HL Deb 25 February 1997 vol 578 cc1111-28

7.30 p.m.

Lord Glenarthur rose to ask Her Majesty's Government what progress is being made on reallocation of specialties among West London hospitals and what is their expectation of the effect upon research of any further reallocation.

The noble Lord said: My Lords, in asking this Unstarred Question I must declare an interest. For over five years now I have been chairman of St. Mary's, Paddington, NHS Trust, one of those important elements in the NHS in West London whose activities and skills could be affected by any reallocation of specialties.

I am delighted that so many noble Lords with deep knowledge of health issues have chosen to speak this evening. I am sure that I speak for the whole House when I say how particularly pleased I am that the noble Lord, Lord Hussey of North Bradley, has chosen this occasion to make his maiden speech. His experience in the health field as well as in many other fields, is enormous and I know that we all keenly look forward to his intervention.

I begin by saying that I am an enthusiastic supporter of reforms introduced to the National Health Service over recent years—reforms which were beginning when I was a Minister in the then DHSS in the early 1980s. I am a supporter particularly because, in my present role, I have seen just how much the reforms have improved the care of patients, and that, surely, is what all of us in the health service, indeed in this House, want above all. But any attempt to introduce a more businesslike approach to such a complex service as the NHS was never going to be easy. It was never guaranteed to bring perfect results, not least because technical developments continue to grow apace and with them grows the number of patients needing, and able to benefit from, more advanced treatments.

The health service is about combining medical science and research, both academic and applied, and teaching with established facilities for patients. Each element has its vested interests. But each can work—and does work—together for the good of patients, coupled inevitably and quite properly, with careful use of resources.

The introduction of the internal NHS market in parallel with the autonomy of trusts, has helped bring back a sense of purpose and focused management at a local level. I would, however, be the first to accept that the health service market cannot be a "pure" market—a total free-for-all. It must to some degree be a "managed" market.

My reason for asking this Question this evening primarily relates to the management of this market. Despite the Tomlinson Report, the specialty reviews of about four years ago and the work of the London Implementation Group, uncertainty still exists in West London. There have been positive developments in medical education (for example the integration of medical schools through Imperial College) which have helped set the scene for the future. Indeed, a huge amount has been settled. London's health service will be the better for it. But recommendations to resolve site issues in West London have never been wholly followed through and further studies are in train.

Academic medicine, and the institutions in which it is mostly practised, is an essential element in NHS provision. The recent report of the King's Fund London Commission, The Contribution of London's Academic Medicine to Healthcare and the Economy, rightly makes that clear. It highlights the strengths and world-wide reputation of the capital's academic medicine, and describes its contribution to the population's healthcare. But let me inject a note of caution from where I see things: we must not allow academic institutions to be the tail that wags the health service dog.

The health service must not be reorganised simply in order to suit academic strategists, important though they may be. That would be folly; it would ill serve patients and it would undermine existing real centres of excellence.

At the risk of what may sound like special pleading, but more to make my point, perhaps I may give your Lordships two examples of how such a policy could affect my hospital, St. Mary's. We have a long tradition of treating patients with end stage renal failure. We have been performing kidney transplants for many years and we have now developed into pancreatic transplants. We perform about 50 kidney transplants a year. The Hammersmith—a famous hospital and academic foundation, in which the noble Lord, Lord Winston, plays a major part—does less than 30 renal transplants. St. Mary's has 100 per cent. survival rate at one year after the operation, which is something that we take particular pride in. At St. Mary's we are the largest provider of haemodialysis in Greater London. Our standards are above those set by the Renal Association. We deal with more acute renal failure cases than others and we have all the necessary pathology services to support them. We have developed a ground-breaking "hub and spoke" model, so that patients can be treated closer to their homes. But all these achievements would be put at nought if some of the thinking that we believe is taking place becomes a reality. It would spell the end of St. Mary's renal service apparently because having such a specialty at St. Mary's simply would not fit the academics' plans, regardless of the needs of the patients.

Perhaps I may give noble Lords another example at St. Mary's and that is cardiac care. There are four hospitals primarily involved in cardiac care in West London—Harefield, The Brompton, Hammersmith and St. Mary's. Each of course has its special features. The Harefield has an outstanding surgeon, Sir Magdi Yacoub, among many others. The Brompton specialises in cardio-thoracic care. The Hammersmith is the Royal Postgraduate Medical School, the only one of its kind in the United Kingdom. And St. Mary's uniqueness in part stems from its wide range of other specialties, which are intrinsically linked to our cardiac care. Both our renal and our vascular expertise means that we are better able to deal with any associated complications that arise from cardiac work. However, if one looks at a breakdown of activity by procedure at each of these four world-famous hospitals, the stark facts are that the Hammersmith, the leading academic base for tertiary work, treats the lowest number of cardiac patients. The Brompton, focusing as it does on cardio-thoracic work, treats only about half as many again as St. Mary's, which is a teaching hospital, has many specialties and is a local district general hospital. This is not in any sense to denigrate the enormously high standards of any of those other institutions, I merely use them to illustrate a statistical fact.

Since the initial specialty reviews, St. Mary's has been able to double the number of heart operations performed and has pioneered new techniques such as angioplasty and stenting. We have developed and taught these procedures. Without such advances many patients would have required coronary artery surgery. So what we are doing is good news for all our patients.

About 30 per cent. of our activity is from our immediate local purchasing health authority, Kensington, Chelsea and Westminster, which the noble Baroness, Lady Jay, knows so well, and 70 per cent. from our top four purchasers. So we are providing support for our local populations in each case. I would argue that this must not be put at risk. St. Mary's is now a leader in a number of fields because we have made the internal market work. In both renal and cardiac specialties we went out and won the business and that is what my noble friend and her colleagues in the department have been keen to encourage others to do as well. We have developed far higher standards and considerable expertise. Now they are a success at St. Mary's and for St. Mary's patients. We cannot loosen our grasp on such advances. It would be more than foolish; it would be a derogation of our duty to patients.

The underlying purpose of my Question is to seek an assurance from my noble friend Lady Cumberlege that she will not allow the intellectual might of academic institutions to be the main driving force in the provision of high quality, local healthcare and this must be a question which affects other trusts in London as well as my own. What are the considerations her department is weighing up? What are the timescales involved? Does she accept the effect upon business planning for trusts of the uncertainty the current review generates? And will her department bear in mind that what matters above all else is that collaborations and partnerships bring effective academic science to bear, without putting at risk the stability of institutions which have increasingly demonstrated an ability to manage resources, improve patient care and help make a success of the internal market.

7.39 p.m.

Lord Winston

My Lords, it was a pleasure to listen to the noble Lord, Lord Glenarthur, who is a wonderful advocate for St. Mary's Hospital. He has introduced a most important debate which is obviously very dear to my heart also. I promise your Lordships that I shall not be speaking on behalf of Hammersmith Hospital; I am not sure that I could match the noble Lord's advocacy. I am sure that all noble Lords will listen with great pleasure to the noble Lord, Lord Hussey of North Bradley, who is to speak next and to make his maiden speech.

I should like briefly to draw your Lordships' attention to what is truly a unique opportunity. It is a world-class opportunity for west London. With the opportunity afforded by Imperial College School of Medicine, we have the opportunity to make what by any standards will truly be a world-class medical school with St. Mary's Hospital, the National Heart & Lung Institute, Hammersmith Hospital, Queen Charlotte's Hospital and Charing Cross and Westminster Hospital. That medical school will have a budget which will probably exceed that of Harvard and which will compare more than favourably with the Mayo Clinic and with Johns Hopkins Hospital. There is no doubt that it is a fantastic opportunity for Britain and for British medicine. It is most important that it does not founder. As your Lordships will know, it has an outstanding HEFCE rating which is improving all the time. We are pleased to see that happening at St. Mary's Hospital. It is great news. We are dealing with five-star institutions which will contribute greatly to medical education.

There is no doubt in my mind that the research done at that medical school will have the most major impact on the whole of the NHS. It is not just a question of individual specialties, although some have been mentioned, such as chest disease, vascular medicine, obstetrics and gynaecology and renal and liver medicine. It is also important to point out that at St. Mary's Hospital major and important research has been conducted into the value of primary care. Added to that, which is of crucial interest and great importance to the health service, there has been throughout the medical school an increasing focus placed on the need for evidence-based medicine and the evaluation of results.

Two essential problems face Imperial College School of Medicine. The first is the inevitable concern about the Culyer exercise. It is an important exercise and it is understandable that the Government want to spread the funding across the country, but there is a risk of diluting academic funds to be truly competitive. We feel strongly that the Government are right to recognise the need for selectivity. That is something that the Government have emphasised and this is an ideal opportunity to implement it. We hope very much that the funds will not be diluted too much. Of course, they need to be competed for, but they are important. Clearly, one problem is that if those funds are withdrawn to any extent, the effect on the trusts will be profound. They may founder in consequence because they depend on that sort of money.

The other concern was raised by the noble Lord, Lord Glenarthur. I refer to the question of competition between trusts. It is most important that we find a way to increase co-operation between trusts. We have done that in my own group. We have a close collaboration with St. Mary's Hospital on reproductive medicine. I believe that it could be a model for many other branches. It is ridiculous, for example, that 50 renal transplants are carried out at St. Mary's with rather a few more than 30 being carried out at Hammersmith. Whatever the figures, surely it is much more sensible to share the proceeds and the academic value. It would be terrible if such a strong academic institution which has such potential foundered simply because of failed NHS partnerships. I hope that the Government will do all that they can to support this.

7.43 p.m.

Lord Hussey of North Bradley

My Lords, it is a great honour, albeit a daunting one, to address your Lordships for the first time and I hope I may crave your customary indulgence to those making their maiden speech.

I am most grateful to the noble Lord, Lord Glenarthur, for raising this important issue. I must first declare an interest. I have been chairman of the Royal Marsden Hospital since 1985 and on the board of the Institute of Cancer Research. They work as one. On behalf of the King's Fund, I am chairing for the second time its Commission on London Health—possibly another triumph of hope over experience.

We have just received a formidable report from the deans of London's medical schools stressing that London is a medical power-house with a world-wide reputation for clinical care, research and education. It is an under-valued national asset, contributing notably to our economy. Brains, ideas and their application are the currency of the future. Top quality patient care depends on top quality research. Yet university funding for equipment has been cut by 30 per cent. and core staff numbers are being reduced. Investment in London's academic medicine must be a priority for our national prosperity.

What is true of London as a whole is certainly true of west London which on its own has an outstanding concentration of medical excellence. Many changes have taken place since the Tomlinson and King's Fund reports. Among their recommendations was further rationalisation in research and patient care. I firmly supported that, but I did not support the suggestion that the Royal Marsden and the Royal Brompton should be closed and rebuilt on the site of Charing Cross Hospital. Happily, those eccentric proposals were blown away. The Marsden was not closed and I should like to thank your Lordships for your great support, for which the hospital and, more importantly, its patients are deeply grateful.

Five years later, I hope that your Lordships will feel that your efforts were not wasted. For each of its first three years, the Marsden Trust has operated within its budget. Moreover, in the recent HEFCE review, the institute and the Marsden came second out of 30 undergraduate and post-graduate medical schools—second to Oxford University. If it had to be a university, I must say that I am glad that it was Oxford.

Imperial College, the Hammersmith and the Brompton also finished high in the merit table. We need not fear for the quality of research in west London, but for its funding. The Marsden's research grant is reduced by £15 million and NHS prices will increase by 140 per cent. Although the money is redistributed among the authorities, I fear that they may use it for purposes other than the referral of their patients to specialist hospitals. That is bad for patients, bad for research and bad for the hospital. We must maintain the necessary patient flow critical to our clinical research programme. But, as the noble Lord, Lord Winston, said, there is increasing collaboration. I believe that the most important is the grouping around Imperial College. I hope that the Institute of Cancer Research will shortly become involved in that.

However, there are problems. More people are reaching an age when they are likely to need treatment and are living longer just at the moment that that treatment becomes more expensive. There has been an explosive growth in medical technology, especially in expensive but effective drugs. The cost of treatment in some areas outweighs the savings in others. More capital investment is needed. In the Marsden, we have opened a new breast and diagnostic unit, entirely paid for by voluntary contributions. I believe that it will be increasingly difficult to sustain the health service on its present funding, a point also made by the academic deans.

Finally, I should like to pay a tribute to the nursing profession with which I have been connected for many years, starting during the war when I was nursed by German Catholic nuns who tended us prisoners with dedication and compassion, demonstrating also an unexpected talent for bartering our cigarettes for eggs and vegetables on the black market. In retrospect, they were quite exceptionally politically correct. The part played by nurses and their impact on the morale and health of patients is often overlooked, as is the benefit of nursing research. There is increasing evidence that the care of specialist nurses, accustomed to handling the challenging problems of pain, disability and emotional stress can lead to patients getting better more quickly or at least to making their lives more comfortable. For that reason, the institute has recently established a Chair of Nursing Research. Specialist cancer nurses are at the forefront of cancer treatment.

I believe in the health service. Support for it is deeply rooted across the nation and across all political parties, but in the past 50 years the terms of trade have changed. The equation between what the national budget can afford and what treatments the developments in research technology and medicine have made possible is increasingly difficult to balance. In some way, that balance must be restored.

7.50 p.m.

Lord Butterfield

My Lords, I am greatly honoured that I have been given the opportunity to speak immediately after my old colleague the noble Lord, Lord Hussey, and to congratulate him on his splendid maiden speech. That is the main responsibility of the immediately following speaker. He has spoken knowledgeably. I shall spend most of my few minutes praising Duke Hussey rather than developing the themes that may come forward in the health service.

I agree with much of what previous speakers have already said. As a former professor of the University of London who is very concerned about the London schools, I hope that there will not be a battle between the academic units and the clinicians. What this city needs is collaboration. That word has been used on all sides of the House. Whatever happens, I make the plea to leaders and Ministers that collaboration should be encouraged.

I should like to say a little about the noble Lord, Lord Hussey. In the summer of 1942 a number of cricketers were sitting around in Vincent's Club in Oxford. They were greatly worried about how they would dismiss John Bridger, who was then a leading and prolific all-rounder for Cambridge. Somebody said that there was a chap in Trinity who had got Bridger out in all of the house matches when he was at Rugby. We called in Duke Hussey who did exactly as we wished. He got Bridger out at the very beginning of his bowling spell. He complained, quite rightly, that I had taken him off too soon; otherwise, the match would have been won before tea. Never mind. He then went off to join the Grenadier Guards and served bravely and splendidly in Italy. He was wounded and lost a foot. Noble Lords have heard that he was nursed by some splendid German nuns.

Since the Second World War he has had what can only be described as an incredible career. I consulted Who's Who and Dod's and made a few notes. This man was managing director of Harmsworth Publications soon after his return in top gear. He was on the executive board of the Thomson Organisation. He was chief executive and managing director of The Times during a very difficult period for that newspaper. Those of us who watched him in his time there were firmly of the opinion that Duke would make sure that good sense prevailed rather than wild politics.

He went on to become director of William Collins, and for 10 years was chairman of the BBC. Some of your Lordships went with me to a luncheon with Duke just before he stepped down. He made a prodigious after-lunch speech. We have much to look forward to if we can get this man on his feet many times. The most memorable point in the speech that I remember, which is related very closely to the remarks of the noble Lord, Lord Glenarthur, about the need to watch the costs of the health service, was Duke's comment that he was the man who taught the BBC a four-letter word. I was rather shocked. He said that the word was "cash". One had to appreciate that one could not do everything one wished because there were cash limits.

Duke Hussey has been on the board of the British Council and chairman of the King's Fund London Committee. He is also a trustee of the Rhodes Trust, which is quite an achievement, and also an honorary Fellow of his college, Oxford Trinity. I say to the noble Lord, Lord Hussey, that we look forward with immense pleasure to hearing him make many contributions from the Floor of this House, and perhaps elsewhere, in the future.

7.54 p.m.

Lord Walton of Detchant

My Lords, I am sure that many noble Lords share my sense of frustration in not being able, because of constraints of time, to hear a longer contribution from the noble Lord, Lord Hussey, whose distinction in so many fields, as the noble Lord, Lord Butterfield, said, is outstanding. He has given us an intriguing foretaste of things to come; we trust that we shall hear from him many more times.

In discussing this Question, I propose to depend to an extent on my personal experience in many years of practice in neuroscience. When I first began training in this field there were consultants who worked for part of the time at the London teaching hospitals and for part of the time at hospitals like the National, Queen Square, or Maida Vale. They were able through their observational and descriptive skills to make major advances in that field. How the situation has changed. There has been the development of new technology—magnificent new methods of imaging—and the related clinical neurosciences of neurophysiology and so many more, and the burgeoning advances in molecular biology bringing in sight gene therapy for some of the most crippling neurological disorders which have transformed the situation. All are demanding of time, expertise, expensive equipment and, very largely, demanding of collaboration between doctors and scientists working in the laboratory.

Why does this Question concentrate on research? Research is the lifeblood of medicine. Today's discovery in basic laboratory research brings tomorrow's practical developments in patient care. I believe that in today's health service it is increasingly difficult to bring home that message to some managers who are obsessed, very reasonably, with the crucial importance of increasing patient throughput. In neurology one can take the example of Parkinson's disease. The discovery by some Viennese pharmacologists many years ago revealed that the substance dopamine was not being secreted by cells at the base of the brain. This led to the introduction of levodopa.

When the Tomlinson Committee and the King's Fund Committee began their work there were 11 departments of clinical neuroscience scattered throughout London and 10 departments of oncology. Frankly, some of them were not viable because of limited resources and staffing. Hence, it has become crucially important that these highly specialised skills should be concentrated into much larger units where doctors can work alongside basic scientists, with particular emphasis on their being placed in association with multi-faculty colleges such as Imperial College, to which the noble Lord, Lord Winston, and others have referred. That policy is bearing fruit. Previously many of those isolated departments scattered throughout London received rather low ratings in the research assessment exercise. But as the Deans Report on academic medicine in London has clearly demonstrated, these multi-faculty institutions and the departments of clinical science with which they are associated are now rising steadily within the research assessment scale.

I had the privilege of chairing an inquiry by your Lordships' Select Committee on Science and Technology into academic medicine, particularly medical research in the light of the NHS reforms. We were pleased that the Government were committed to devoting 1.5 per cent. of the NHS budget to R&D. It is crucial that part of that budget should be used to preserve the infrastructure for biomedical research within our teaching hospitals and within these institutions in London. It is also crucial that part of that money should be used to preserve the tertiary referrals that are the lifeblood of clinical research and which have seriously declined. In particular, as a consequence, the interests of the special hospitals such as Hammersmith, the National Heart and the National Hospital for Neurology and Neurosurgery must be preserved.

Finally, there is a very serious concern about the future of clinical academic medicine. There are 57 vacant chairs in the UK, and far too many early retirements are occurring at the moment. We trust that the inquiry sponsored by the committee of vice-chancellors and chaired by Sir Rex Richards will come up with firm recommendations on the future of clinical academic medicine of which the Minister and her colleagues will take careful note.

8 p.m.

Lord Dainton

My Lords, perhaps I may first express my gratitude to the noble Lord, Lord Glenarthur, for asking this Unstarred Question. I should like also to congratulate my noble friend Lord Hussey of North Bradley on his maiden speech. I hope that his future contributions to our debates will be frequent and as persuasive as the one we have just heard. I hope also that having hitherto been known universally as "Duke Hussey" he will not feel too diminished by being addressed in this Chamber as a mere Lord.

In accordance with the rules of your Lordships' House, I must declare formally an interest in my role as president and formerly chairman of the Royal Postgraduate Medical School based at the Hammersmith Hospital, which, as has already been said, is the only academically led hospital in the country. I need not speak about its international reputation which is well known.

For well over 40 years I have had a deep personal and professional interest in research in clinical medicine carried out by staff of university medical schools and institutes. For various periods in my life[...]—for example, as chairman of the Advisory Board for Research Councils and its predecessor, the Council for Scientific Policy, and subsequently as chairman of the University Grants Committee—I was responsible for the allocation of public funds to be used for that purpose. I learned many lessons.

First and foremost was that the quality of future patient treatment rests upon the quality and extent of medical education and research today, which in turn are increasingly and critically dependent upon basic scientific research, as the noble Lord, Lord Walton, eloquently stated. That is why I have always advocated close collaboration between high quality departments of biological and physical sciences and with medical schools and institutes of the University of London. Therefore I welcome the marriage of Imperial College to the Royal Postgraduate Medical School.

It is equally important that the specialist referral hospitals and their units associated with those institutes and schools but owned by the NHS should be funded appropriately for their special purposes. There is abundant evidence that for obvious reasons, not least the longer investigations and therefore longer patient stay and more sophisticated equipment and technical support in those research hospitals, the cost per patient treated is necessarily higher than the average elsewhere. That is why, as chairman of the UGC, I supported enthusiastically the proposal of the late Lord Ennals to establish special health authorities with their own funding streams. But now the SHAs have gone, and I do not mourn that necessarily, and the Government have accepted the Colyer Report's recommendation that special funding for those hospitals and what is called the special increment for teaching and research should be replaced by a single funding stream.

Unfortunately, the NHS Executive has interpreted that stream as coming from purchasers anywhere within the UK. Because of that differential cost, as I pointed out to your Lordships on 2nd December 1992, such an arrangement could only mean rationing by price of referred patients and a very doubtful financial future for those special hospitals.

It is no wonder that many who work in those hospitals, and especially clinical academic staff, are deeply worried. I should be grateful if in her reply the Minister could answer a few questions. First, does she accept that without special safeguards the quality of research in hospitals such as the Hammersmith and the Royal Brompton will diminish to levels which will adversely affect the postgraduate medical schools and institutes; secondly, that such a diminution will inevitably work through in time to lower the quality of patient care in the future; thirdly, that that is such a grave matter that steps should be taken now to remedy the situation? Could she—I should be grateful for this—tell us what those steps are or will be? I am sure that her department must be well aware of that problem.

8.4 p.m.

Lord Phillips of Ellesmere

My Lords, I must first add my tribute to those that have already been paid to my noble friend Lord Hussey of North Bradley on his notable maiden speech. I shall return in a moment to one of the important points that he made. Before that, however, I am bound to recollect that just three years ago Sir Rex Richards and I reported to the Secretary of State for Health on how the research strengths of the Hammersmith and Charing Cross Hospitals could best be preserved and extended if the two institutions were brought together on one site. At that time our main concern was that adequate resources should be made available to allow the creation of an outstanding and fully integrated medical school, comprising a new centre at Imperial College and the associated hospitals and research institutes in west London.

Happily, in the past three years enormous strides have been made towards the creation of that medical school and all seems set for the intake of the first cohort of students in the autumn of 1998. Those students will have the privilege of completing modular intercalated science degrees during their training and engaging in project work during that time within a clinical environment.

When I decided to intervene briefly in this important debate I had two points in mind that I wished to make in particular. The first was to express concern that so far the Royal Marsden Hospital and Institute of Cancer Research had not yet agreed to be associated—however loosely—with the new medical school. I was therefore enormously pleased to hear my noble friend say that he confidently expected the Royal Marsden and ICR to join the venture before long.

My second concern has been shared by a number of other speakers. It is that the abandonment of the special health authorities and the incorporation of their resources in the general NHS research funds will lead to an erosion of clinical research in west London just as the plans to create a medical school of international standing are coming to fruition. I hope that in replying to this short debate the Minister will be able to reassure your Lordships on that point.

8.7 p.m.

Lord Annan

My Lords, even though I have only four minutes I must congratulate my noble friend Lord Hussey on his maiden speech. He is what those English aristocrats who used to control boxing in the 18th century (the Corinthians) called a glutton for punishment. As chairman of the Kings' Fund, as chairman of the governors of the BBC, as director of Times Newspapers, he knows what it is to be assaulted by fire from all sides. Few have had more courage or sagacity than he. That is why we very much hope to hear him in the future.

I do not want to follow the noble Lord and the noble Lord, Lord Dainton, for example, who have intimate experience of the West London situation, except to say that I hope that the Minister will give us some optimism that anomalies can sometimes be ironed out, such as the example which I heard only this afternoon, of a great research hospital which keeps patients in bed longer than a district hospital for the very good reason that it wants to observe those patients to see what is wrong with a complicated case.

I want to say something in defence of the Government's policy of reallocating specialties. Since the 1960s when Lord Todd reported on medical education, the department and the funding authorities have been trying to rationalise resources in the West London hospitals. It has been a long and discouraging task, opposed often tooth and nail by the doctors concerned. But in the end it has been successful and, for example, the pre-clinical schools are now integrated in multi-faculty schools and the institutes of London are now following suit.

I must warn the Minister that from what I hear there is keen competition between the four main centres to lure those institutes with promises of additional funding to join them. Institutes which for long have been linked with one multi-faculty school are now being wooed to move to another. Will the Minister say who monitors, and, if necessary, intervenes to thwart palpably inequitable arrangements?

Nevertheless, great progress has been made in bringing together specialists, but the difficulty arises when one has such a galaxy of talent as exists in the four West London schools, as to how to proceed further in rationalising the particular specialties in those schools. Can the noble Baroness give an indication of the troubles ahead? Having listened to the speeches, it is clear that there are great troubles and difficulties ahead. Naturally, each school wishes to preserve what it regards as the specialty for which it is world famous. No doubt, some accommodations will have to be made and I am asking the Minister whether she is optimistic about that.

I wish to comment on a matter which perhaps is not totally relevant but is of concern in relation to specialists. How far has the new scheme of specialist registrar training affected the supply of specialists and their distribution? The European Union ruled that anyone who was a specialist was eligible to apply immediately for a consultancy post. That led the General Medical Council and the Royal Colleges setting up a specialist training authority to supervise the mechanism of issuing certificates of specialist training. That shortened the time before which registrars could apply for a consultancy. Is the Minister satisfied that the problem referred to in Section 17 of the guide to specialist registrar training is viable? Is she convinced that those who opt for a period of research—that is, for a Ph.D—will not be handicapped in their competition for a consultancy post?

8.12 p.m.

Baroness Jay of Paddington

My Lords, I too thank the noble Lord, Lord Glenarthur, for asking this important Question tonight. I am delighted to have the opportunity to congratulate the noble Lord, Lord Hussey, on his characteristically powerful and lucid speech. He has been a long distant but admired acquaintance ever since our paths first crossed some 25 years ago in the world of journalism. More recently I very much enjoyed the experience of working closely with him on the second version of the London King's Fund Commission. I must declare that interest tonight as many of the issues we discuss are relevant to the debate.

Another interest that I must declare, as referred to by the noble Lord, Lord Glenarthur, is that I am a member of the Kensington, Chelsea and Westminster Health Authority, which is the main purchaser of the health services provided by the St. Mary's Trust, which the noble Lord chairs. It is as a purchaser that I wish to make my few remarks tonight.

As one would expect in your Lordships' House, we have heard several distinguished contributions from highly distinguished academic experts in the field of medicine. But my main preoccupation is the impact of the Question on services to patients and on the overall effective use of NHS resources in London. I echo the concerns that the noble Lord expressed in that regard. Obviously, we must continue to provide high quality specialist services in London which are accessible on an equitable basis to the whole population. But that does not preclude sensible rationalisation of those specialist services.

One of the most disturbing aspects of the past few years has been the fact that there has been so little change in the organisation of specialties since the original King's Fund Report, chaired by the noble Lord, Lord Hussey, the Tomlinson Report entitled Making London Better, and the Government's response to that, and the six detailed speciality reviews which were commissioned after Making London Better was published. The progress has rightly been described as glacial in that there has been virtually no movement at all. One could take the totally revisionist view that that was simply because all the proposals made in the special reviews and in the original reports were completely wrong. I am more inclined to agree with the review of one paper recently submitted to the second King's Fund Commission which states: The only conclusion to be drawn", about specialist rationalisation being so slow, is that powerful vested interests have been able to frustrate some of the objectives of the specialty reviews". It would be useful if in reply the Minister could address the general question of why change has been so slow and what her department is inclined to do to improve the management of change in the next period in order to improve services and benefits for patients in West London.

I wish to ask a further specific question relating to the influence of the private finance initiative on change. Have the uncertainties about the existence of the private finance initiative made a considerable difference to progress, because people are concerned that the capital expenditure needed to make some of the changes will not be forthcoming?

As several noble Lords have emphasised, there has been considerable progress in the reorganisation of the medical schools. Of course, we are enormously impressed and delighted by the strength of the Imperial College reorganisation. We support and applaud its aspirations to nationally excellent standards in research as well as being a base for clinical services. However, as the noble Lord, Lord Glenarthur, said in his introductory remarks, we must be careful that that tail does not wag the dog.

In practical terms, I would be disturbed as a west London purchaser if it were the case that for academic reasons, which might be very good, all the serious and important specialties were concentrated on the Hammersmith site. I should be grateful if the Minister would indicate the department's reaction to that possibility if it becomes a practical reality. That cannot be the best possible solution for patients, however good it may be for the academic situation seen in isolation. Although my noble friend Lord Winston is constantly reassuring me about the accessibility of Hammersmith Hospital, my personal experience, and the experience of the patients to whom I have talked, is that it is still a difficult hospital to reach, despite what I understand are very important changes to the car parking.

My overall feeling is that it is refreshing, if slightly depressing, to revisit the original specialty reviews which were published four years ago and to see what their proposals were. Their overall ambition of reorganising specialties had a great deal of sense, although, as did the noble Lord, Lord Hussey, one might quarrel with the individual proposals, in particular in his case concerning the Royal Marsden Hospital.

I conclude by quoting what is succinctly put in the specialty review on cancer, which should guide our thoughts about how the whole enterprise on specialties should be challenged. I should be grateful if the Minister would respond to the question of whether the Governments as a whole accept the overall recommendations of the specialty reviews. In the specialty review on cancer, the simple conclusion was: The overwhelming majority of cancer specialists in London accept that the historic pattern of specialist centres need major change and that a smaller number of larger centres would he more effective in delivering high quality service, teaching and research". Is that still the Government's position?

8.18 p.m.

Baroness Cumberlege

My Lords, I thank my noble friend Lord Glenarthur, who among many other things is a distinguished trust chairman, for tabling the Question and for opening the debate. I also congratulate the noble Lord, Lord Hussey of North Bradley, on his maiden speech. It was a speech which befits a noble Lord who is not only admired and respected throughout the country for his courage, achievements, charm and prodigious talents, but in your Lordships' House, as my noble friend Lord Butterfield said, for his huge bravery.

I have no experience of warfare, but I know that the noble Lord fought not only on the battlefield for us, our futures and our children's futures, but for his own life in a hospital bed. Six consecutive birthdays were spent in some hospital or another. That surely demonstrates a will to live. And what a life, what a contribution to the welfare of the nation's good. We are enriched by his membership of this House, and the quality of speakers in tonight's debate is a testimony to that.

London occupies a unique position in world medicine. It is recognised for its expertise, excellence and talent. Not only does it excel in clinical medicine but also in scientific achievement. In a recent report from the University of London, the contribution to this country is made clear.

Academic medicine generates £225 million each year from undergraduate students, a quarter of whom come from abroad. Every year around 1,000 overseas postgraduate students (from 115 countries) come to study medicine and dentistry in London. Each of those will also of course make a contribution to the local economy, but most important of all, they will return to their homeland taking with them knowledge, techniques, skill, wisdom and often affection for the United Kingdom.

On a recent visit to South Africa I was heartened to hear of the good experience which the Minister for Health, Dr. Zuma, had of her medical training in this country. As the leader of health policy for the emerging South Africa, her experience will influence not only the way in which healthcare is provided but also teaching, research and academic medicine in South Africa.

London has great strengths, not least in pharmaceuticals—46 of the world's top 50 companies and more than 40 American bio-technology companies have chosen London or the south-east as their base. Our capital city has many fine hospitals and medical research institutions which are nationally and internationally recognised as centres of world excellence. I am told that we have more than Boston, Paris or New York. A number of your Lordships, as we have learned tonight and as many of us have known for some time, are of course not only associated with these great institutions but indeed have made them what they are today.

But London is of course the place where Londoners receive their healthcare and while it strives to excel in all fields, it also has to provide day-to-day health services. As a Government, we are conscious of this and have adopted four clear principles: first, we seek to develop high quality, more accessible primary and community services; secondly, to achieve a better balanced hospital service on fewer sites; thirdly, to concentrate specialist services, reinforcing and building on their excellence and improving their effectiveness; and, fourthly, to ensure London retains its premier position by merging free-standing undergraduate medical colleges with institutes and with the University of London's multi-faculty colleges to form four world class institutions—a move welcomed by the noble Lord, Lord Dainton, who has such a deep knowledge of those issues.

The noble Baroness, Lady Jay, mentioned the framework for the future of London medicine which was set out in Making London Better, the Government's response to Professor Tomlinson's report. The Government accepted that there was duplication of specialist services. There was a need to improve the quality of patient care and to maintain the critical mass essential for world-class education and research. Given the number of NHS trusts, health authorities and academic institutions, it has been a complex business to bring the parties together.

Although I understand the concern of my noble friend Lord Glenarthur about the uncertainty, we have achieved a great deal in the past four years. I understand too the impatience of the noble Baroness, Lady Jay, but we all know that when we are trying to achieve what appears to be a Herculean task, many people need to be involved and reaching decisions is not easy.

The noble Lord, Lord Hussey, and the noble Baroness, Lady Jay, quite rightly highlighted cancer services. We have developed our strategy to ensure the best possible services for patients. Starting at the beginning when patients first suspect a problem, we have set out to improve primary care so that frightened and worried people can get a speedy and accurate diagnosis, with a quick referral from a knowledgeable GP. If necessary, they should be referred to a cancer unit of sufficient size to support a multi-disciplinary team, a team with the expertise and facilities to treat common cancers; lastly, if it is a rare or complex carcinoma, to a centre specialising in the treatment of these sometimes obscure but always difficult cases.

These proposals are in hand, with each region designating cancer services as centres or units. In North Thames, the process has been led by health authorities with the region in a co-ordinating role. Centres will be designated provisionally this spring and given an action plan. Confirmation of the designation will depend on the level of progress made in 12 months towards implementing the plan, but designation is only the beginning of a longer-term programme. Decisions about cancer centres will of course affect research in two ways: first, the London centres, which currently lead the field in terms of research, will be encouraged to link with others in order to widen the research base and encourage patients to take part in clinical trials; secondly, changes in referral patterns will be gradual and influenced by the type of cancer to be treated. I take the point made by my noble friend Lord Glenarthur that we want to ensure that trusts are able to align their services with research interests and not simply be feeders for research.

As my noble friend mentioned, health authorities have jointly reviewed the specialist cardiac activities of the four centres—at the Royal Brompton, Hammersmith, St. Mary's and Harefield hospitals. They have been working with the trusts and Imperial College and have been discussing the options for future development as it affects not only cardiac services but the impact on teaching and research. We hope the work will be completed later in the year.

Renal, neurosciences and children's services are also under discussion. Good progress has been made. Health authorities and academic bodies in west London have agreed on a process but further discussion is needed before a decision can be reached. I know this will be disappointing for my noble friend but I can assure him that patient care will not be eclipsed by the needs of teaching and research. They are not competing demands but ingredients which when combined form the bedrock of a forward looking healthcare system, in which I know St. Mary's will play a pivotal role.

The noble Lord, Lord Winston, drew attention to the excellence of research in west London which has been independently recognised by the recent Research Assessment Exercise (RAE) published by the Higher Education Funding Council for England (HEFCE). Five star rating (the highest possible) was awarded to not only the Institute of Cancer Research (associated with the Royal Marsden) but also the Royal Postgraduate Medical School (associated with Hammersmith Hospital), the National Heart and Lung Institute (associated with the Royal Brompton). Imperial College (associated with St. Mary's) obtained a grade 4 for both clinical laboratory sciences and hospital clinical-based research. The Institute of Cancer Research also obtained a grade 5 for pharmacy and a grade 3A for nursing. As the noble Lord, Lord Hussey, said, those ratings were among the best in the country.

I have talked about both research and service excellence in general terms but it is important to translate that into practice. What have been the contributions to science and improved services? What have been the benefits to patients? I do not have time today to list all the developments there have been but I should like to mention a few of them.

The MRI scanner—the magic magnet, as it is known—at the Hammersmith Hospital is the only one of its kind in the world. It reduces the potential problems of brain-damaged children. In his modesty, I do not think that the noble Lord, Lord Hussey, mentioned the fact that the Royal Marsden and the Institute of Cancer Research carry out more research than any other cancer centre in Europe. Harefield Hospital has undertaken the world's largest programme of heart and lung transplantation and carries out more thoracic surgery than any other centre in England. The Royal Brompton Hospital runs leading edge services, including a unit for cystic fibrosis services, which is a world leader. In addition, the medical informatics team is at the front of an eight-country project to develop networked medical information systems for diagnosis and the tracking of patients. At St. Mary's, as my noble friend Lord Glenarthur is so aware, there are important developments in heart surgery. A team is developing a new technique for early detection of abnormal electrical activity.

Those are all exceptional innovations. But I understand the concerns of the noble Lord, Lord Winston. However, I am heartened that with his expertise and inside knowledge he supports the Culyer proposals. I endorse the views expressed by many noble Lords this evening in regard to collaboration. In particular, the noble Lord, Lord Walton, mentioned that. I can assure your Lordships—in particular, the noble Lords, Lord Annan, Lord Dainton and Lord Phillips—that funding has been a top priority in our considerations.

We believe that the Culyer proposals will show a way forward. In future, R&D support funding will be allocated competitively where it will be best used. Indeed, it is hard to argue against that principle. The NHS Executive has already published assessment criteria which cover dimensions such as quality, importance and cost. In assessing bids, it will also give careful attention to how R&D funding is to be co-ordinated with other education and training and, of course, patient care.

Trusts in England have until the end of June to make a bid for funding for up to four years ahead. Clearly, I cannot say at this stage what the outcome will be for any trust or, indeed, for any part of the country. That will depend on their bids. However, I can say with confidence that the new system will allow us to make increasingly good use of the enormous capacity for R&D in the NHS and the money that we allocate to the NHS locally to exploit that capacity, which is considerably more than £300 million a year.

We have had a most interesting debate. I know that many noble Lords will continue to play a key part in the development of services in west London. It is a challenging agenda, but a worthwhile one, which should deliver even better standards to patients and encourage the development of high quality teaching and research. As the noble Lord, Lord Hussey, told us, top quality patient care depends on top quality research.

I am aware that I have not answered all the questions that were put to me, not least those posed by the noble Baroness. I shall certainly follow them up in a written form later in the week.