears in the evidence of Dr. Evered of the MRC, printed on page 61 of volume 1, that the amount of research and development work in England and Scotland,is much greater than in Wales and in Northern Ireland".Indeed, that inadequacy is amply illustrated by comparing the brief and barren Appendix 12 printed in the report which relates to Wales with the fulsome Appendix 11 relating to Scotland and the 897 information-laden Appendix 8 relating to research activity in England. One has to ask what R&D programmes are being undertaken in Wales.
The written evidence of the Department of Health is almost silent on the issue except that it offers this pretty bland sentence, to be found on page 6 of volume 1. I quote:NHS Wales has allocated funds to support research and development directed towards better health, better services and choice, and better value for money".Not much light there, my Lords. The statement goes on to add:The Research and Development Forum has identified an initial series of research priorities".But that leads to the question: what are those priorities? So far as I can see, from reading the report and the volumes of evidence, they are not identified in the department's evidence.
Moreover, the disquiet and the frustration which are felt among researchers in Wales, emerge in a sad letter from Professor Borysiewicz of the University College of Medicine, which is printed on page 478 of the second volume. The professor writes:Among researchers in Wales there are numerous areas of disquiet pertaining to the organisation, commitment and continuity of NHS R&D but clearly these are not going to be resolved until a new director is in post".Secondly, there has been this inordinate delay on the part of the Welsh Office in appointing the R&D director. Indeed, this was a cause of anxiety to the Select Committee itself. I am glad that the committee has drawn our attention to this state of affairs. It has done so in paragraph 4.53 and in recommendation 5.30 of the report.
As the report was published seven months ago, I should like to be assured that the Welsh Office has by now sorted out the various problems and that it is on course to create the right environment in Wales for medical and health service researchers. Nevertheless, I have to say that the delay in making an appointment accords ill with professed support for research.
Thirdly, and finally, there may be another point of some anxiety. This derives from a sentence in Appendix 12 of the report which reads,according to press reports, the Secretary of State for Wales took a personal interest in the selection of projects"."Personal interest" is not exactly a term of art. What is the meaning and implication of that term in the context of Appendix 12? Does it mean that the Secretary of State as a layman, and not in his capacity as Secretary of State, sought to influence the choice? I recognise that the Government must have an effective say in this area as in other areas of policy involving public expenditure. On the other hand, I am sure it would be- agreed that research priorities should not be influenced by the personal preferences of the Secretary of State as a layman. Therefore, I want to ask for clarification of the meaning of the sentence which I have quoted and which is to be found in Appendix 12.
The Welsh Office and the research selection procedures must leave no doubt in the public mind as to whether choices of research priorities are decided on the 898 merits of the case. I should add that the evidence does not reveal whether the personal interest of the Secretary of State in the end prevailed. I am wondering whether it did.
All I have sought to do on this issue is briefly to draw attention to that part of the evidence submitted to the Select Committee which suggests that the Welsh Office has fallen short, possibly far short, of giving satisfaction in this area. I shall listen with great care to whatever information the Minister can give the House when she comes to reply.
§ 3.36 p.m.
§ Lord Perry of Walton
My Lords, as a member of the committee I start by paying tribute to the noble Lord, Lord Walton of Detchant, who was a splendid chairman. The noble Lord, Lord Flowers, and I were both very privileged to be members not only of this committee but of the original committee in 1988 which produced the report on priorities in medical research. I should like to give two small quotations from that report. Paragraph 9.10 said:Science-led research should be dominant. The main focus of public policy in medical research should be the creation of a strong infrastructure for research and the supply of a strongly motivated and well-trained research community".Paragraph 9.14 said:The funding of applied research in medicine is unsatisfactory, and the key lies in the NHS".In all my recollection of the meetings of that first committee in 1988 I cannot remember one single occasion when we did not talk of the NHS needs which we spelt out at great length and which were very important. We said that they should be complementary to the basic biomedical research to which the noble Lord, Lord Walton, has already referred. We were naturally delighted in 1989 when the Government accepted virtually all the recommendations of the 1988 report and when in 1991 the new NHS research and development strategy was published. It was a new culture in the service. It was a knowledge-based service and it was to be a culture of evaluation. That was an absolutely splendid decision that everybody welcomed.
The one recommendation that we made in 1988, which was not accepted by government, was that the new strategy should be supported by a special allocation of funds. The Government rejected that on the grounds that it would not be compatible with the science budget. It seemed to me then, and it still seems to me now, that that was wrong because the NHS R&D strategy is not a part of the science base. It is NHS expenditure and not a science expenditure.
In 1988 there was no internal market in the NHS, but the introduction of the internal market led to another new culture in the service based on value for money. Whether one agrees with that culture or not, it is certainly compatible with the NHS R&D strategy, which is a knowledge-based and evaluation culture, but it is not compatible with science-driven research, which is not always cost-effective. Many things which are started do not succeed; only some of them do, but they are very important.
899 The introduction of the market ignored the needs of the new strategy for research and development. That was natural enough because it is only 1 per cent. of the expenditure of the NHS; 99 per cent. of it is for looking after patients. As the noble Lord, Lord Walton, mentioned, that led to the creation of the Culyer task force to produce a report on how to deal with research problems. It came up with the idea of a single stream of NHS funding which was actually divided into three streams. One fund was for research promoted by the NHS itself; the second was to cover the service costs of projects in NHS institutions, with many of them being externally funded; and the third was to provide research facilities in those NHS institutions, mainly the teaching hospitals, which were centres of high quality research.
These were sensible principles and they were generally welcomed, but they mixed up funding for NHS R&D strategy with funding for the support services that I mentioned, which are really services for the science base itself. The Culyer task force principles did not go into detail as to how they were to be implemented. In May 1995 an implementation plan was published but there were no details. I regret to say that that plan only created six more implementation sub-groups, and we await to hear their results.
Our report in May of that year suggested in our many recommendations ways in which some of these matters could be implemented. But in September, in the Government's response to our report, as the noble Lord, Lord Walton, said, they gave general endorsement to these proposals but not any details as to how they were to be implemented. They said that our suggestions were under consideration by the various implementation sub-groups, but we still do not have any details as to how they are to be implemented.
The NHS R&D strategy is controlled by the central research and development committee which reports to and advises the director of research and development, who in turn is a member of the NHS Executive and advises it. It controls the money bags. When the central research and development committee was set up, it very rightly, following the recommendations of the 1988 committee, adopted an approach that was problem-led and not science-driven. But the Culyer recommendations for a single stream of research includes, as I said, part of the service support of a science base. I believe that that has led to the root cause of the natural academic fear that the central research and development committee and the NHS Executive will in time come to favour problem-led projects; despite the assurances that have been given by Ministers and others, the trend will always tend to be in that direction.
That is not in any way to say that it is not important to cover all these NHS problem-led matters. All the many institutions of the NHS such as general practice, nursing and so on all need problem-led research. Perhaps I may give one example from our current report which appears in Chapter 5, paragraph 13:We welcome the creation of a stream of 'research facilities funding' to support the additional infrastructure needed in NHS settings which support clinical research to a significant extent. The 900 central research and development committee must resist the temptation progressively to shift the balance away from essential core funding in favour of project funding".That brought a response from the Government which was not very reassuring: they said that they accepted the need for stability in institutions doing high quality research. My conclusion was that, without guaranteed separate stream funding for academic research, I could see no way to remove long-term academic fears. These fears already affect adversely our medical schools. I beg the Government to act soon in producing details of how they are going to solve the problem.
I now come to paragraph 5.29 of the report where we said:We note the combined effect on clinically qualified academics of uncertainty engendered by the NHS reforms (including the problems noted above in relation to referrals, hospital rationalisation, local pay and the continuing capacity of the NHS to fund academic posts); the shortage of career-grade academic posts; the increasing loads of service provision, administration and teaching; the consequences of the unified training grade; and the proposed changes to the system of Distinction Awards. We consider that the disincentives to a clinical academic career are now so great as to warrant an immediate enquiry in their own right".The Government's response to that recommendation was that the evidence we had for our recommendation was anecdotal and there was no firm basis for it that they knew of. But in the past few days I have received from the BMA a report completely endorsing the recommendations in Chapter 5, paragraph 29. As the noble Lord, Lord Walton, mentioned, a report came from the CVCP, which has acted unilaterally on that very recommendation.
I should like to go a little further in quoting the CVCP which stated:Difficulties exist in recruiting and retaining clinical staff in academic posts in some fields … Problems are caused by:a lack of confidence in the NHS as a provider of resources for teaching and researcha perception that career progression is more secure and rapid in non academic medicinean apparent disregard by the NHS of the universities' interests adds to the uncertaintydistinction awards at the 'C' award level are to be made locally. Academics believe that they will find it difficult to compete for these awards which represents a further disincentive to take up or stay with an academic career".The CVCP then stated that it was taking steps to set up an independent inquiry.
It is clear that worries are widespread in academic medicine. Another cause of those worries, apart from those mentioned by the CVCP, is that an increased clinical load continues to fall on the clinical academics employed by the universities, with the result that they have much less time for research.
Finally, I should like to call attention to the communication that I have received from the BMA which tells me that jobs in clinical departments at some medical schools are already being filled by non-medical scientists. That gives me a sense of déjà vu because, when I went to Edinburgh in 1958 as professor of pharmacology, nearly all of the pre-clinical Chairs and senior posts in pharmacology were held by medically qualified doctors. There was an enormous differential in 901 salaries between those for pre-clinical senior staff and those for clinical senior staff, not only in terms of the university salary but also because the clinical staff were eligible for distinction awards. The result is that nowadays there is hardly a medically qualified man holding a senior appointment in a pre-clinical department in our medical schools. That represents a real loss for the training for medical undergraduates because such people, able as they are as scientists, have no understanding or experience of patient care in medical science. We must not let that happen in clinical departments.
§ 3.53 p.m.
§ Lord Butterfield
My Lords, I am grateful for this opportunity to express my appreciation of the chairmanship of the noble Lord, Lord Walton. He did us the honour of sending the text of what he was going to say to those of us who served on the committee. As I read it, I realised that, as has often happened to me before in relation to the noble Lord and medical affairs, it was hard to see what I should be able to add to the complete case that he had set out. Indeed, on many occasions in your Lordships' House I have heard noble Lords say, "Previous speakers have said most or all of what I wanted to say, and I can only say how much I agree with them".
It is in the spirit of trying to widen your Lordships' view of the remarkable development that has occurred for the NHS in this country under Professor Michael Peckham that I should like to add a few small pieces of extra information. Perhaps I may first tell your Lordships about Michael Peckham. All of your Lordships will know that intellectual activities have an artistic and creative quality and content. I was absolutely delighted when I met Michael Peckham for the first time in his office because he showed me on the walls pictures which he himself had painted. That is not very common among professors of clinical subjects. Some of us have daughters or sons who paint, but do not do so ourselves, so I was most impressed.
I should like to pay tribute to the way in which Michael Peckham has dealt with this incredibly complex national problem. I agree with the feelings that reign in Wales, Scotland and Northern Ireland about the importance of carrying the message to those parts of our United Kingdom. Michael Peckham took a complicated and complex subject and worked it out. The lovely thing about Michael Peckham is that he has a very clear mind and an extremely good way of expressing himself at meetings and in committees. I am sure that the noble Lord, Lord Walton, will nod his agreement to the fact that when Professor Peckham appeared before us, he spoke straightforwardly about the problems, I think that we all realised that usually he had the great advantage of talking about the problems as he knew them at that moment, whereas we were talking of what we had heard perhaps a week or two before.
Michael Peckham has one other great asset in his work, Mrs. Peckham. She is medically qualified. She is what we call an epidemiologist. She looks at problems in the round, out there, outside the laboratory. I once 902 had a Scottish master, a Fellow of the Royal Society, Ronald Grant, who told me when I went to work for him that he was worried by the fact that I had recently married because it was his very strong impression that the best research was carried out by misogynists who could think of nothing but research. Well, Michael Peckham had the enormous advantage of being able to talk about research at home all the time and he will probably have got very good advice from a lady we all recognise as highly intelligent and very knowledgable. If Professor Peckham is here—he may be—I hope that he will accept that, in saying that, I do not wish to detract from his own achievements.
Having said that, perhaps I may say how very much I agree with the comments that have been made about our Clerk. In addition, our earlier committee owed a great deal to Professor Walter Holland of St. Thomas' Hospital who way back in 1988 perceived how important it would be to stir up and infuse the NHS with practical science and health services research as well as fundamental medical ideas.
During the past five years Michael Peckham has seen a revolution come about: we now talk about knowledge-based medicine. By that, I hope that we mean medicine which is based on what is known (from recent research) about the best way to do this, that or the other. We should not be talking about computers and saying, "This person has had this test; push the button and give them that". Whatever happens, knowledge-based medicine must be put to the patients with understanding, with an understanding of human beings. The importance of that aspect of medicine is referred to in our report.
It is important to look at what has happened during the past five years while Peckham has been at the helm. It is important to realise that it was launched, miraculously, without exciting an enormous amount of irritation and jealousy in the Medical Research Council and among the academic professors and others who might easily have taken a serious view of an organisation which could get into top gear with the promise presently of 1.5 per cent. of the costs of the NHS. In round numbers, we are talking about 1.5 per cent. of £30 billion. If you were a chemist working for the great German firm Hoechst, you would think that 1.5 per cent. spent on R&D was not a high proportion. However, for those of us in medical research, it is a very high figure.
While preparing for this afternoon's debate, I have been delving around trying to find out about that 1.5 per cent. in terms of the allocation of funds. As a benchmark, the MRC spends about £300 million a year on medical research, and the charities roughly the same figure. In a recent press release, the Secretary of State for Health indicated that he has increased the resources for the R&D strategy to £436 million in the coming year. That is a very large sum of money. It will not be quite the bonanza that some people think, because all of us in the research corridors of non-power are aware that when one talks about the price of the research strategy in the NHS that will include all the calculations of what the noble Lord, Lord Walton, referred to as the knock-for-knock principle.
903 We never did any accounting on what it cost to have the tests done for my diabetes. It is probably a good thing that we did not. Nor did other people have the costs of the beds they used for their research put against their accounts. That was all part and parcel of the knock-for-knock: we took care of the patients; they paid for our excess costs. I suspect that much of that £436 million may have to be accounted for in the modern NHS as money needed to support research: money that the research will cost.
All of us on the committee felt strongly that it was important that the regional directors—the people whom Sir Michael chose to support him—should have funds with which they could support young people starting out in research. There are two wonderful phrases. One is an old phrase—"pre-protocol research"—which meant that one was doing research that was so early that one could not work out exactly what one was going to do. One was going to make some exploratory observations—pre-protocol. There is another new, wonderful phrase that I found in a document sent to me by my friends on the MRC. It is called "response mode support"; in other words, it is responding to a suggestion that something is tried and undertaken.
It would be important to all of us on the committee to hear, if the Minister can tell us, whether any part of that £436 million will be allocated to regional directors of R&D for them to spend on the local medical schools and on encouraging young people to start. That same man—R. T. Grant—who was a little upset that when I joined him I had recently married, would be very concerned were there to be no means for young people to start research. I was called obstreperous. That was why I was put into research. "We have got to get rid of him off the ward. Put him in a research lab. He is too obstreperous". There must be a means by which young people can get their start. My plea is that we ensure, through clever and lighthanded management centrally, that money is made available to the regional directors of research, all of whom we know and of whom we think the world. They are very good men.
Finally, I strongly support the anxieties that were expressed in the committee and have been expressed this afternoon about morale in the academic medical departments. I see the noble Baroness, Lady Gardner, on the opposite Benches. She will remember when we were talking about the newly organised health service and how I, and I believe the noble Lord, Lord Walton, were keen to have a uniform salary. We made the point from the academics' view that, if we did not have a uniform salary structure, there were real risks that people would not be able to do what we would think of as the good things.
In fact, there is no uniform salary structure. Understandably, authority has been given down the line to hospitals to have their own salaries within the NHS. We cannot do that yet academically within the ordinary organisation of university posts. Perhaps we will have to do that to reignite the morale of the young doctors who are in the teaching departments. Meanwhile, Minister, if you can indicate that there will be money for regional directors of R&D that they can use to 904 encourage young people, there will be a feeling that, after all, the research community is respected. It desperately needs encouragement.
§ 4.5 p.m.
§ The Earl of Selborne
My Lords, it will be already evident to noble Lords that there was much highly expert advice available within the committee. There were many people serving on the committee who knew a great deal about the subject. The noble Lords, Lord Perry of Walton and Lord Flowers, had served on the 1988 committee. Above all, we were lucky enough to have the noble Lord, Lord Walton of Detchant, as our chairman. Although it is a formality sometimes to congratulate the chairman, as the first layman on the committee to speak I have to say that we relied heavily upon his knowledge and experience, despite all the other expertise that was available to us.
The subject, as has been said, was being revisited for the second time, the committee in 1988 having produced what must be termed a seminal report. We have heard of the great work of Professor Michael Peckham and of the change of culture—it can only be described as that—within the NHS now that there is an R&D strategy and all that flows from it. There is no doubt that the 1988 committee report was highly instrumental and influential in bringing about that change of culture.
I pay tribute to the late Lord Nelson of Stafford who chaired that committee and who was able to serve as a co-opted member of the committee for a while until ill health forced his retirement. That demonstrates how the Select Committee procedure enables continuity of expertise which has proved highly valuable in this instance. Having done so much in 1989—the Government took a year and three-quarters to respond, but respond they did and very effectively—it appeared by 1993 that much of that great progress was at risk.
This Select Committee inquiry would have been established earlier in 1993 had not the then Secretary of State set up the Culyer task force. The fears which were clearly apparent at that time arose from the changes in fund holding, concern about the long-term future of clinical research, and concern as to whether the hard-won changes in the culture could survive. The terms of reference of the Culyer task force were appropriate. When we saw that it was to report within a relatively short period—it was briefed to report by April 1994—I am sure that we were right to step back, report on Culyer, if necessary, and take note as well of the development of the R&D strategy led by Professor Peckham. That is precisely what the report in the event proved to be.
There was no great difficulty determining that the Culyer recommendations dealt with the major central issue from which all the uncertainty and concern arose, which was the funding stream. Clearly, changes in administration and fund holding cause all sorts of alarm bells to ring. From the Culyer Report came the single funding stream and the 1.5 per cent. about which noble Lords have heard. Everything else pales into insignificance. The next issue is how one determines the apportionment of that funding stream. A stream is a 905 slightly misleading metaphor; it is more like a delta. It starts as a fund: what is important is how it is distributed.
The Culyer Report makes it clear that there are three branches to the delta: first, projects and programmes, to which one must add supporting functions which would include information strategy and the development of research capacity; secondly, service support; and thirdly, research facilities.
As a layman on the committee I was perhaps a little cynical as time after time we heard special pleading from all sorts of sectors as to how important it was that that particular sector should be the beneficiary of the funding streams. People were capable of rubbishing the expertise and talents of other sectors. The academics would point out, for example, that there was little research culture within the area of general practitioners or nursing and how dangerous it was therefore to divert too much funding there. It is important to discount special pleading and to take a clear-sighted view at regional level as to where funding should go.
Of the three streams, the first, which concerns projects and is supported by the information strategy, is an extremely important development of the research and development strategy itself. It is almost inconceivable that way back in 1992 there was no clear record of the research that was going on in the National Health Service. There was no central data bank. Therefore, the project register system was started in 1993. It is a network of registers of research projects with guidance from a central co-ordinating unit. The intention is to produce a national database of medical research projects. It is essential to know what research is being carried out in the National Health Service and helpful to have that linked adequately with the Medical Research Council, the work of medical charities and the work funded or undertaken by industry. I hope that we shall be able to move towards a totally comprehensive register system which will be widely available to anyone who has any right to access. At the moment there appears to be little access outside regional research and development directorates. There are, however, funding implications. A register of this nature must be kept up to date and properly resourced.
A second component of the information strategy is the Cochrane Centre and latterly the York Centre. The Cochrane Centre is part of the international Cochrane Collaboration. The report makes several statements about that exciting concept. Perhaps I may explain the rationale of the Cochrane Centre to those of your Lordships who are not familiar with it. Since resources are finite it is important that they are used efficiently both as regards the delivery of care and research. Information about the effectiveness and cost-effectiveness of healthcare interventions must be readily available and used by decision-makers in the National Health Service. The planning of new research must be based on clear information of what is required, what is not already available and what is already being done in research programmes.
The Cochrane centres are conducting reviews of the work in progress and are determining best practice. There are pitfalls, made clear to the committee and 906 mentioned at paragraph 2.17; for example, using techniques beyond their proper limits. There is clearly a need to make information available in a user-friendly way to the practitioner but there is clearly a danger of overload. However, there is overload already from perhaps more traditional methods of imparting information. One of the merits of current developments in information systems is that much complicated, highly specialist review information can be made available to the practitioner or to the manager in a way that should be user friendly. While recognising the constraints from which these techniques suffer, I greatly welcome the initiative. It is a highly important part of the information strategy.
Finally, perhaps I may comment on the role of the regional directors of research. It is the key level at which the competing pressures for funds, to which I referred earlier, must ultimately be decided. We have heard today that academic medicine should not be discouraged from undertaking its proper role of contributing towards education, training, research, design and much else. But there is also need for research in prevention and care in the National Health Service. Perhaps that is something of a Cinderella area and not always of great interest to the clinical research community educated in biochemistry and physiology.
We have heard that the academic community has many concerns about possible threats to the research programmes. Perhaps I may make a plea that, having recognised that, we also recognise the research opportunities and contributions that can be made by general practitioners, the nursing community and non-medical health professionals. All have a perfectly valid role to play in research. If they do not have the research culture so historically and firmly behind them, that is all the more reason why the research culture needs to be developed in those areas. I am sure that the present research and development strategy is correctly designed in order to obtain wider research funding.
§ 4.15 p.m.
§ Baroness McFarlane of Llandaff
My Lords, I with the noble Lords, Lord Perry and Lord Flowers, had the great privilege of serving on both the Committee on Priorities in Medical Research, chaired by the late Lord Nelson of Stafford, which reported in 1988 and on the present Committee on Medical Research and the NHS Reforms, so ably chaired by my noble friend Lord Walton. The Government response to the 1988 report was very positive and led to the appointment of Professor Michael Peckham, whose praises we have already heard sung today. I am sure that we would all wish to join in congratulating him on all that he achieved in a short space of time. Within three months he announced a new research and development strategy with the objective of delivering health service care which is knowledge-based and has a culture of evaluation. That can be made possible only through high-quality research.
The noble Lord, Lord Walton, gave the House a commendable introduction to the background of the present committee, the concerns of the medical 907 profession and the concern that the amount of health service research could lead to detraction from clinical medical research. It is right, therefore, that the major focus of our report should take that as its main point; that is, hospital-based clinical research and its vital relationship with academic medicine. Those are of immense importance to all those engaged in healthcare. It is only by pushing back the boundaries of medical knowledge that advances in treatment can be made. In that respect, it is in the interest of the patient that there is a seamless robe between the practice of clinical medicine and academic research.
I wish to dwell a little more on a point to which the noble Earl, Lord Selborne, has already alluded. I wish to open up the debate into the area of the other disciplines involved in health service research. Only brief references were made at various points in our report, principally in the paragraph related to research outside the major university hospitals and in paragraphs 1.18, 3.16 to 3.18 and 5.8. It is my view that despite the dominance and accepted importance of medical research, a number of the older professions, such as my own of nursing and midwifery, have only recently had access to higher education and to research thinking and research facilities. Furthermore, a number of newer professions in the health service need to research their practice. If the delivery of healthcare in the NHS is to be informed and knowledge-based with a culture of evaluation, the research and development of all professions needs to be cultivated. That is why I was particularly grateful for the reference in the Government response to our report at paragraph 16 which states:We recognise that all professional staff have an important contribution to make. However their contribution will depend upon support and professional development. The implementation of evidence-based practice will be greatly facilitated by the participation of nurses and members of other professions allied to medicine who spend most of their time in direct patient care. This is a priority for RDRDs and their NHS networks".The Culyer Report, to which reference has been made, suggested that all NHS settings should compete for R&D funding on equal terms. Our report expresses the concern that some disproportionate amount of research resource could be diverted from the needs of medical research. To me, that seems a rather defensive position, but we need to identify a distinct stream of funds within the R&D levy to underpin research in primary care, general practice and community settings.
We state categorically that while hospital-based research is of vital importance:it must increasingly share resources with research in primary care settings, and research in what Professor Culyer calls the 'Cinderella disciplines': general practice, nursing, midwifery and. health visiting and the professions allied to medicine".Six months on from the report, I have come to dislike the description of my own profession among others as a Cinderella discipline. I should prefer to talk about under-resourced disciplines. I believe that now is the time to redress the balance in the interests of patient care between those disciplines and what is being devoted to medical research.
908 It is useful to look at what the NHS R&D strategy has done for some of those professions. Most of the nurses with whom I have spoken were happy with the outcomes of the recommendations arising from the 1988 report Priorities in Medical Research and the strategy that arose from that. In particular, they are in favour of a multi-disciplinary approach to health service research. That has resulted in a far greater involvement of nurses in research teams and a better allocation of resources to the development of academic disciplines.
That is a positive outcome with which I go along pragmatically. But there may be some negative outcomes in concentrating on multi-disciplinary research. First, the distinctive nursing contribution may not be identified and nursing, within multi-disciplinary research, may become invisible. Secondly, the knowledge base for nursing practice, which we would hope would emanate from research, would not be identified specifically. Lastly, the research models and methodologies developed for other disciplines may not always be suitable for investigating questions of nursing practice.
Of course, there are some who take a simplistic view that the only respectable and universally applicable research method is the randomised controlled trial, and they hold that nothing else can be dignified with the name of research. There are many professions which would question that thesis. Some nursing questions lend themselves to randomised controlled trials; others are far more susceptible to, for example, the social sciences.
In 1992, the Director of Research and Development and the Chief Nursing Officer set up a task force on research in nursing, midwifery and health visiting which was chaired by Professor Adrian Webb who is now vice-chancellor of the University of Glamorgan. The task force was asked to consider the nature of nursing research; how to set priorities; conduct research; train researchers; and get research translated into practice. It reported in 1993 and in my view, that report complements wonderfully the report which we have before us today.
It saw nursing research as a branch of health services research, embracing nursing practice, nursing services and their delivery, the nursing professions and their workforces and their training and deployment, health promotion, and service systems alongside other professions—a very wide range of interests.
And so I believe that that report is a useful indicator for nursing. It recommended that nursing research should have a full and equal partnership in the NHS R&D strategy and observed that neither the managerial culture nor the nursing practice culture has been sufficiently supportive. The task force made a number of other recommendations in respect of targeting and enriching research, targeting and enriching funding education for research and the need for an information strategy.
Besides the Webb Report, I believe that the situation in nursing research, as an example of a profession other than the medical profession, has been highlighted in the research assessment exercise carried out by the Higher Education Funding Council in 1992. That demonstrated 909 the need for the enrichment of nursing research and education in nursing research very prominently. Both Alison Tierney from the University of Edinburgh and Jane Robinson from the University of Nottingham analysed the results. They appear pretty catastrophic for academic nursing. Twenty-nine nursing departments participated. Nursing ranked at the bottom of the league table of academic disciplines. It came 72nd out of 72 academic cost centres.
That may call into question the whole future of nursing as an academic subject and the allocation of research resources. However, a more detailed analysis of those reports reveals some of the contributing factors. Of the 29 departments assessed, 58 per cent. received the lowest possible rating and a further 24 per cent. were given a two rating, making 82.7 per cent. of the departments having a below average rating. Only five departments rated as average and above: two were given a rating of three; and three departments received a rating of four on a scale of five. No department received a five rating.
But if one analyses the results further, one sees that all the higher grades were in the older universities with longer-established units. All the departments in the new universities—the ex-polytechnics—received a rating of one, with the exception of one that was rated a two. Clearly, the rating may reflect something of the history of those institutions but the returns also illustrate that the length of time for which a department has been established is indicative. That suggests that a discipline such as nursing has a steep learning curve on which to catch up in terms of knowledge and expertise in nursing. I must reflect that the department of the University of Manchester, which I headed until my retirement, achieved departmental status only in 1973; and some progress has been made in 20 years. When we look at some of those older professions which now have a status in higher education—and some of the newer ones—we are considering professions which need a tremendous amount of help in the learning curve which is entailed in taking up a research function.
The Royal College of Nursing has commented on our report and accepts many of its recommendations. The college sees the need for an infrastructure funding for research and development, and calls for central monitoring of the deployment in that respect. Its monitoring of the implementation of the Webb Report revealed that it was very patchy. The college endorses the need for a director of research and development in both Wales and Northern Ireland, and has major reservations about our recommendation in paragraph 3.18 that the development of the research workforce capacity should be managed and distributed at local level. In that respect, the college sees a possibility of the disciplines becoming further marginalised. Therefore, that, along with other comments, come from the Royal College of Nursing.
I have attempted to use my own profession as an example to try to illustrate some of the problems of professions moving into higher education, especially as regards their funding for research.
§ 4.31 p.m.
§ Baroness Gardner of Parkes
My Lords, I must apologise to the House for arriving late for today's debate. I had so much wanted to hear the noble Lord opening the debate. I welcome the marvellous report that he has produced. However, I was delayed on my way here and, no matter how fast I ran up the stairs, I did not manage to get here on time. Therefore, I hope that I do not repeat any of the earlier comments made. I shall certainly read the noble Lord's opening speech with great interest.
I have the greatest respect and admiration for those involved in erudite, academic research. But as vice-chairman of North East Thames Regional Health Authority, I also have a very specific interest in how research relates to the every-day delivery of patient care and the needs of the National Health Service, both locally and nationally. When we had to appoint a regional research director for North East Thames, I was fortunate to chair the panel. One of those on the appointment panel with me was Professor—but not then Sir—Michael Peckham. At the end of the interviews, when we had had the choice of many good candidates and, indeed, two quite outstanding ones, we had to weigh up which to choose. One of the questions that I put to the professor was, "How many people with direct general practice experience do you have as directors of research?". The answer was that this person would be the first. It was for that reason that we appointed Professor Andrew Haines, whose appointment I believe has been a great success. It is important that we bear in mind the relevance of research to the treatment of patients.
As I am now chairman of the Royal Free Hospital Trust, I am very aware of how "patient driven"—which I suppose is the expression that I would use—are our research and interest. I say that because we are a most academic hospital; indeed, we are the largest single-site undergraduate teaching hospital in London. The trust and the academic unit are so closely allied that you cannot even differentiate as to which is which within the hospital building. We occupy the same building and are completely intertwined. I believe that that is most desirable. We are not only teaching undergraduates; we are also undertaking marvellous research.
As I listened to the debate, I could not recognise the scenario put forward earlier in the afternoon that academics. are feeling a little depressed and not valued enough; indeed, perhaps a little unappreciated. I believe that the noble Lord, Lord Perry, made those points. I do not find that at all. Our research people are full of enthusiasm and do all sorts of amazing things that the rest of us can do nothing but marvel at. So many of those initiatives have a practical application to the patients in our care.
I also believe that it is most important that those centres of excellence should continue. I have in mind the very synergy of so many academics under tike one roof, all of whom have independent thoughts and views; indeed, one stimulates the other with ideas. It is a situation where they gain from having other people bringing forward ideas and thoughts. Something which 911 appealed to me very much in the report was the section on pre-protocol research. I believe that that is to be found at page 28. It is most important.
On page 26 of the report we come across something which is most essential—the R&D levy and the core infrastructure. That is terribly important. There is no way that we could have that quantity of very specialised research duplicated everywhere. In order for people to try out their ideas and develop their interests, they must have the fantastic X-ray machines available. They must have the very latest equipment. There is no way that any country in the world could afford to have such marvellous pieces of modern equipment available in every location. It is much better to have it in the centres of excellence where the people with the brains to use it can be found. That is the way to produce good results for all of us.
I believe that the R&D levy is a most important feature. I say that because the core structure—the infrastructure—could take up almost 80 per cent. of the R&D money. It is a very expensive part of the procedure. But without it research could not continue as it is now.
However, the pre-protocol issue is different. It is about curiosity-driven research. I believe that that is an aspect which we must never underestimate. There will always be carefully designed and thought-out research programmes. Indeed, they are well listed in the report. But if we think back through history to Marie Curie's discovery of radium and Alexander Fleming's discovery of penicillin, we can see that they were findings which came about as much through curiosity as anything else. Yet the whole world has benefited from such marvellous research which would never have happened if we had been tying our researchers and our thinkers purely to matters which had been set down in advance.
I believe that the recommendations for the pre-protocol research in the document are excellent. They will encourage enthusiasts to continue to look at new ideas and new discoveries which will be for the benefit of us all. The report is a marvellous document. I have not had time to read all of it, but what I have read has very much impressed me. Clearly there will be enough reading to keep me going over Christmas.
§ 4.38 p.m.
§ Lord Nathan
My Lords, it has been a privilege to sit as a layman under the chairmanship of the noble Lord, Lord Walton, who guided us through the intricacies of medical research and the National Health Service with consummate skill and clarity. Indeed, it was an education for me. I propose to confine my brief remarks to research in relation to the patient outside hospital. Therefore, I shall concentrate on the implications of one sentence in the report which appears at paragraph 3.18 and refers to the need for,research into the implementation of care in the community, and into the integration of primary services, taking into full account the concerns of the patient".There are many well-known reasons for the shift from primary to secondary care. There have been welcome initiatives in pursuing research on R&D priorities in 912 relation to the interface between primary and secondary care. The subjects, numbering 21, identified in the report of a group under the chairmanship of Professor Roger Jones, published in 1994, certainly require investigation. They include the transfer of information across the interface between healthcare professionals and other agencies; the impact on referrals and discharge of including patients and carers in decision-making; and aftercare, rehabilitation and community care for priority groups. They are but examples drawn from the long list. They impinge on the subjects of special concern to me.
It seems to me that urgent consideration needs to be given to ensuring that in the primary care sector the patient knows who is in charge of his care, that that person will be responsible for managing the team and organising the treatment and care by the appropriate member of the team, and that the person in charge is available to be consulted. The exchange of information between those involved is of first importance in the interests of the patient. That requirement is, of course, additional to the wider need for exchange of information between all involved in healthcare, to which Professor Jones's report relates.
I suggest that this area deserves a research study on its own so that the guidelines for action will be clear. They need not be the same in every situation. Such a study will inevitably be interdisciplinary, involving those in the voluntary sector, social services, nursing and other professions allied to medicine, as well as the medical profession itself.
This leads me to wonder whether there would be advantage in the development of some new medical school incorporating a patient-centred curriculum, with students meeting patients from the first year onward and experiencing a range of practice settings; community-oriented clinical training with experience across the whole spectrum of health services, including their interface with the support services and experience of multi-disciplinary care; and consideration of socio-economic factors in health. Such elements would involve so radical a departure from the curriculum of existing medical schools that it seems that they might most easily be implemented in a new institution.
The Culyer Report devotes considerable space to care in the community, which I much welcome. It is a subject of great public concern. I shall be grateful if the Minister will indicate the priority the Government intend to give that area of research.
§ 4.42 p.m.
§ Baroness Jay of Paddington
My Lords, I should like to follow all noble Lords who have spoken in congratulating the noble Lord, Lord Walton of Detchant, and his committee on this excellent and extremely timely report. I was personally disappointed that I had to stand down as a member of the sub-committee. Reading the evidence taken by the committee and the full report has made me even more aware what a valuable and fascinating inquiry I have missed.
The report is as interesting in the indirect light that it throws on the general state of the NHS four years after the so-called reforms were introduced as in its analysis 913 of the state of medical research, the prime subject of the inquiry. As has already been mentioned, the NHS R&D programme spent its early years in the shadow of health services reorganisation. Given the findings of the report, it is unfortunate that we were not able to discuss it earlier in the year. Six months ago, when the report was first published, your Lordships' House was still considering the Health Authorities Bill, and much of what the noble Lord, Lord Walton, says in his report—and indeed what he proposed in his amendments to that Bill—would have been given extra force if we had considered the Health Authorities Bill and the report at the same time.
The report and all noble Lords who have spoken have rightly paid substantial tribute to the NHS R&D initiative, and particularly to its first director, Professor Sir Michael Peckham. Here I must declare an interest as an original member of the central research and development committee under his chairmanship from 1991 until last December, and I still act as chairman of the North Thames Regional Advisory Committee on Research and Development, where I have the pleasure of working with Professor Andy Haines, who has already been mentioned, and I am grateful to the noble Baroness, Lady Gardner of Parkes, for making his appointment to that position.
My close observation of the programmes as a very lay, lay person has made me a great admirer of their success and, particularly, of the political skill of the directorate in bringing research and development to the top of the NHS agenda. Few people would have predicted when Professor Peckham took up his post five years ago that by now the concept of "evidence based medicine" would have become almost a cliché in research institutions, and at least some NHS management offices, all over the country. As the report says:The strategy receives endorsement from across the spectrum of health care and research".However, as the report also emphasises, the energy and enthusiasm of the programme itself and of the academic researchers on whom it crucially depends have often been frustrated by the overall funding and organisational environment in which the programme tries to flower. And—to continue the metaphor—the reforms have provided a pretty unfriendly and stony soil for the new plant to root and develop.
The problems created specifically by the reforms seem to fall into three areas: problems of appropriate research funding and organisation by local trusts and purchasing agencies which are the decision makers in the new NHS; the impact of this fragmentation on getting research into practice—or, as it is known, the GRIPP initiative; and the problems of attracting bright young doctors to academic medical careers when they regard their future as being uncertain. I should like briefly to look at all three.
The noble Lord, Lord Walton, has this afternoon described the now accepted proposals of Professor Culyer's Committee on single stream research funding and the hopes that this will give secure financial underpinning for national research. The Culyer scheme is of course, as many speakers have said, designed to 914 counteract the effects of the internal market and its sometimes short-term approach to the contractual basis of healthcare. I join the noble Lord, Lord Walton, in welcoming the creation of a compulsory research levy on all purchasing authorities. However, I remain a little sceptical about the willingness or the capacity of every local agency to fulfill the spirit of the research and development strategy. There still seems to be substantial scope for foot-dragging about both research and development.
I was interested to read the comments of John James, who is himself an NHS chief executive and also a member of the Culyer Committee and the new central research and development committee, who wrote in the Journal of the Royal College of Physicians of London, referring to his Culyer group,all of us were convinced that up and down the country there were macho-purchasers, both districts and fundholders, who blatantly disregarded anything except the most short term considerations. But of course none of us accepted this as a description of ourselves…But no purchaser, however much he or she wants to be on the side of the angels, really knows what impact his or her actions have on activities within a Trust".It is these hands-off, indirect relationships in the new NHS which raise questions about the long-term, successful implementation of the broad implications of Culyer. I am glad that the noble Lord, Lord Walton, reserved the right to revisit this vital issue. The new funding arrangements will need careful monitoring and evaluation. I hope that the Department of Health will play a formal role in that process.
Overall, my main concerns about the continuing success of the R&D programmes are based in my anxieties about that fragmentation of the NHS—the breakdown into several hundred small businesses. Those concerns are made explicit in the report and summarised on page 12, where the committee quotes the Office of Science and Technology in saying:The importance of the NHS as a test-bed for medical research is vital. By virtue of its national coverage, the NHS is able to provide a broad, well-documented database of patient information and a , wide range of patients".But the committee goes on to note:as the NHS R&D Strategy began to take shape, concerns began to be expressed that the NHS reforms…were threatening to break up this vital test-bed. These concerns…echo through our evidence".Those concerns may echo through the evidence, but the committee does not seem to have found anything convincing to dispel them.
The committee has made the important recommendation, already referred to by several noble Lords, that regional research and development directors should have special funds to enable them to cut across local short term market fluctuations in the interest of clinical trials and other research. In the same paragraph, the committee lays stress on the need to take positive steps to educate purchasers, managers and, importantly, lay members of health authorities about the significance of research to developments in patient care. I hope that the Government will take active steps to support those recommendations.
There is, however, a problem about the mechanisms to achieve those and other recommendations in the fragmented health service. The noble Lords, Lord 915 Walton and Lord Perry of Walton, specifically referred to those. We on these Benches argued during the passage of the Health Authorities Bill that the abolition of the regional health authorities would substantially weaken the structural links between the NHS and academic medicine. The noble Lord, Lord Walton, proposed amendments to ensure that postgraduate deans would be formally integrated into the regional offices which will succeed the RHAs next April. The Government rejected the amendments and there are now only informal exhortations to executive outposts to keep close to local academics.
The future status of the regional research and development directors, who have been crucial—as was emphasised this afternoon—in building the foundations of the new programmes, is still unclear in the new offices which will be staffed by civil servants.
I note the recommendation at paragraph 4.33. It calls for the establishment of a policy and strategy committee in each region. Members of the committee noted that the strategy committee should be,chaired by Regional Chairmen, including within their membership the Postgraduate Dean, the RDRD, the Regional Director of Public Health, and nominees of relevant universities".I welcome the Government's response: that they want to see such an organisation in place; and the reference in the report to the statement of the Minister, the noble Baroness, Lady Cumberlege, at Report stage in your Lordships' House of the Health Authorities Bill that,There is nothing to stop regional chairmen within their regions building any mechanisms they wish in order to strengthen those links".—[Official Report, 24/4/95; col. 751.]However, we need more than permission; we need active involvement in order to get those important mechanisms going. In the absence of the noble Baroness, Lady Cumberlege, perhaps the noble Baroness, Lady Miller, can give us some insight into the Government's current position on that recommendation.
Several other noble Lords have asked what is happening under the new legislation regarding the proposed regulation that the new health authorities will have a university member where there is a medical school in the area. I understand that although categoric assurances were given during the passage of the Bill, those regulations have neither been consulted on nor published. That is very disturbing.
If a strategic regional committee existed, as the report suggests, and if there were proper medical school representation on the new health authorities, we could be slightly more confident that mechanisms exist not only to oversee and, it is to be hoped, to steer regional programmes, but also to get research into practice and purchasing and to nurture the careers of academic researchers.
Current threats to the careers of academic researchers are given considerable critical attention by the report. They have been given considerable critical attention by noble Lords who have taken part in the debate. As the noble Lord, Lord Walton, said, his committee felt the present situation to be sufficiently serious for it to warrant an immediate separate inquiry. The report 916 speaks of the "uncertainty engendered by the NHS reforms". There are specific concerns about the market system impeding adequate patient flows for research. They are well illustrated by a series of alarming examples on page 34 of the report.
There are concerns about the impact of locally determined pay on academic doctors who may not benefit from that system. Those concerns are echoed by organisations like the Committee of Vice-Chancellors and Principals and the British Medical Association. No wonder, as the noble Lord, Lord Walton, said, the report concludes in this section that the strong disincentives to the bright young doctors of today bode ill for the future of clinical teaching and research and therefore for the future of medicine.
Like the noble Lord, Lord Walton, I too am glad that the CVCP has set up an independent inquiry in that area but, frankly, regard it almost as a dereliction of duty that the Government have chosen to ignore that recommendation.
Other issues which have been raised this afternoon are equally important. I refer to the balance between biomedical and the health services research; and the distinction between the NHS funded programme and other important sources of finances such as the MRC and the medical charities. My noble friend spoke of the specific problems of Wales. I echo his hope that the research and development director for Wales and for Northern Ireland will be appointed as soon as possible.
In conclusion, I should like once again to thank the noble Lord, Lord Walton, and other Members of your Lordships' House who served on the committee with him. They have provided us with an enormously important document which not only analyses the role and direction of medical research but also gives us the first systematic appraisal of the impact of the NHS reforms on a crucial element in the successful development of our healthcare system.
At the International Conference on the Scientific Basis of Healthcare arranged by Professor Peckham in London this autumn, Mr. Dorrell said that,The R&D programme has the potential to make the single biggest contribution to patient care in this country as we approach the next century".That is probably true, but it will only be true if government health policies facilitate rather than impede research and development.
§ 4.56 p.m.
§ Baroness Miller of Hendon
My Lords, I should like to apologise for the absence of my noble friend Lady Cumberlege, who is in South Africa representing Her Majesty's Government at the Commonwealth Health Ministers Conference and who would normally have responded to this debate. I know that she would have wished to have been here to have heard this excellent debate. I only hope that I can do it justice in her place.
Like others of your Lordships, I should like to thank the noble Lord, Lord Walton of Detchant, not only for providing us with the opportunity of having this most 917 interesting debate today but also for his efforts in chairing the committee which produced this valuable report, Medical Research and the NHS Reforms. The Government welcomed the constructive spirit of the report. It congratulated them on the success of the NHS R&D strategy; and the debate today in raising awareness of this strategy has provided its own contribution to one of the key recommendations of the report—namely, that the work of the NHS R&D strategy should be more widely known.
The report covers a wide and complex field and it raises many research and educational issues central to the future delivery of national health services and to the quality of patient care. The Government are quite clear on the importance of this point. We have repeatedly emphasised that research and development is vital to the NHS if the service is to continue to prosper into the new millennium.
This is because R&D provides a crucial link between advances in science and the day-to-day practice of medicine and healthcare. The effectiveness of the service depends on a smooth flow of information, which in turn will help ensure that appropriate, soundly-based decisions are taken throughout the NHS. This role will become even more important as the pace of scientific discovery quickens and the service faces a host of new technologies and procedures.
I am not sure that I understood the point that the noble Lord, Lord Walton of Detchant, made with regard to the central initiatives under threat. There is an ambitious programme of centrally funded research which covers all important priority areas—for example, mental health, cancer, primary care and so on. But I am grateful to my noble friend Lord Selborne for his magnanimous comments on the wide-ranging content of the NHS R&D programmes and the supporting information strategy.
We have been reminded today by the noble Lord, Lord Walton of Detchant, that it was an earlier report from the same committee of this House which acted as the catalyst for government action in this area. It was the recommendations of the report, Priorities in Medical Research (1988), and the exertions of its chairman, the late Lord Nelson of Stafford, which paved the way for the establishment of the NHS R&D strategy and resulted in the appointment of Professor Sir Michael Peckham as the first director of R&D at the Department of Health. My noble friend Lord Selborne paid tribute to Lord Nelson, and we would like to add our tribute to him.
The current report confirms the achievements of the strategy so far, and these have been endorsed across the entire field of healthcare and research, including primary and community care, about which the noblé Lord, Lord Nathan, was worried. The centrally funded priority research programmes include primary and community care subjects, and Professor Haines, who was mentioned by my noble friend Lady Gardner, leads the national programme on primary care research. That is a vital recognition of the support that has been won for this relatively new initiative inside and outside the health service. Building on that support will be an essential 918 task in developing the strategy in the years ahead. I hope that the noble Lord, Lord Nathan, is happy with my response.
The report also paid a generous tribute to Sir Michael Peckham, as did the noble Lords, Lord Walton and Lord Butterfield, and the noble Baroness, Lady Jay. We would also like to pay our tribute to him. After five stirring years, Sir Michael leaves his post in the department at the end of this month. Much has been achieved and the Government and the NHS owe him a great deal, as the findings of the report testify. We were all pleased to hear what the noble Lord, Lord Butterfield, had to say in that respect about Sir Michael. I hope that someone will send him a copy of Hansard so that Lady Peckham may see it.
One sign of his achievement was the great interest shown in the NHS R&D strategy by all the delegates who attended the department's Scientific Basis of Health Services Conference held recently in London. Over 1,100 people from 40 different countries came together over three days to learn and share developments in translating advances in science and research into the best professional practice. The level and enthusiasm of the delegates underlined just how much progress has been made in the past five years. In opening the conference, the Secretary of State took the opportunity to reaffirm the key importance of R&D developments to the NHS both now and in the future.
The Government have actively promoted this recognition of R&D. We are determined that the new NHS should provide the best possible environment in which R&D can flourish. We recognise that an effective R&D strategy is crucial to the new, modern, evidence-based NHS in delivering good and effective care to its patients. We also realise that robust new mechanisms will be needed to provide a strong and durable basis for organising and supporting research within the new NHS. That was why a task force was established under the chairmanship of Professor Anthony Culyer of York University to address those issues.
Your Lordships' report commended the Government for acknowledging the difficulties for R&D caused by the introduction of the new NHS and for setting up the task force. It also welcomed the task force recommendations and again emphasised the general support of the health service and research communities for the principles underpinning those recommendations. New arrangements for supporting R&D based on those recommendations are now being set in place. They will harness progress in science and address health service issues. In particular, they will provide a sound basis for separately supporting research and patient care while promoting synergy between them. Those plans are of international interest and concern.
As long ago as last April we announced a three-phase plan to implement the report's recommendations and create a single funding stream from an NHS R&D levy on purchasers. Substantial progress has been made since then. The first phase will come into effect next April through the introduction of an interim R&D levy based on existing budgets. In the second phase the initial levy 919 will be adjusted in April 1997 to reflect the true costs of R&D. Last month guidance was issued to assist NHS hospitals and community health service providers to identify and cost their current R&D programmes as part of a nationwide exercise. Plans for the third phase, the full operation of the arrangements, are on schedule for April 1998.
The noble Lord, Lord Perry of Walton, asked the Government to act soon to allay fears that funding may shift under the new arrangements from support for the science base to needs-led projects. I am pleased to reassure the noble Lord that the new arrangements will include mechanisms for ensuring the correct balance between NHS support for the science base and support for the needs-led work, to which the 1988 report of your Lordships' committee drew attention. The new national forum will play a crucial role in advising them.
I can also reassure the noble Lord, Lord Butterfield, that the new funding arrangements will preserve the current powers of regional directors of research and development to disburse funds for the purposes which he so eloquently described. Regional directors are at present in control of in excess of £35 million.
I should also like to reassure the noble Lord, Lord Walton, in his concern about the schemes in London. As happens elsewhere in the country, those schemes will be able to test for private finance. We expect them to be successful. In the unlikely event of a scheme not attracting a private sector partner, it may still apply for public sector funding, which will continue to be available for priority schemes. I am also grateful to my noble friend Lady Gardner for reminding us of the importance of pre-protocol research. The Government's response to the committee's report confirmed that the new funding arrangements will address that.
I can also reassure the noble Baroness, Lady Jay, that the Government will monitor carefully all three phases of implementation. Regional offices already have teams in place to support and track progress. Evaluating and making the best use of research evidence is central to the aims of the R&D strategy. As with the other programmes, the health technology assessment programme seeks to identify NHS priorities and then to evaluate the effectiveness of current technologies and procedures. The information gained is then shared with the health service.
The Cochrane Centre and the York Centre for reviews and dissemination also play a key role in spreading the word about the state of research knowledge across a range of disciplines. The centres produce information in a form which is relevant and usable, both as an aid to practice and as a way of avoiding unnecessary duplication of research.
Equally, the department's R&D initiative seeks to increase the knowledge base about effectiveness, to make it available to decision makers and to encourage its use to change practice and monitor the results. In health, as in so many other fields, the march of technology gathers pace all the time. Busy clinicians (which of course includes nurses) need to know the results of research in ways which suit their busy 920 schedules and are relevant to the fields in which they practise. I am pleased to tell the noble Baroness, Lady McFarlane of Llandaff, that we have emphasised the important role which general practitioners, nursing staff and professions allied to medicine must play in the development of NHS research. We are developing a research capacity strategy for the NHS which will build on current schemes for research training in the nursing, therapy and pharmacy professions. We will publish a first statement on this strategy at the end of the month. We are very grateful for the views of the noble Baroness, which will help us as we consider future arrangements.
Recognising the reservations expressed in the report, we nevertheless take the view that clinical guidelines are one important way of helping to bridge the gap between research and practice. Together with other major initiatives such as clinical audit and education and training, they can help ensure that clinical practice is sufficiently responsive to changing evidence of best practice.
As the report points out, close links between the NHS and the universities are an important aspect of this development. At the Department of Health, the Steering Group on Undergraduate Medical and Dental Education and Research (SGUMDER) has provided a valuable national forum for identifying and considering such issues, including research. SGUMDER has already produced three reports, including the 10 key principles for effective joint planning and liaison between the universities and the NHS, and a fourth report is imminent.
Partnership and collaboration with other funders of health and medical research are a vital part of our work. Advances in science and technology and the need for health care to adapt to change call for new ways to provide co-operative working between these different funders. This is to avoid the unnecessary duplication of limited resources. This partnership is pursued through the concordats the health departments have concluded with the research councils and through our links with charities and with industry. The newly established national forum chaired by the director of research and development is proof of our commitment to such an approach. I am pleased to tell the noble Lord, Lord Prys-Davies, that the Welsh Office health department expects to announce the appointment of a new director of research and development later this month. We look forward to the new director actively developing and carrying forward the NHS R&D strategy for Wales.
Several noble Lords, particularly the noble Lord, Lord Walton of Detchant, referred to the recommendation in the report for an independent review of factors affecting clinical academic recruitment. I had intended to say that I was very pleased to tell the House that the Committee of Vice-Chancellors and Principals, after much consideration and informal consultation, has agreed to establish such an inquiry. However, the noble Lord, Lord Walton of Detchant, beat me to it. I am sure that all noble Lords were pleased to hear that piece of news.
The noble Lord, Lord Prys-Davies, mentioned academic pay. Although it is true that the present mechanism does not enable medical academic pay to be 921 increased at the same time as the review body on doctors' and dentists' pay recommendations for National Health Service medical salaries are published, nevertheless, the Government remain committed to the principle of linkage. I hope that that will also reassure the noble Lord, Lord Butterfield.
The CVCP, which will be entirely independent of government, will be chaired by Sir Rex Richards, the former vice-chancellor of Oxford University. The committee hopes to announce the details early in the new year, but in the meantime may I just say that we welcome this development; we regard it as an acceptable way forward and will await the report with interest.
We welcome the opportunity this debate has given us to consider this report, Medical Research and the NHS Reforms, and to explore the achievements of the NHS R&D strategy and related developments in the Health and Education Departments. The issues raised will be crucial in shaping the agenda for building a stronger NHS underpinned by R&D.
We look forward to building on the partnerships we have already established and to working with others who want to see, and who stand to gain from, the continuing development of R&D within the NHS across the United Kingdom.
The Government acknowledge that the rapid advances in basic science and health services research make this an exciting time for researchers and a time of opportunity for government to adapt to the widening scope of modern medicine and develop a health service fit to face the future.
I thank everyone who contributed to this debate. I am aware that, with the exception of the noble Lord, Lord Prys-Davies, my noble friend Lady Gardner and myself, all noble Lords served on the health committee, as indeed did the noble Baroness, Lady Jay, even if not for the whole time. It is therefore possible that I have not answered in detail all the questions of such high calibre that were put to me. I will read the debate with great care and write to noble Lords, particularly the noble Baroness, Lady Jay, with whose points I did not have time to deal at the very end.
§ 5.15 p.m.
§ Lord Walton of Detchant
My Lords, I am deeply grateful to all noble Lords who contributed to the debate. To have chaired this sub-committee of the Committee on Science and Technology of this House was a very rewarding and challenging experience. I am grateful for all the remarks made about my personal contribution to the work of the committee. I also wish to reiterate what I said about the outstanding contribution made by our Clerk and our specialist adviser, Sir Keith Peters, regis Professor of Physics at Cambridge, whose wise and cogent advice throughout the inquiry was so helpful to the committee as a whole.
It would, I am sure, be a mistake at this hour to go into detail about the remarks made by so many noble Lords in this challenging and fascinating debate. I was grateful to the noble Lord, Lord Perry of Walton, and to the noble Earl, Lord Selborne, for the way in which they 922 drew attention to the 1988 committee inquiry, so ably chaired by the late Lord Nelson of Stafford, which initiated the very welcome and effective development of research and similar work in the National Health Service. I echo all that was said in congratulating Sir Michael Peckham and his regional directors on their outstanding leadership.
In our report we stressed the crucial importance, as the noble Earl, Lord Selborne, said, of dividing the single stream of funding recommended by Culyer into three streams—the delta, as he referred to it—one of which will support R&D both centrally and regionally, including crucially important locally operated clinical research schemes to enable young doctors and nurses, and others in the community, to take their first steps in research. The second will be the important support for research—biomedical as well as health services research—in our major centres of academic excellence. I wholly agree with the remarks of the noble Baroness, Lady Gardner, on the crucial importance of their preservation and on how important it is to continue to support pre-protocol and curiosity driven research in our NHS. The third component will be support, as many noble Lords suggested, for research in primary care in the community undertaken by nurses and other healthcare professionals, not forgetting the very important contribution to developments and patient care made by scientists without medical qualifications in the NHS.
To respond to the very interesting proposal of the noble Lord, Lord Nathan, in my former medical school of Newcastle-upon-Tyne medical students are introduced to patients on their very first day. Every medical student in that school is taken out by a general practitioner in the first week and introduced to a family in the community whom he or she is expected to follow throughout the entire medical course, writing reports first on their social background and subsequently on their medical problems. Students do that while they are studying the basic medical sciences. So many of the ideas to which the noble Lord referred are already being implemented in a number of medical schools.
In a very cogent and detailed speech, the noble Baroness, Lady Jay, pointed out how important it is to maintain the close relationship between the universities and the NHS upon which so much of the work referred to in today's debate depends. I was delighted to hear the Minister state that this was the cornerstone of the Government's policy. We look forward to hearing more about the regulations relating to university membership of health authorities and to whether this government proposal, accepted in their response to our report, will allow regional committees of the type that we envisage in our report to be established. We shall be interested to hear whether it will be a firm government recommendation.
As the noble Baroness, Lady Jay, said, the NHS is the test bed for medical research, a test bed which must be preserved. I was glad to hear that the levy will. be in partial operation in April next year, will come into full operation in April 1997 and will be in absolutely final full operation in 1998. That is very good news. I have no doubt that the work of the implementation groups of 923 which we have heard will be monitored closely by your Lordships' Select Committee on Science and Technology under the leadership of the noble Earl, Lord Selborne. It is very important that that committee will continue to monitor the way in which the report is implemented by government. There is much more that we shall wish to learn over the coming months.
The contribution to medical care of research and development and of clinical academics nationally and locally is incalculable and will always be so in the future of the NHS. This has been a most encouraging debate. Many other points could have been raised but I hope that note will have been taken of this matter. As the noble Baroness, Lady Miller, said, it is crucially important that the Government's welcome for work on its NHS R&D strategy should become more widely known, not just in the academic and NHS community but by the public at large.
On Question, Motion agreed to.