Medical Teaching and Research

HL Deb 21 November 2001 vol 628 cc1182-223

6.12 p.m.

Lord Walton of Detchant rose to call attention to the issues now confronting the National Health Service with particular reference to medical teaching and research; and to move for Papers.

The noble Lord said: My Lords, ever since, as a young medical registrar on £400 per annum, my salary was virtually doubled at the introduction of the National Health Service I have been one of its most fervent supporters. This brave and imaginative initiative was something of which we had very high hopes. All of us in the medical profession in those early years, and subsequently, worked exceptionally long hours, if only because of the excitement of clinical practice and caring for patients, the joy of teaching young, bright medical students and the intellectual fulfilment which arose as a result of being involved in fruitful clinical research. That clinical research not only nurtured clinical practice but brought about untold new developments in patient care.

At snail-like pace new hospitals were built, although with cheap materials because of government cost limits. Health centres appeared and GP premises were slowly upgraded. Vocational training transformed standards of primary care and support staff were recruited, so that in every respect primary care improved over the years.

In those days almost no one sought early retirement; indeed, the majority of members of my profession tried to find ways to continue to work after the age of 65. But from the earliest days clouds began to gather on the horizon. Many stentorian voices, not least my own, continually pointed out to government after government that we were spending less than 6 per cent of our gross national product on the NHS compared with 8 to 9 per cent in Germany and a very much larger figure in the United States. There were too few general practitioners, as is still the case, offering only five to eight-minute consultations; too few acute and intensive care beds; and too few consultants in all specialties. Five years ago there were 190 neurologists in the UK compared to 400 in Finland with a population of 4 million. Only today we learn from the British Thoracic Society of the appalling consequences of too few consultants in respiratory medicine. We now have about 240 neurologists, but that is only half what a proper service requires.

Report after report of the royal colleges has urged governments of both main parties to increase funding and consultant numbers and to reopen closed acute beds as our population ages, huge technological developments increase patient demand and expectation and new and effective, but often very expensive, drugs produced by that jewel in Britain's industrial crown—our pharmaceutical industry—come on stream. Effectively, we have seen the overt rationing of resources, postcode prescribing, trolley waits in accident and emergency departments, sometimes increased waiting lists and innumerable new initiatives by governments which impose additional administrative burdens on doctors, nurses and other staff.

All too often we have heard governments say when putting in more funding that there will be no more money at a later stage and we must have more efficiency savings. As a consequence, disenchantment and frustration grew.

Where are we now? I credit this Government with their desire to increase funding in the NHS and to recruit many more medical students—1,000 a year. That is welcome. But is the new funding which is coming on stream and now the policy of the Government too little, too late? A recent survey by the BMA shows that 48 per cent of general practitioners are considering early retirement. Many consultants are burnt out and in despair and also seek early retirement. Even the new hospitals built under the private finance initiative, such as Cumberland Infirmary and the University Hospital of North Durham, have provided fewer beds than the hospitals that they replaced.

We also see what I believe to be seriously misguided decisions, such as that made by Oxfordshire Health Authority to close Burford and Watlington community hospitals which provided care to patients on early discharge from acute hospitals, with the consequence that beds are blocked in acute hospitals like John Radcliffe.

Who will teach the new medical students? The Council of Heads of Medical Schools has pointed out that there are now 73 vacant clinical chairs. Recently, it has revealed 322 vacant lecturer posts in clinical medicine. Early in the days of the National Health Service there was an article of faith called the knock-for-knock agreement which was to the effect that the clinical services provided by doctors employed in clinical specialties in the universities would be compensated for by the teaching given by NHS consultants and registrars. The idea then was that six sessions would be devoted by clinical academics to clinical practice with the remaining five protected each week for teaching and research.

The recent report by the Council of the Heads of Medical Schools shows that academic clinicians spend a minimum of 40 hours a week—some as many as 58 hours a week according to a recent report—in clinical service. Where is the time available for teaching and research? In some NHS hospitals there are even some consultants who refuse to teach because of the sheer burden of their clinical work. Why is that the case? The answer is that managers exert pressure to increase throughput and cut down outpatient waiting times and inpatient waiting lists simply to meet government targets and new initiatives. The result has been a serious decline in recruitment into clinical academic medicine. The attractions of an academic career in medicine were not only the care of patients but also involvement in teaching and research. Therefore, the academic field has been gravely eroded. We must not forget that for many years the UK has had a proud international reputation in the field of biomedical and clinical research. As a result of these factors, that reputation is now in serious decline.

I commend the initiatives of the General Medical Council to weed out poorly performing doctors. But I believe that the great majority of doctors, nurses and other staff in the health service give outstanding dedicated service and long hours of work, sometimes under intolerable conditions. Will the Government do something to get rid of the culture of blame, which is now so prevalent throughout the NHS? Doctors and other staff continually have to look over their shoulders. Furthermore, is there any hope that the number of political initiatives, as well as political interference—if I may use the term—in the affairs of the NHS, may be sharply reduced, if only to allow health service providers to get on with the job?

Those in the NHS look enviously at their colleagues in Europe, who have more beds, more consultants and superb research equipment. Last week, a consultant told me that, on a recent visit to Uppsala in Sweden, he found that eight consultants were undertaking the amount of work that he, alone, was expected to do within the NHS.

The litany of gloom is not a figment of my imagination. It is a genuine, heartfelt cri de Coeur. So what are the solutions? First, increase the number of acute beds and increase the recruitment of nurses, who may well have to be paid more in order to attract further recruits. Open more outlet beds in community hospitals. Increase rapidly the establishment of consultants in all specialties and establish more GPs and medical training positions, which the Government intend to do, but not at a sufficiently fast rate. Expand the public-private partnership. Many more routine operations and other procedures could be carried out on NHS patients utilising spare capacity in private hospitals. I know that it will be controversial, but I urge the Government to restore and expand tax relief on private medical insurance, which I believe was withdrawn for the elderly because of outdated ideological concerns.

Secondly, I invite the Government to implement more rapidly the recommendations of the Saville report from the Academy of Medical Sciences on the training of clinical scientists. That will require funding. A further report is expected from the academy on such implementation. Will the Government consider making available public funding for the Academy of Medical Sciences, as they do for the Royal Society, in order to help the academy to act as an agent in furthering the implementation of the Saville report? What has happened to the Follett report, which contains many excellent points?

Several years ago, the House of Lords Select Committee on Science and Technology produced a report based on an inquiry which I had the privilege of chairing. It recommended instituting pilot studies of the development of university hospitals under joint NHS and university management. Is it not time that an initiative of that kind was brought forward in order to improve the standing of clinical academic medicine? Recently, the Council of Heads of Medical Schools recommended setting up a joint initiative between the Department for Education and Skills on the one hand and the Department of Health on the other to develop a training and teaching authority which, I hope, would provide support in pursuit of these aims. Such measures are absolutely vital to overcome the crisis in clinical academic medicine.

Thirdly, I believe that the Government must seek additional sources of funding. Of course we already capitalise on public goodwill. Over the length and breadth of the country, people raise funds to buy new equipment, to help the work of hospices and to assist many other organisations. However, those efforts can make a contribution only at the margins. Furthermore, it must be recognised that, while the Government happily put more money into scientific research and the Association of Medical Research Charities makes a truly outstanding contribution, regrettably there are fewer clinical academics with the time and opportunity to carry out research using those funds for reasons which I have already explained.

The amount of money that the Government have now committed themselves to investing in the NHS is still, I believe, not enough. Please will the Government stop tinkering at the edges and consider urgently alternative and additional sources of funding? Thirty years ago, I recommended to a then Royal Commission on the National Health Service, chaired by Sir Alec Merrison, that the Government should at least consider hypothecated taxation and that they should think about an index-linked, income-related health tax as a supplement to national insurance. I know that all will respond by saying that the Treasury will not stand for it. Are the Government brave enough to confront that mystical body and persuade it that at least those ideas have some merit? Is it not time that such proposals were examined in depth and in detail?

The increased government funding recently announced has been most welcome and I do not doubt the Government's good will towards the National Health Service. But we cannot go on as we are at the present time. Radical measures are needed, not least to save clinical academic medicine and to be able to teach those additional medical students now coming on stream. We need to restore and preserve this country's proud reputation in biomedical and clinical research. That is an objective which we should all seek to pursue. I beg to move for Papers.

6.26 p.m.

Lord Turnberg

My Lords, I am most grateful to the noble Lord, Lord Walton of Detchant, for initiating this very important debate. As usual he has delivered his remarks with enormous clarity and in so doing has stolen some of my best lines. However, I should like to make a number of points.

First, it is important to emphasise that academic medicine is not something distinct and separate from the practice of clinical medicine. It is not merely academic; it forms a completely integrated part of the practice of medicine. Without it, we shall not advance medicine and we shall not be able to teach future medical practices to today's students. We must be able to transcribe the fruits of the many exciting advances being made in the biomedical sciences into clinical practice.

Never have there been such bright prospects for future cures and treatments. Here I should express an interest as vice-president of the Academy of Medical Sciences. But if we are to achieve all this, we must have in place the academic clinicians to do the work. At a time when, as we have just heard, we need more such clinicians at least to staff adequately the medical schools that have recently been created, we cannot even fill the existing vacancies. The reason why academic medicine is unattractive, despite the excitement of progress in medical research and despite the fact that in the UK we are pretty good at it, is—we heard this from the noble Lord, Lord Walton—largely because of the pressures of clinical service work.

Clinical academics serve two masters: the universities and the NHS. They are stretched between the two. The balance has now swung much too far over towards clinical service, to the immediate detriment of teaching and to the future detriment of patients. What can be done about that?

In 1990, a committee was set up comprising members from the Department of Health and the Department of Education. It was chaired by the Permanent Secretary to the Department of Health, Sir Christopher France, and sought to ensure that universities and the NHS co-ordinated their efforts and collaborated so that academic medicine could prosper. That committee agreed 10 key principles. In 1996 those principles were revised and included a number of extremely important points. I shall quote one or two as examples: The provision of undergraduate medical and dental education and research, guided by clearly defined and co-ordinated national policies, must be supported by effective joint planning". A further principle states that: The universities and the NHS should work closely together in funding research and development within the NHS in England". Many of the other principles are set out in a similar vein. I am afraid that the standing group has fallen into abeyance and the key principles have been largely forgotten. I ask my noble friend on the Front Bench whether he would strongly consider setting up a new committee established along similar lines to take on that work and to revise and revisit the 10 key principles, some of which were again introduced in the recent Follett report, to which the noble Lord, Lord Walton, referred.

I should like my noble friend to consider in particular one element; that is, to make it possible for an academic department, comprising perhaps a dozen academics, to contract with their NHS trust to provide a total service, as a department, in specialties such as cardiology, neurology, surgery and so forth. Within that department, some would provide the clinical service for most of the time, while others undertook research. This flexible approach could be effective and efficient for both the service and the research, but it is currently not possible while individuals within a department have to do everything according to their individual job plans. Will the Minister look kindly on what seems to me to be an eminently sensible approach?

Finally, perhaps I may mention one other serious threat to research which, in this case, I am afraid, largely is to be laid at the door of the Department of Health. I am not sure how long my noble friend will remain my noble friend when I tell the House that a whole segment of important research, which depends on the use of information derived from patients over many years in, for example, cancer registries and other disease registries, has now ground to a halt.

Section 60 of the Health and Social Care Act was specifically designed to ensure that this kind of research, given certain safeguards, could be pursued. In practice, the body which was to undertake this work, the Patients Advisory Group, which was to be set up and running by October, the deadline, has not been. Meanwhile, research ethics committees around the country do not agree that this research can be done, with the result that disease registries are not registering patients, and research has stopped.

I understand, unofficially, that the group will meet in December, but its membership and its chair have not been announced, nor has notice been given of the way in which it will go about its work and what criteria it will adopt. It gives me no pleasure whatever to know that the worst fears I expressed during the debate on the Bill have been realised. Instead of ensuring that epidemiological research can be undertaken—for which the Bill was designed—the bureaucracy in which it is so ineptly enmeshed will effectively strangle it.

The longer this situation is allowed to continue, the greater the damage to research and to the patients who will depend on that research. I hope that when he comes to reply the Minister will offer some reassurance that there will be a resolution of this self-inflicted damage.

6.32 p.m.

Lord Colwyn

My Lords, it is always daunting to take part in a debate initiated by and with contributions from academic members of the medical profession. They are the kind of professors who, some years ago, used to set my examinations. However, I am grateful to the noble Lord, Lord Walton, for this opportunity to discuss some of the issues confronting the NHS. There are so many, a fact reflected in the speech of the noble Lord, Lord Walton. We seem to have come such a long way since my party lost an election because one patient spent one night on a trolley.

I declare an interest as a practising dental surgeon, although the Minister will be delighted to hear that I am not going to speak about dentistry today. We shall be doing that at about this time tomorrow.

The modern, research-based scientific advances in medicine over the past 50 years have been beneficial to countless numbers of patients. This growth of knowledge has been such that different specialties have developed, each competing for and making legitimate demands on the NHS budget, which has always been, and will always be, incapable of funding the personnel and materials needed to treat all those patients who are perceived by conventional methods of diagnosis to be ill.

It has been estimated that about one-third of all patients with chronic symptoms have no organic disease, and that another third have symptoms unrelated to their organic condition. Scientific advances in medicine have also affected the patient-doctor relationship and caused difficulty in communication.

This crisis in healthcare is world-wide and will not disappear. We cannot legislate our way out of it, nor pass the buck until someone else pays for it. Because of its dependence on expensive technology, medicine simply cannot be delivered to the people who need it.

There is a serious risk of hospitals having to restrict the services that they provide and, because patients are not getting the services they require, more and more are going to other kinds of practitioners. At the same time, as the noble Lord, Lord Walton, said, the routine, day-to-day practice of medicine has become less and less satisfying. It is not easy to work on your own. The autonomy, which was so attractive some years ago, has gone. Many doctors now have to work in corporate settings, where a bureaucrat tells them how many patients to see and the insurance companies dictate how medicine is practised by their policies of reimbursement.

What is done in medicine today is not always what a doctor chooses to do, but what is going to be paid for. No one envisaged the increase in practice litigation, which is destroying doctor-patient relationships. If you come to regard every patient coming in the door as a potential plaintiff in a lawsuit, it will detract from the relationship that you have with patients, which was once a great source of satisfaction to doctors.

In our report, the Select Committee which considered complementary medicine, which the noble Lord, Lord Walton, so capably chaired, recommended that there should be more consistent training offered to complementary therapists in all the different disciplines, and that formal training should be offered to doctors, dentists, nurses and physiotherapists who wish to practise complementary disciplines, both at undergraduate and postgraduate levels. The Government agreed and promised funding. I shall be interested to hear how this is moving forward.

This setting up of a formal training structure should produce practitioners and therapists who have a research-based background. This will lead to the increased research that is so essential in the creation of a new approach to medicine—one that is based on a model of health rather than disease; one that trains practitioners to take time to listen, to value nutritional and lifestyle influences on health and illness, to offer treatments in addition to drugs and surgery, and to understand the potential of the organism for self-repair and healing.

Less than a century ago, most orthodox medicine was what we now call complementary or alternative because there was little understanding of the mechanisms of human disease. Today we understand some of the chemical, neurological and psychological factors that contribute to the complexity of the human being, but the fact that so many people are turning to complementary medicine indicates that conventional medicine is failing in some areas.

A massive research commitment will be required to investigate the mechanisms in CAM, ranging from social psychology to genetics. There is already an evidence base that could be used to inform trial design, particularly for herbal remedies and acupuncture.

There is no longer a right way of practising medicine. Both conventional and complementary systems are a mixture of wisdom and folly; both have very sensible ideas and both have weaknesses. The challenge is to look round dispassionately and critically and to take those elements of different systems that make sense. This is best described as "integrated medicine". It works from the premise that people can get better, and it must be cost-effective. I declare an interest as president of the renamed All-Party Group for Integrated and Complementary Medicine—or Healthcare.

Earlier today, together with the noble Lord, Lord Walton, and the noble Earl, Lord Baldwin, I attended the Integrated Health Awards, at which His Royal Highness the Prince of Wales, who is president of the Foundation for Integrated Medicine, presented a wide range of practitioners with awards for the best examples of the integration of complementary and conventional healthcare.

Two winners were selected from a short list of 11 projects. The first winner was the Derriford Maternity Acupuncture Service, a unit which initially offered acupuncture to provide more choice of pain relief for women in labour but soon expanded to a popular outpatient and in-patient service for ante-natal and postnatal problems. The second winner was the Blackthorn Medical Centre and Trust, which is an NHS general practice and charitable trust which adopts an anthroposophical approach towards providing treatment, rehabilitation and supportive employment for patients suffering from chronic illness. Its methods are aimed at actively engaging patients in re-establishing the quality and direction of their lives, thereby reducing dependence on statutory health and social services. His Royal Highness confirmed his belief that integration is the way forward, and I am grateful for his continued support for the concept of integrated medicine.

Patients have the right to take responsibility for their lives and the right to receive all the information that they need to do that. I believe that medical training and research should reflect the fact that multidisciplinary co-operation is the strategy that best provides health and healthcare. Education is the core for understanding, and medical teaching should reflect the need for a basic knowledge of the theory, practice and application of the wide range of complementary therapies.

6.40 p.m.

Baroness Northover

My Lords, I thank the noble Lord, Lord Walton of Detchant, for introducing this important debate. Medical research and teaching are the key to the future of the NHS and neglecting their current problems will cost us all. I look forward with particular anticipation to hearing the noble Baroness, Lady Greenfield, whose contribution to science, but also in sharing that knowledge with the public, has been outstanding. Bridging the gulf between science and society is especially relevant today.

I find myself hearing quite a bit on this subject one way or another. My husband is a surgeon who runs an Imperial Cancer Research Fund cancer unit and he is also a professor of surgery at Imperial College School of Medicine. I used to teach the history of medicine to medical students within the University of London.

Teaching and medical research have been integral to the National Health Service since its foundation over 50 years ago. Teaching had of course long been part of hospital practice. Research was far patchier and in many ways Britain lagged behind the United States and Germany. But under the NHS, clinical research in particular developed rapidly and productively. We had a particular strength in our clinical trials. Assisting this was a public-spirited feeling among NHS patients that it was appropriate and in the public interest that they should take part in trials.

But things have changed over the lifetime of the NHS and there are now new question marks over teaching and research. There is a continuing decline, as we have heard, in the number of medical academics and that is set to get much worse. How can we plan to expand, as the Government do, the number of medical students by 56 per cent while the number of medical academics is falling? With so many unfilled chairs of medicine and surgery, there will be fewer leaders and role models for those who might follow on, making it even less likely that the problem will sort itself out.

Reduced training time means that fewer junior doctors are undertaking sustained research. That means that fewer will see the attractions of academic research, further undermining efforts to fill academic posts. How can we advance the cause of evidence-based medicine if those coming through the system are less familiar with this approach? I heard with great interest the recommendations of the noble Lord, Lord Walton, to reverse these trends. I look forward to the Minister's response.

But there is one area in relation to medical research which can be addressed immediately. It is something which does not require large investments of money. No doubt the Minister will be pleased to hear that. However, it requires commitment. That is the issue of medical researchers having access to confidential patient information for the public interest purpose of research. We have just heard the noble Lord, Lord Turnberg, speaking about that.

For years this kind of information has been a vital tool for researchers. Without that, how could Sir Richard Doll have demonstrated the link between smoking and cancer? Your Lordships will remember that this was considered in the Health and Social Care Bill which we passed just before the election. Whether it was because of the new data protection laws or whether it was always a tricky area under common law, the GMC issued new guidance to doctors. This guidance served to scare doctors away from passing information through to the disease registries and elsewhere lest they appeared in court.

After much debate inside and outside your Lordships' House, the Bill was passed and included a Patient Information Advisory Group to oversee regulations in this area. It was to contain a balance of those with an interest in the area, including advisers from the patient's point of view. So where is it? No names for the group have yet been announced although I understand that they may be on the Minister's desk. Where are the draft statutory instruments? I understand that the draft regulations are in such a basic and early stage that they are nowhere near ready to be published.

I therefore wish to learn from the Minister answers to these questions. How many people has he working on this area; when can we receive the names of those in the group; when will we see the regulations and when can the medical research community continue its research? One medical researcher in this area remarked rather bitterly to me that the reluctance of the UK Government to move rapidly in this area, which was so clearly in the public interest, contrasted rather darkly with the speed with which that same Government are proposing to take sweeping new powers to restrict our civil liberties in the face of terrorism.

Sir Julian Peto of the Institute of Cancer Research pointed out on 29th May in the Sunday Times that some health authorities are refusing to provide women's computerised cervical screening records for potentially lifesaving research commissioned by the NHS. He added, not surprisingly, that, the requirement that we contact 100,000 women would prevent this research from being done". I thought that we were on the road to the resolution of this problem. I expect the Minister to give concrete assurances that the delays hitherto are to be a thing of the past.

There are many problems today in medical education and research as they relate to the NHS. Let us at least resolve this particular problem forthwith. I therefore look forward to the Minister's satisfactory reply I shall now sit down so that we can hear the speech of the noble Baroness, Lady Greenfield.

6.46 p.m.

Baroness Greenfield

My Lords, amid the very warm welcome and kind advice that I have been very grateful to receive since my arrival in your Lordships' I louse, it has been repeatedly emphasised to me that one has to adhere strictly to times: every second counts. I have some small experience of that already in television and radio. On one occasion when I was on the "Today" programme, towards the end of the interview I was horrified when the presenter said, "And now, in the last 30 seconds, since you work on the brain, can you tell us about the soul?". Time is once again short. The subject is perhaps not quite as wide or as deep, but for some of us it is just as important.

I would like to comment on the issues as someone who has taught medical students at Oxford University for 15 years. I still have a lab there where I conduct medical research into Alzheimer's disease.

I fear that those conducting medical research and teaching in the university might be, as already in the National Health Service itself, re-evaluating the cost-benefit balance. Everyone has always known that salaries for academics are much lower than in the private sector, most typically compared to those in big pharmaceutical companies. But now other factors are creeping into the equation. There is an increased teaching load. Medical student numbers are set to rise relative to the number of lecturers and that will mean less time spent on research. In addition, research is becoming more expensive. Information technology is now much more sophisticated and becomes rapidly obsolete each year so that computers have to be replaced.

With the current trend towards molecular biology, the consumables for this type of research are much more expensive and therefore the final budget is much greater. Perhaps it is no wonder that the public sector funding bodies are beginning to become increasingly risk averse, less speculative and less open to the novel, adventurous projects and less open to interdisciplinary research which, arguably, is why one was engaged in it in the first place as it presented an intellectual challenge.

There is the audit. Let us imagine that you have been teaching for several decades and someone is listening to your lecture and evaluating you. Imagine how you might begin to feel somewhat demoralised, even resentful. What about the audit for research? Again, that is surely pushing scientists into playing safe so that they can publish.

Let us now add to the landscape the burgeoning bio-technology sector. Here there is no drain in teaching loads. One has to do novel research. That is a prerequisite otherwise your company will become extinct. You have the chance to learn other transferable entrepreneurial skills and let us not forget the possibility of an enhanced income. No wonder that some of the brightest and best are defecting from the campus to the science park.

Therefore, how can we motivate university scientists to stay where they are and engage in the public sector doing research and teaching medical students? The answer lies in enhanced interaction between the private and public sectors. We are getting much more used to university "spin-out" companies as part of the landscape of academia. That is due in part to admirable schemes such as those of the Medical Research Council and the Wellcome Trust, and to the Government's university challenge schemes. But the problem is that they apply when you have a patent in your sights. You can seek help from such projects once you are near to gaining a patent. What happens for the university scientist whose work is in the pre-patent stage? You cannot apply to the public sector, because that will violate your intellectual property. So where do you obtain the funds to carry through an idea that might eventually be exploitable commercially? What we need are more funds to help scientists to do that.

One possibility would be to have, let us say, 1 per cent surcharge on grants. Another would be to encourage universities to plough back the money that they are making from their equity stakes in existing spin-outs to help the much more fundamental research that goes on in universities. And the money should not be spent merely on that. At Oxford, for example, the ratio of technology transfer unit staff to research workers is 1:500. It is impossible for people to be alert to the patentable possibilities of the work in which research scientists are engaged. Surely we should be increasing the number of technology transfer staff, especially if we want to lure them back from the private sector where they are used to the levels of salary.

Surely money should also be spent on organising fora, on workshops, and perhaps on developing websites, so that the average university scientist, who has never before contemplated the prospect of the private sector, will easily be able to access an idiot's guide. If we can do that, we can start to encourage people to think outside of the ivory tower. We can start to bring about a mindset whereby people can blend private and public sectors for the benefit of both.

Almost 400 years ago Francis Bacon developed a pretty Latin dichotomy. He said that there were two types of experiments: experiments lucifera, versus experiments fructifera—those that shed light, versus those that bore fruit. I suggest that if we are to meet the challenges of 21st century medical teaching and research, such a distinction is as inaccurate as it is obsolete.

6.52 p.m.

Baroness Greengross

My Lords, it is a privilege to follow the noble Baroness. She made a truly remarkable maiden speech, based on a depth of knowledge and understanding that makes it obvious to all of us who heard it that her contribution to this House will be an outstanding one.

For me, the noble Baroness's address was not as remarkable as it would have been had I not heard her speak previously. I refer in particular to a recent occasion when she entranced a huge audience at the culmination of the Millenium Debate of the Age (for which I was responsible) at Greenwich. She spoke about the human brain and its potential, and about our realistic capacity to use our scientific and technological knowledge to improve the health and well-being of humankind. Many Members of this House will also know of the noble Baroness's dazzling academic career, now both as a professor at Oxford and as director of the Royal Institution, where she has already achieved an enormous amount. She has raised the profile of science, and particularly of women in science, with the public as well as with professionals. I know that noble Lords will wish to join with me in congratulating her.

I also congratulate the noble Lord, Lord Walton, on initiating this important debate. Much attention is rightly given to the problems that are faced today in the NHS. They are critically important to all of us. But I want to emphasise that we must also think ahead to tomorrow's agenda, where training and research are particularly highlighted.

Society is ageing fast—in some countries staggeringly so: particularly, for example, in Japan and Italy. In the 3rd November edition of the Economist Peter Drucker wrote: the dominant factor in our society will be something to which most people are only just beginning to pay attention—the rapid growth in the older population and the rapid shrinking of the younger generation". Such is the global impact of that factor that the United Nations is convening a world assembly on ageing next spring.

With regard to training, I want to point to the importance of injecting across the board what is known as a "life course" approach. Bearing in mind that the majority of patients seen by healthcare professionals will—a fact that we must welcome—be older people, all our professionals need to understand how people develop throughout their lives and the key factors, both endogenous and extraneous, that affect their health throughout their lives.

Through an organisation called the International Longevity Centre-UK—which I chair—I am part of an international partnership which is examining this issue with the World Health Organisation, which has firmly embraced a life course approach as the key perspective in its ageing and health programme. It is already used in part; but if it is injected more widely it can give individual healthcare professionals a holistic and integrated response to some of the greatest challenges that they face, bringing together in a single framework the ability to look back across the life of an individual, and also across generational cohorts, emphasising both temporal and social factors. It aims to identify biological, behavioural and psycho-social processes which operate across the life-span and across the generations. It helps us to identify critical periods of growth and development, chains of risk and springboards which can alter life course trajectories, with implications for a person's future health.

I am gratified that many medical students—mostly from the International Federation of Medical Students' Associations—have enthusiastically adopted this approach, which I hope we can take forward in this country, as we are beginning to do with the welcome support of many experts in medical and nurse training.

Turning to research, I welcome the announcement on 12th November that the Government intend to invest £8 million in research into ageing and services for older people. This will be conducted through the research councils, taking forward past work done under the EQUAL banner. But more is needed—not only by government but by all sectors. There is a need for all of us to rise to the challenge and the opportunities presented to us by the demographic shift.

More thinking could also be done within government. The DTI's foresight panel on ageing, which I raised in a debate in this House in March, highlighted various important issues, many of which touch on health, but which need to be taken forward more enthusiastically.

There are still too many examples of clinical trials stopping at the age of 65. In professional practice, the rigid demarcation lines drawn by age rather than competence and ability to perform critical tasks is totally out of tune with reality. That is illustrated in today's Times, which points out that Professor Magdi Jacoub is banned by his trust from performing operations because he has just reached the portentous age of 66. Surely his skills are worth assessing in a more individual manner. The cost to patients and to the NHS might well be much greater than the cost of appraising his abilities in a way that should be routine for all of us along our own life course.

While I know that there are many issues confronting the NHS, I hope that your Lordships will agree with me that is it fundamental to examine NHS training and research in the present situation of increasing longevity. I see it as an opportunity to be welcomed, not a threat to be feared, so long as we plan ahead as best we can.

6.59 p.m.

The Lord Bishop of St Albans

My Lords, perhaps I may add my congratulations to the noble Baroness, Lady Greenfield, on her incisive, wide-ranging and deeply committed speech. I hope that she will accept my gratitude as a Bishop for all that she represents in the world of science to which all of us are so deeply indebted. And I should love to have heard her speak for 30 seconds on the soul!

Philip Larkin had a wonderful capacity for downbeat and melancholic honesty. One of his favourite aphorisms, which I treasure, was that which stated: Life was so flat you could see the tombstone at the end". Debates about healthcare are frequently littered with statistics. We have had several examples this week, including the league tables concerning heart surgery and, on the "Today" programme at five minutes before seven this morning, the brilliantly constructed opening salvo from the British Thoracic Society, to which the noble Lord, Lord Walton, has already referred. It was about deaths from respiratory disease and it quoted the figure of one in four.

I have no problem with statistics—clearly they are a useful management tool. However, there is only one statistic about human beings that has 100 per cent accuracy; it is that each of us will die. That statistic, as a result of the pioneering work of the hospice movement, has impacted upon palliative care and bereavement counselling in many hospitals and trusts. However, the quality as opposed to the quantity of that care is not easily susceptible to statistical analysis. When it comes to the quality of spiritual care that is offered to the dying, management-speak falters and stutters to a halt.

The death of a patient, I venture to suggest, represents a moment at which medical staff are brought face to face with their own mortality. Ask not for whom the bell tolls". Exactly the same can be said of the clergy when we say prayers with the dying or stand at a graveside. I n the face of death, each of us is forced to draw on the wellsprings of our own faith and belief—whatever they may be.

I recognise that this debate is about the NHS. While we rightly concentrate on measurable improvements in health service delivery, I wonder whether we sometimes do that at the expense of ignoring the profound human issues that daily affect staff and patients alike. My plea is that in the NHS a wholehearted commitment should be made to ensure that the range of religious and other beliefs that are held by patients are recognised by the chaplaincy team and by everyone in the relevant structures. In a multi-faith society, the complexity of the issues that are involved is considerable. I hope that when the Government publish guidelines for spiritual care-givers—it would be interesting to know the date on which those guidelines will be published—they will encourage trusts and others to offer training to all staff in those matters. I hope that chaplaincy teams will be specifically involved in that initial training. Research in that field may not appear at first sight to be of as urgent a priority as other pressing medical conditions. However, if we ignore the profound significance of death, we shall fail our patients and staff at the point of greatest need.

I move, if I may, to a different level of discourse. Her Majesty's Government have made much of their laudable desire and determination to have more consultants and doctors in training by 2004–05. However, I pick up around the place a certain degree of tired scepticism about whether or not those numbers can really be achieved. The pressure is undoubtedly on to reach the targets. It is not clear how the objectives can be achieved in all honesty. For instance, can the Minister assure the House that junior doctors will not be put on some fast-track system so that accreditation can be achieved in a shorter period than normal? Lying behind that is another question. Can the Minister assure the House that if fast-tracking is used, standards will not fall?

I return to my initial point. The learning of skills in healthcare is not a matter of treating either patients or staff as if they were engineered and engineerable objects. Slapping "go faster" stripes on junior doctors to try to achieve ambitious and laudable objectives will be counterproductive. Skills and wisdom require appropriate timescales in which to mature. When dealing with the most vulnerable in society and with fellow human beings in their greatest need, only the highest, most well-founded and mature levels of skills and wisdom will do.

If the targets are going to be met, it would be helpful at this stage to know how. If they are not going to be met, a degree of openness now would, ironically, be more confidence-building than much rhetoric followed by failure. That would involve building demoralisation even more firmly into the system. That benefits no one, except perhaps the makers of Philip Larkin's tombstones.

7.6 p.m.

Lord Rix

My Lords, it is good for those of us approaching the sere and yellow to retain some unfulfilled ambitions. I confess to having more than one. Near the top of my list is an ambition to convert the young doctor who, when faced with a patient with Down's syndrome, kindly but simply asked the patient's mother, "How long has he been retarded?".

My ambition has been honed over a good many years—so far without much success. Indeed, as long ago as the early 1960s I visited the then Minister of Health, Mr Enoch Powell, to enlist his support for a postal campaign to all NHS doctors, midwives, nurses and maternity units, giving them some pertinent facts regarding the birth and ongoing health problems of people with a learning disability who were then cruelly referred to as mental defectives. Mr Powell listened politely to my request and turned it down. Statistics, he pontificated, proved that nearly every member of the health service knew exactly what to do in that situation. He added that the matter was totally under control and that the health service was not the Post Office.

Unhappily I must also report that, on trying again 20 years later, Mencap, of which I am proud to be president, received a similar cold shoulder from the heads of medical schools. I am therefore delighted that my noble friend Lord Walton of Detchant has instigated this debate. It encourages me to have yet another go; it allows me to put the case for people with learning disabilities to enjoy some modicum of interest when medical education is being considered. Only a minority of doctors in training are exposed in any way to formal teaching about the healthcare needs of those people.

Not so long ago, large numbers of people with learning disabilities lived in Victorian institutions that we chose to call hospitals and the healthcare of the patients was seen as the responsibility of the doctors—some dedicated, some desiccated—who worked there. Now, thank God, very few people live their lives in such places. And that healthcare responsibility has been placed fairly and squarely on the shoulders of the general practitioners and consultants to whom the rest of us turn for help when we have health problems.

Unhappily, there is a great deal of evidence suggesting that people with a learning disability do not get as good a deal from their doctors as we get from ours: Rough-hew them how we They seem, on average, to be less likely to attend the doctor, hesitating, no doubt, because of their likely reception. Yet people with learning disabilities have a higher incidence of health problems, which are undiagnosed and untreated. Indeed, some of those health problems are directly related to the disability, but others are not.

When the patient finally sees the doctor, there may be communication difficulties—difficulties for the patient in explaining and difficulties for the doctor in understanding. Further difficulties arise from the doctor's misunderstanding about consent to examination and treatment, despite the excellent guidance recently issued by the Department of Health. Screening and healthcare programmes, too, appear to be denied to both male and female learning-disabled patients, and consequential problems are caused by late or incorrect diagnosis.

It follows, therefore, that improved training while a medical student, plus improved postgraduate training, could help to prevent the present grave disadvantages suffered by patients with learning disabilities. I am happy to say there is a little glimmer of light on the horizon. First, the Government have issued a number of reports on the health of people with learning disabilities, culminating in the White Paper, Valuing People. Government recommendations include the identification of patients with learning disabilities—a basic requisite, I would have thought—improved support for their access to generic health care; and individual action plans which, where appropriate, cover screening. Along with that goes encouragement for all healthcare professionals to have appropriate training. Amen to that!

Secondly, in conjunction with the Royal Society of Medicine, including its distinguished immediate past president, the noble Lord, Lord Soulsby of Swaffham Prior, Mencap held a seminar to bring together current wisdom on this topic, and earlier this year Professor James Hogg distilled a report on the proceedings, Improving Essential Healthcare for People with Learning Disabilities: Strategies for Success. Needless to say, that underlines the importance of medical training, which, with the support of the current president of the Royal Society of Medicine, Dame Deirdre Hine, who also carries responsibilities for enhancing quality in the NHS, we hope to convey to those responsible for such work.

Thirdly, there are a number of other promising initiatives, among which I single out training for doctors in particular and healthcare professionals in general, produced by Professor Sheila Hollins and her colleagues at St George's Hospital, the training team of which includes two ladies with learning disabilities. I commend the St George's initiative to your Lordships and, more particularly, to the Minister.

These days we recognise the right of people with learning disabilities to empowerment and citizenship. Those rights will not be advanced unless we allow the right to health, which in turn depends greatly on the quality and extent of medical training. Just over 2,000 years ago, Ovid could well have been reflecting on the way in which the health needs of people with learning disabilities have too often and for too long been neglected when he wrote—and I shall leave the Latin translation to my noble friend Lady Greenfield— Too late is the medicine prepared when the illness has gained strength by long delay".

7.12 p.m.

Baroness Warwick of Undercliffe

My Lords, I join others in thanking the noble Lord, Lord Walton, for introducing this timely debate. I also congratulate the noble Baroness, Lady Greenfield, on a fascinating and forceful maiden speech, compellingly presented. She will be a great asset to this House.

In speaking in this debate, I declare an interest as the chief executive of Universities UK. I hope that that gives me a vantage point, because it allows me some insight into the successes of medical teaching and research as well as the problems facing them, which I hope your Lordships may find illuminating.

The relationship between the universities and the National Health Service is a very close one. First, the higher education sector provides virtually all the pre-registration education for the nation's doctors, dentists, nurses and midwives. Secondly, universities provide most of the clinical and basic medical research on which the future of UK healthcare depends. Thirdly, universities' clinical academic staff, often in positions of leadership, make a substantial contribution to patient care. That partnership between the NHS and the universities is vital to achieving an improved NHS that meets the needs and expectations of the country. It therefore follows that if improvements are to be made in the performance of the NHS, the contribution of the universities is essential; and, needless to say, universities need to be resourced and equipped to fulfil their role in that partnership.

The education of health professionals is undoubtedly a very important growth industry for our universities. In 1999–2000 some 225,000 health and medical students studied in UK universities. That equates to approximately 12.5 per cent of the total number of students in higher education. Furthermore, the recent review of social work education recommended the introduction of a new three-year social work degree, which would be delivered through partnership between universities and employers. That also indicates the extent to which higher education plays an integral part in the nation's health and social well-being.

With regard to medicine, figures recently released show that the number of applications to study medicine in 2002 has increased by almost 18 per cent. It therefore seems clear that the encouragement and resources provided by the Government have paid off. The figures also positively reflect the work being done by universities to widen participation in medicine, particularly in schools that have no tradition of encouraging pupils to enter medical schools. In addition, they are developing shorter medical programmes for graduates from other subjects wishing to enter the profession. In that regard, the Government could help through a willingness to fund experimental schemes for professional training and retraining.

Of course, those schemes exist in addition to all the other initiatives across the country to widen participation in the higher education sector generally, such as mentoring in schools and hosting summer schools for prospective students from lower socioeconomic groups. But such initiatives are not cheap. Supporting new types of students once they are in university is an expensive business. When published later this month, Universities UK's spending review submission will make it clear that the Government need substantially to increase their funding for these programmes, so that universities may receive enough help to attract and support these new students into medicine and more generally.

However, it is not just a question of attracting and supporting students. As the noble Lord, Lord Walton, said, universities also need to be able to attract additional teachers for these new students. The Council of Heads of Medical Schools has shown that there are 73 unfilled clinical professor posts and 136 unfilled clinical senior lecturer posts. We can only attract more medical academics by giving universities the resources that they need properly to reward and motivate their staff.

I am delighted to proclaim biomedical research in universities a real achievement, or, as the noble Lord, Lord Walton, said, a real jewel for the United Kingdom. It is a glowing demonstration of the benefits of working in partnership, which in this case takes in universities, the NHS and the pharmaceutical industry. University research underpins new treatments and improved patient care. It also provides an opportunity for medical and healthcare professionals to develop the skill of using evidence to underpin practice.

Additional funding already allocated for new medical students totals £95 million. Regrettably, capital funds are limited, and research funds for new medical centres are lacking, hampering the creation of new centres of medical research. Perhaps the Government will review the way in which capital and research funds are distributed to those new medical schools.

In conclusion, the growth of partnerships between the NHS and universities has been a great success story. I hope that the Minister will agree that it could be taken further if links between teaching hospitals and the NHS were increased through the establishment of clinical centres of excellence, and I hope that he will address that point in his reply.

7.18 p.m.

Lord Patel

My Lords, I declare an interest. I am a consultant in the NHS and a professor of a university. I am also the Chairman of the Clinical Standards Board for Scotland, a sister organisation to the Commission for Health Improvement.

I would have liked 60 minutes, not six, to inform the Minister of the issues now confronting the NHS, if he is not already aware of them. Six minutes will have to suffice for today. First, however, I congratulate the noble Baroness, Lady Greenfield, on her excellent maiden speech. I also thank my noble friend Lord Walton of Detchant for initiating today's debate.

Before expressing my own views about the woes of the NHS, I will get the good news out of the way. Many of today's ills of the NHS—shortage of staff, shortage of beds, poor access to services and care—have their origins in the reforms of the late 1980s and 1990s. The Government have now agreed that the NHS needs more resources and they are providing them, on which they should be congratulated. However, perhaps the Minister will agree that in the long term other ways of funding the NHS, apart from Exchequer funds, will have to be found if the UK is to match the quality of healthcare of some of our European partners.

The NHS has huge shortages of nurses and doctors and the omens are not good. Today I shall concentrate on doctors, but the nurse shortage is even worse. Nearly 25 per cent of our doctors qualified overseas—most in developing countries. Despite their training, experience and ability, they feel discriminated against as they cannot get on to specialist registers and therefore be considered for consultant appointments. More and more patient care is delivered unsupervised by doctors in training.

Entry to medical school is also being affected. I am informed that four medical schools this year had to go to clearing to fill their quota. Nearly 5 per cent of graduates leave the profession and many more choose non-clinical work. The training of specialists is too long and inflexible. Basic training before entry to specialist training is also too long. In both cases, that acts as a disincentive to academic training. The answer is early entry, shorter specialist training and many more specialists providing care, but not all necessarily leading to consultant status.

I hope that the Minister also agrees that the new medical education standards board should have the responsibility and the authority to make sure that training programmes meet the needs of the service. Clinical academic medicine has other problems over and above that—a lack of clear career pathways, tenure track appointments and workload related to teaching, research and service.

One of the new demands placed on clinical academics is the need properly to professionalise medical education. That involves training medical educators and recognising them in promotional ladders. The new medical schools have realised that and are actively recruiting, mostly by poaching from established medical schools, which is the only place where such expertise exists. We need targeted funds to provide opportunities and develop medical education expertise.

Protecting academic time is difficult because of issues such as burdens of service, external quality assurance and coping with massive NHS changes, but it must be an absolute requirement. The Follett report is welcome in that context.

RAE pressures are another difficulty. Clinical senior lecturers and other clinical lecturers are compared directly with their non-clinical colleagues, despite the fact that they spend more than 50 per cent of their time on patient care. It will be a huge help for them to be counted as half of whole time equivalent. That would remove a significant disincentive to the employment of clinical academics.

Academic remuneration is another area that needs to be addressed. I hope that, whatever else they say, the NHS consultants' contracts will also be reflected in clinical academics' pay structure.

There has been some progress through many schemes supported by medical research councils and the Department of Health and others, particularly following the Saville report, as has been mentioned, but much more needs to be done if recruitment of both clinical academics and clinicians is to improve. A commitment to that is required. I hope that the Minister will show us the way forward.

7.24 p.m.

The Lord Bishop of Portsmouth

My Lords, like many others, I am grateful to the noble Lord, Lord Walton, for initiating this important debate. I have been dazzled by the array of medical academe manifested so far, including the wise and profound contribution from the noble Baroness, Lady Greenfield. I hope that the draft lay MPhil thesis that follows will not be sent back for resubmission too expeditiously.

The various NHS reforms announced over the past 18 months seem to be going in the direction of devolving the control of NHS resources away from the centre and outward to the primary care trusts. That is bound to exert a growing tension on the practice of medical education. All that, coupled with the aspiration to give patients a greater say in the provision of services, seems laudable in itself, but, as ever, we need to take what our friends across the pond call a reality check.

The NHS Plan promised a 6.3 per cent increase in funding over five years to 2004, but all the signals that I receive indicate that there is a considerable gap between the provision of high-tech services and the reality of local delivery. That exerts another tension on the practice of medical education. It is no good having MRI scanners costing millions of pounds but having waiting lists of up to a year to use them. I could mention an example of that but I shall not. It is no good saying that there will be more doctors when the reality on the ground is that GPs in Gosport, for example, are closing their lists through the pressure of the number of patients. It is no good saying that more nurses will be provided but to do so by importing able and trained staff from overseas, which is very much our gain and their home country's loss. I understand that the Isle of Wight has been reasonably successful in encouraging nurses who have taken early retirement back to work. A similar observation can be made about the target of 7,000 more consultants by 2004. That would mean 70 more in Portsmouth and 20 extra per year. This goes back to some of the observations made by the noble Baroness, Lady Northover.

I have spoken on a number of occasions in the House on issues relating to the provision of public services in health, housing, prisons or education. On each occasion, the same point has applied. If I came from the north country, I might be tempted to say, "You can't have owt for nowt". As a Scandinavian by descent, I am pleased to note that some of my ancestors appear to have shared their culture and, to adapt a phrase from the speech of the noble Lord, Lord Walton, perhaps their non-mystical bodies in the northern areas of this country.

I am continually amazed that we expect from our public services a level of provision comparable with those of our European partners yet we appear to have no intention of spending sufficient resources to supply that. We are faced with a circle that it appears cannot be squared. However uncomfortable the issue may be politically, it will need to be addressed. To speak the unspeakable, we may well have to consider the mixed economy found in much of northern Europe. where public healthcare and private insurance run hand in hand—a situation obtaining in many countries that have traditionally been further to the Left than ours.

Speaking from these Benches, I must in conclusion bring to the debate the reflection that there is an imperative from all faith traditions, including my own, that care for the disadvantaged in society is not an option but an obligation. Those who are On the margins, whether through age, gender, ethnicity or wealth, should expect that, hand in hand with society's calls for personal responsibility, there will also come the provision of efficient and effective public services. The highly complex system that has been developed in the National Health Service fails to deliver at various points what all parties aspire to. That can lead to the madness whereby, in my diocese, the excellent facilities and services provided by the Royal Military Hospital at Haslar have in recent years been threatened with closure. I know that the issue is complex. I have read all the material on it, but the people of Gosport feel badly let down because 50 per cent of the Haslar facilities have traditionally been NHS facilities.

We cannot think of the provision of these services in an idealised and abstract form. They are rooted in the loyalties of local communities. Those communities, as well as the individuals within them, have rights

I hope that the reforms that have been announced in recent weeks will lead to a narrowing of the gap between aspiration and reality. The debate has shown how essential a high-level, innovative and flexible education infrastructure is to ensure that that happens.

7.29 p.m.

Lord Chan

My Lords, I add my thanks to the noble Lord, Lord Walton, for introducing this timely debate. My aim is to examine medical teaching and research in the context of the National Health Service Plan introduced by the Government 16 months ago. It promised an ambitious programme of improvements for the NHS and local government. Outcome targets were set for people-centred services to provide the highest standards of care and to tackle major causes of disease and health inequalities.

Two key essentials identified to deliver the NHS Plan are an adequate number of staff and evidence-based practice founded on robust scientific clinical research and development. The Department of Health's implementation programme for the NHS Plan identified workforce issues, including recruitment, retention and training and development. On staff numbers, it states: the NHS plan commits the NHS to 7,500 more consultants, at least 2,000 more GPs, 20,000 extra nurses and 6,500 extra therapists by the year 2004. The increases in GPs and consultants will not be met, despite the increase in medical student intake of our existing and new medical schools. According to the department's Medical Education Unit, the number of medical school places rose by 1,000 last year, Over the next decade, medical student intake will rise to 7,000 per annum.

I declare an interest as an honorary public health professor at the University of Liverpool, where the new medical student curriculum is taught. Practice-based learning is better at equipping our future doctors with the skills for lifelong learning than is the former system of rote learning. However, the number of full-time clinical teachers is decreasing because, as noble Lords have said, excellent teachers are not rewarded as well as are medical researchers. For clinical teachers of surgical specialities, an academic career restricts income that can be earned in private practice.

With the important growing emphasis on primary healthcare in the NHS, more exposure of medical students to GP practice is becoming increasingly difficult. In Liverpool, 30 per cent of our inner city GPs are single-handed doctors, and the same is true in other English inner cities.

The Secretary of State for Health has recently been recruiting doctors from our European neighbours. While that is necessary to meet workforce targets, another source of doctors in the United Kingdom appears to be being overlooked. That is the estimated 2,000 refugees with medical qualifications, who could be recruited if they were offered a scheme of clinical attachments, support to pass tests in English language and in basic modern medicine, and an induction course to practise in the NHS.

In 1999, the Department of Health published a report of the working group on refugee doctors and dentists. That report, supported by the Advisory Group on Medical and Dental Education, Training and Staffing, produced several short and long-term recommendations to help integrate medically qualified refugees into our health service. Has the department considered implementing any of the report's recommendations?

Medical research has traditionally tended to be biological and disease-centred, leading to publication in high impact journals such as Nature. Such research is highly prized by universities for funding assessments, but does not usually cover the broad priorities of the NHS, including population health, which is focused on reducing health inequalities and improving the quality of health and social care.

I therefore welcome the position paper, NHS Priorities and Needs: R&D Funding, published in February this year. My concern is directed to the imbalance between the relative abundance of research and the paucity of development to harness the fruits of medical research for the NHS, patients and communities. I hope that that imbalance will be an issue that the Minister will raise with medical and NHS researchers, managers and doctors, as well as with the National Institute for Clinical Excellence.

7.34 p.m.

Baroness Masham of Ilton

My Lords, I thank my noble friend Lord Walton of Detchant for raising this most important subject. I congratulate my noble friend Lady Greenfield on a truly masterful maiden speech.

My grandfather trained and worked as a physician in Scotland. Many people from all over the world have been proud of the medical qualifications they gained in Scotland. The Government tell us that we are short of doctors and surgeons, yet a ridiculous situation exists. South African orthopaedic surgeons with five years' training appear unable to get onto the UK General Medical Council's specialist register because they lack an extra year's training. It is ironic that South African surgeons can work as locum consultants, doing all the work of a consultant, and with a substantive post. However, the new rule and change in political emphasis make it extremely difficult for such young people to make progress unless they return to their country of origin—or perhaps go elsewhere in the European Community—and are able to get onto a training programme formally to complete an extra year's training.

It seems extremely difficult for young doctors to get onto a training programme in the UK to specialise. I heard that the professor of orthopaedics at Bristol University had 200 applicants for two training posts. The lack of facilities—especially human resource—to train young doctors in a specialty appears to be the major problem. Also, those older than 35 are advised by the colleges that they would be wasting their time.

At a local hospital near where I live in North Yorkshire, two South African consultants are trying to formulate a plan to comply with the new ruling, and a young Pakistani surgeon, who is a Fellow of the Royal College of Surgeons and has all the enthusiasm and talent to become a good consultant, is finding it impossible officially to study further.

Why cannot the Government, in co-operation with Scotland, set up some training and assessment programmes in Scotland to help to solve that problem? It will be impossible to shorten the waiting lists without good surgeons and their aftercare teams of nurses and therapists.

The Minister knows my interest in the need for specialist units for conditions such as cancer treatment, spinal injury and many other challenging, rare conditions. In some cases, it would be neither practical nor cost-effective to have all specialist centres in every region. How will the Minister ensure that patients are not denied life or death choices? What is the current situation with extra-contractual referrals, and what are the plans for the future? That is one of the most important matters involving patients, their doctors and post-graduate training.

Another important update that I hope the Minister will give us concerns how patient participation will be incorporated into the English NHS, without being fragmented. Wales and Scotland are building on existing community health councils, maintaining independence. Patient participation should be part of medical education, helping to make doctors human and receptive.

There seems currently to be a limited list of charitable funders identified as qualifying for support in research and development for the National Health Service. Although I know that work is in progress to extend the list, many charities remain unaware of the official recognition procedure. Limiting the number of charities that will attract service support funding may jeopardise much research currently undertaken within the NHS.

There are many good and dedicated people working within the NHS. They need encouragement and appreciation. The agency staff culture which has grown within the NHS in the past two years is draining many of the resources which should go to direct patient care and much needed updated safe equipment for many of our hospitals.

7.40 p.m.

Lord Rea

My Lords, I join other noble Lords in congratulating the noble Lord, Lord Walton, on drawing our attention to the crisis in academic medicine. Of course, he has flagged up the issue ever since he joined the House.

I think that every noble Lord who has spoken has pointed out that there is not only a shortage of academic staff in medicine and nursing in the UK but also a shortage of their products—the nurses and doctors who serve us in the National Health Service. In several branches of clinical medicine, and not only in the "Cinderella" services, there are serious shortages and unfilled positions, as my noble friend is very well aware. In general practice, which is the front door to the rest of the National Health Service, that is well recognised by the Department of Health, and 2,000 additional general practitioners are planned by 2004. In parenthesis I should say here that the BMA's GP Committee feels that 10,000 more GPs will be needed to undertake the additional tasks that will be required as the National Health Service develops.

Medical school places are being sharply increased which, as the noble Lord, Lord Walton, and others pointed out, is in itself excellent news. But the quality of those new graduates will suffer if there is not a corresponding increase in numbers of academic staff, both clinical and non-clinical, to ensure that these graduates have a sound basis for their professional life in the National Health Service.

Across the Channel the French health service was recently classified by the World Health Organisation as the best in the developed world and, therefore, the best in the world as a whole. It is, of course, more expensive than the National Health Service, consuming some 9.6 per cent of a greater GDP than our 6.9 per cent. That was the figure at the last count, but perhaps my noble friend can say where we are now. It is, of course, gratifying that we intend to proceed to a figure of 8 per cent which is the European average. In fact, the French system is more expensive than it need be, with excessive prescribing, payment of doctors by item of service and direct access of patients to specialists. So, it is quite possible that we could achieve the same standards as the French with perhaps less cost, even with the 8 per cent figure that is proposed. However, there is a huge backlog of underinvestment to make up before that proportion of our national income would be able to sustain a health service in which the infrastructure is as good as it is in France.

France has three doctors per thousand of the population which is nearly double our 1.7 per thousand; and the European average is 3.4 per thousand. It is probable that the French and the European levels are too high, but the population makes use of them and appreciates them. However, I suggest that demand is not the same as need and that we could provide an excellent service with perhaps fewer doctors per thousand than the French but with many more than we have now.

In nursing much the same applies although the contrast in numbers is rather less stark. There are 5.6 nurses per thousand of the population in France and 4.3 per thousand here. That means that the French have a 30 per cent higher nurse to population ratio. As other noble Lords have pointed out, the Department of Health is making a determined effort to attract, recall and retain nurses, but it is having to run in order to keep still. I am not the only one who is unhappy that as part of that drive we are actively recruiting some nurses from poorer countries with far greater health problems than we have. But as with medicine, increasing the intake of new recruits into nursing will make more demands on nurse educators. As the Royal College of Nursing says, there are now, not enough nurse educators to supervise the existing clinical placements of nurses in training". One of the problems facing the National Health Service and the Department for Work and Pensions is the persistent high level of sickness absence among the working population, despite steady overall improvements in our basic health statistics. Of course, as the Thoracic Society pointed out two days ago, there is an increase in asthma and lung cancer among women. But I think that these contribute only a very small proportion of that sickness absence and that it is mainly due to a mixed bag of recurrent and chronic conditions which are not life threatening. Among those, depression and social and family related problems loom large. They occupy a high proportion of medical time, particularly in primary care. The symptoms presented by those patients are many and varied; some are very puzzling and may result in referrals to specialists in outpatients departments. Others, of course, find their way to complementary practitioners. General practitioners and all clinicians benefit by sharing the care of those troubled patients with other professionals such as nurses, counsellors, psychotherapists, social workers and complementary practitioners.

The National Health Service would work more smoothly if this group of patients were handled better. Much time in primary and secondary care could also be saved. Liaison between doctors and the other caring professions can be greatly enhanced if at an early stage of their training there is inter-professional contact, when two or more professionals can learn from and about each other to improve collaboration and the quality of care. I suggest that my noble friend looks carefully into that matter and sees that the Department of Health gives a rather more generous core support to "CAIPE", the Centre for the Advancement of Interprofessional Education. I think he will find that that will pay a good dividend.

7.47 p.m.

Baroness McFarlane of Llandaff

My Lords, I wish to add my thanks to the noble Lord, Lord Walton, for initiating the debate and for the authoritative and spirited way in which he introduced it. I believe that many of us from time to time have had the privilege of working with the noble Lord on various subcommittees of the Select Committee on Science and Technology and know the tremendous contribution he has made to the discussion of medical research. I believe that this debate will form another landmark in the work of this House in respect of medical research.

I believe that the issues now confronting the National Health Service point to the need for research right across the NHS and in professions such as nursing, midwifery and health visiting, together with the 12 allied health professions which are shortly to be grouped together in the allied health professions council.

The debate is timely as I have heard that on 4th December the Higher Education Funding Council for England is to launch two major reports. Last year the Higher Education Funding Council and the Department of Health established a task group to examine the research base in nursing and the allied health professions. To support its work the task group commissioned a major investigation into the current state of the research base by a consortium led by the Centre for Policy in Nursing Research, which is based at the London School of Hygiene and Tropical Medicine. The consortium included representatives of the Association of Commonwealth Universities, the Higher Education Consultancy Group and the Research Forum for the Allied Health Professions.

The consortium produced its report in August under the title, Promoting Research in Nursing and the Allied Health Professions. I understand that the task group has now completed its own report which it says draws heavily on that of the consortium. I have been able to read the consortium report. I found it impressive and compelling in its arguments. The report maps the present position as regards university research in nursing, midwifery, health visiting and the allied health professions. It compares the research activity with that in education and social work, which are comparable professions, and makes international comparisons. It suggests funding models and explores the case for further investment by HEFCE and the Department of Health. I believe it is important that some of its findings should inform this debate.

It was estimated this year by the National Health Service Executive and the Wellcome Trust that the UK invests almost £3.5 billion in medical research from public and private sources. Yet nurses, midwives and the allied health professions make up two-thirds of the staff responsible for direct patient care. The cost of nursing and midwifery salaries is the largest single item of NHS expenditure, and 3p in every pound of public expenditure goes on nursing. Yet little is known of either the clinical effectiveness or the cost-effectiveness of this largest sector of care.

An analysis by the Wellcome Trust shows that only 1.8 per cent of NHS research outputs between 1990 and 1997 related to nursing. The public is thus poorly served by the current capacity for research and by the research output of these professions in this country. If there are to be measures to improve the quality of care, it is essential that we have the basic evidence on which to base practice.

Frequent emphasis is rightly placed on the need for evidence-based practice. We now have a massive infrastructure of research-commissioning bodies and disseminating mechanisms to help that to happen. Yet the Wellcome Trust has indicated that fewer than 1,500 research publications in nursing have been produced over the past eight years at a time when the NHS supports over 13,500 research publications annually.

Recent policy changes in the NHS, such as the move to more home and community-based care, necessitate extended roles in nursing, midwifery and the allied health professions. But if such advances are to benefit the patient and to be cost-effective, they must be based on sound evidence. Therefore, the demand for further research for these professions is essential.

We have a vicious circle, as someone called it, of disadvantage. The consortium compared research activity in nursing and midwifery with that in education and social work. When deficiencies were found in education research, a special teaching and learning research fund, managed for HEFCE by the ESRC, was created. That now has a budget approaching £23 million which is used to enhance the capacity for research-based practice. We may well ask why it compares so unfavourably with the budget for nursing research.

The consortium also made interesting comparisons with America and Canada. We could ask why we in this country are in a position of such deprivation. I plead with the Minister that these two reports should receive detailed consideration and form part of a coordinated solution.

7.54 p.m.

Lord Clement-Jones

My Lords, first, I add my thanks to the noble Lord, Lord Walton of Detchant. In a series of superbly well informed speeches, we could not have had a better demonstration of the value to this House of our Cross-Benchers. I have learned a huge amount in the course of this debate. I want in particular to congratulate the noble Baroness, Lady Greenfield, on her superb maiden speech. She certainly enhanced her reputation as a formidable communicator. I look forward very much to further incisive contributions in the future.

I have no particular expertise in this area. I can pray in aid only that my late wife was a registrar at St Bartholomew's Hospital, specialising in endocrinology. Twenty years ago she ran a very busy practice as an endocrinology registrar. At the same time, she was able to carry out original research which demonstrated, ultimately, the physiological basis of acupuncture. I do not believe that she would be able to do that today. That is precisely the problem on which many noble Lords have put their finger.

Some may say that the noble Lord, Lord Walton of Detchant, painted a sombre picture. However, it seemed to me to be a pretty true and fair picture. I was particularly taken by his apt description of NHS staff providing outstanding service in intolerable conditions. I consider that to be a key phrase in today's debate. I believe that, as I expressed in this House last week, health Ministers should understand that there is grave doubt among medical professionals and managers about whether we should be moving ahead with yet more structural reform in the midst of trying to achieve so much in the NHS.

A recent Financial Times leader was headlined "Maoist NHS", pointing out quite rightly that: Another huge structural reorganisation is under way, taking management eyes off delivery. Devolution is preached but centralised micromanagement still rules". If the NHS were delivering, it would be a different matter. More reorganisation might well be in order. But under this Government it transparently is not. Recent figures show that so far this year fewer waiting-list patients have been treated by the NHS, despite the NHS budget having risen 6 per cent this year and 30 per cent since 1997.

A recent Audit Commission report on the NHS described the problems that patients in accident and emergency services, in particular, face, with people waiting longer in casualty than they did five years ago. Clearly that is mirrored in public opinion. In a recent poll, six out of 10 people believed that Labour had made no difference to the NHS since it came to power in 1997. Indeed, 16 per cent considered that the NHS had become worse under this Government.

The problem is that the funding promised seems to leak out of the system, whether it relates to cancer, mental health or heart disease—all of them key priorities—let alone respiratory disease, which, as we have heard today, is the biggest single killer. All the evidence is that budgets for the major priorities are being raided to make up for lack of funding in other parts of the NHS. Health service managers, it seems, are saying that there are unbridgeable gaps in funding for the NHS this year. They have made it clear that they believe there will be major financial problems this year unless they receive more money or targets are reduced. So far, the response of the Secretary of State appears to have been an announcement that the money to be spent in the private sector is to be doubled. I do not believe that that is a particular vote of confidence in the NHS.

There are many other pressing problems apart from that of finance. Bed-blocking, particularly in the south-east of England, severely affects NHS delivery.

A risk-control expert told a conference last week that bed-blocking costs £32 billion annually. I find that figure very hard to believe, but it shows the scale of the difficulty. The Government now recognise the problem after several years of failing to do so. However, in trying to cure that particular problem they acted too late and with money that transparently was too little. Residential care beds al k. still disappearing at unprecedented levels.

On top of that, as we have heard from many noble Lords, are the issues of recruitment, retention and morale in the health service across a huge range of professions. The problem in these cases is not helped by the protracted and difficult discussions over regulation and the creation of a new overarching body—the council for the regulation of healthcare.

In this climate, morale declines. The noble Lord, Lord Walton, mentioned consultants leaving the health service. I believe that a quarter of our general practitioners want to retire. Even today I have received a letter from a health visitor saying that health visitors are convinced that the role and title of "health visitor" will be abolished in the new regulatory order. I am sure that the Minister can give reassurance, but that demonstrates the level of morale in the service.

The key purpose of the debate has been to highlight issues in the area of medical teaching and research—and as we have heard, there are many issues. I have considerable concern about training. Yesterday we heard from the Royal College of Nursing about the state of nurse education and the problems faced by nurse lecturers in "Charting the Challenge for Nurse Education" in terms of workload, role and clinical practice, with particular dangers for adequate clinical supervision. Are the Government addressing those issues with the Royal College of Nursing?

In terms of training doctors, the noble Baroness, Lady Warwick, highlighted some of the positive initiatives that are taking place. Of course, as she pointed out, they all require more resources. The Minister and his colleague, the noble Baroness. Lady Ashton of Upholland, know full well that I have highlighted the problems with the skewing of medical education as a result of the research assessment exercise (RAE) that values, and gives resource to, research at the expense of medical training. The RAE was described as a juggernaut by no less than the vice-chancellor of Manchester University, which is a fairly telling description. What answer does the Minister have to that?

We have a massive shortage of doctors in this country, which is a legacy of the previous government and the first two years of this one. Yet government policy appears to be designed to ensure that we do not achieve the numbers of well trained doctors that we need. In the past, the noble Lord, Lord Hunt, has recognised the problem at the interface of RAE with the need for teaching quality and resource, but what are his current thoughts? Who will fulfil teaching commitments? Surely not hard-pressed NHS consultants.

I had wanted to cite one example at some length, but unfortunately I cannot. I am sure that all noble Lords could give a number of examples. At Imperial College there have been some 59 redundancies over the past year. Some people have been brought back on short-term contracts, but many of them have not and they are lost to medical teaching.

Despite that type of culling, there is a major problem with the recruitment of medical teaching staff. The noble Lords, Lord Walton and Lord Chan, and the noble Baroness, Lady Warwick, pointed to the vacant chairs that cannot be filled by suitable applicants. The hours that need to be worked to fulfil clinical and academic commitments are clearly unreasonable. It is no wonder that in many specialties doctors are choosing to drop their academic and teaching commitments. Overwork for teaching staff and inadequate training for medical students inevitably follow. As a result of that and similar actions, the workload for medical academics has increased massively. The Minister needs to produce answers.

On research, the noble Baroness, Lady McFarlane, identified key areas where further research is needed in nursing. Similarly, the noble Lord, Lord Chan, in relation to medicine and my noble friend Lady Northover raised some pertinent questions that I hope that the Minister will answer today about the Section 60 regulations and the fate of the PIAG.

A further aspect is the matter of research fraud. A number of prominent research doctors have raised this issue and have proposed a body to respond to research misconduct. Many involved in academic medicine would like to see that set up.

Although this debate has only scratched the surface of this subject, a huge amount of wisdom has been displayed. As the right reverend Prelate the Bishop of St Albans pointed out, there is a considerable degree of scepticism and disillusionment with the Government's performance. The Government still have to demonstrate that they mean business with the NHS and that they are prepared to share their doubts and worries about the NHS and its performance.

The Government took a dramatic step in increasing the funding for the NHS following their first two years of inaction. I did not realise, with reference to the noble Lord, Lord Rix, that Ovid was quite so apposite in the circumstances. A notable number of practitioners have taken part in the debate. I urge the Minister to accept at least their diagnosis, even if he does not accept every jot of their prescription. To paraphrase the noble Baroness, Lady Greenfield, this debate has shed a great deal of light, but it is up to the Minister to ensure that the debate bears fruit.

8.5 p.m.

Earl Howe

My Lords, for those who may be tempted to downplay or belittle the role of your Lordships' House as a House of experts, there can surely be few better rejoinders than this debate today, so ably introduced by the noble Lord, Lord Walton of Detchant. We have heard some outstanding contributions, not least that from the noble Baroness, Lady Greenfield, whom I warmly congratulate.

I believe that the noble Lord, Lord Walton, has done the House a considerable service by raising a topic that is of central importance for the future of healthcare in this country. Indeed it is probably not going too far to say that the targets set out in the NHS Plan for the recruitment of additional GPs and consultants, as well as the maintenance of adequate standards in training those new recruits, depend critically on the availability of sufficient and properly qualified teaching staff.

To appreciate the importance of clinical academics, one has to understand their role. Clinical academics have three principal functions as employees of universities: they are fully trained specialists or GPs who teach undergraduate medical students; they undertake clinical practice which includes direct responsibility for patient care and the training of young doctors; and they undertake research into the prevention, diagnosis and treatment of disease.

It is the last of those, the research activity, that is seen as the raison d'être of clinical academics. Universities are research-led. The work carried out in university medical schools leads directly to advances in the clinical management of disease and to improvements in both the health and the wealth of the nation.

In the past, as the noble Lord, Lord Clement-Jones, reminded us, clinical research was also undertaken by NHS doctors. For reasons that do not need stating, doctors are increasingly unable to perform that role, and it is clinical academics who are now the predominant drivers of research in British medicine. It is to them that the country turns whenever there are new and unforeseen public health crises such as new variant CJD or HIV; and it is often they who are leading contributors to the medical royal colleges, the research councils and the international medical bodies.

The prospects for making real advances in biomedical and health research have seldom been more exciting than they are today. Despite that, over the past 10 years we have seen an increasing reluctance among young clinicians to enter the world of academic medicine. The Richards report of 1997, acting in response to concerns raised by a Select Committee of your Lordships' House, voiced serious worry about the growing shortage of academic clinicians, as graphically evidenced by numerous vacancies in professorial chairs. The unavailability of suitably qualified candidates for such senior posts is seen as a real threat to the future of some key disciplines.

Even at junior level, as many noble Lords have reminded us, there has been a fall in the numbers of clinical lecturers in post. Overall numbers of clinical academics have fallen by 20 per cent since 1992. Unless those trends are halted and reversed, centres of excellence will literally disappear and we shall be unable to provide the standards of training to medical students that both they and the nation expect and deserve.

The disincentives against taking up an academic career have been well articulated by the noble Lord, Lord Turnberg, and other noble Lords. Some of those arise from the need for medical academics to reconcile the competing demands of two employers: the universities and the NHS. In many specialities workloads have become almost insupportably high, with medical academics far exceeding their contracted hours of employment, especially on patient care. The Royal College of Physicians has found that 64-hour weeks are common. There is a shortage of opportunities for protected post-doctoral research and insufficient flexibility to combine such research with clinical training.

But the more fundamental disincentives relate to the absence of a clear career structure; prolonged insecurity of employment before obtaining a senior post; and, significantly, the lack of financial incentives. Medical research is not a lucrative occupation. It must also be remembered that clinical academics, unlike NHS consultants, have no opportunity to generate earnings from private practice. The NHS Plan, while providing for a system of rewards for consultants, does not extend these rewards to academic clinicians specialising in general practice. That deficiency must be addressed. Unless such clinical academics are made eligible for distinction awards, recruitment and retention can only worsen further.

If we look at one of the Government's key targets—cancer—there is already a worrying shortage of clinical oncologists. It took the University of Glasgow and the Cancer Research Campaign over 18 months to replace the head of clinical oncology at the Beatson Oncology Centre in Glasgow. That is not the only example in oncology. In fact, in cancer research posts, more and more of the funding is being left to charities which are finding it very difficult to compete with the draw of Europe and the United States in particular. The situation is unacceptable and really cannot continue if the imbalance between cancer survival rates in the UK and other countries is to be corrected. In pathology, in psychiatry and in surgery the shortages are even more acute.

Last year the Academy of Medical Sciences, under the chairmanship of Professor John Savill, published a succinct and authoritative report on these issues, called The Tenure-Track Clinician Scientist. I hope that the Minister will be able to tell us that the seven principal recommendations in that report are being actively pursued by the Government. I hope too that any such action will recognise the intimate interdependence of the three facets of clinical academic medicine that I mentioned just now. Medical training is funded by two government departments— the Department of Health and the DfES.

I worry sometimes that the substantial new money promised to the NHS, however welcome it is—and it certainly is—may mean that in the joint departmental responsibility for medical education the DoH will assume a dominant role. That would be regrettable. Medicine needs constantly to relate across to the wider science and education base, and the DfES therefore needs to be kept closely involved in the fastchanging field of medical education.

Equally, we need to ensure that the forthcoming delegation of budgets to PCTs will be associated with improved clinical teaching and research in all subject areas, and not either with short-termist attitudes or with a curtailment of academic disciplines.

When the noble Lord, Lord Walton, and my noble friend Lord McColl raised the issue last year of the number of vacant clinical chairs in the UK, the noble Baroness, Lady Blackstone, gave a reply that I thought was quite alarming. She said that the recruitment of university staff was nothing to do with the Government. That answer seemed to me at the time to be an abdication of legitimate ministerial concern. This really is the time for the Government to take the issue in hand and to take it seriously.

It is certainly true, as the noble Baroness, Lady Greenfield, so eloquently said, that for clinical academic medicine to become a more attractive career choice it will take a concerted effort by all stakeholders, including government, the royal colleges and the universities. But the Savill report pointed the way to how this might be done. It is vital both for our healthcare and for our country that such efforts are encouraged and that they succeed.

8.14 p.m.

Lord Hunt of Kings Heath

My Lords, I start by echoing remarks made by the noble Earl, Lord Howe, in paying tribute to the quality of the debate today. Much of that is due to the noble Lord, Lord Walton, both for his initiative in introducing this debate and for the quality of his speech.

I also take the opportunity to pay tribute to the noble Baroness, Lady Greenfield, on what I can only describe as an extraordinary and delightful maiden speech. We look forward to her contributing more in our health debates in the future.

The focus of today's debate is on medical teaching and research but undoubtedly within the wider context of the future direction of the National health Service. I want to respond to the many comments that have been made about medical teaching and research. I agree that they are vital. They have a direct input to the quality of our doctors. The United Kingdom has a worldwide reputation for the excellence of its academic teaching. That is important to us in terms not only of the quality of doctors but also of this country's investment in the science base and in the relationship, as my noble friend Lady Warwick said, with the research-based R&D, pharmacy companies which are responsible for 23 per cent of all commercial investment in R&D in this country.

There needs to be the strongest relationship possible between the National Health Service, universities and the private sector. That must be seen within the wider context of the National Health Service. The noble Lord, Lord Walton, very much echoed by the noble Lord, Lord Patel, raised issues over funding, the shortage of GPs, beds and consultants. I shall come to those matters.

The UK is not unique in facing up to issues and problems in its healthcare system. Most healthcare systems of the world face considerable challenges over the same kind of issues as we do such as funding—although some of them may be at a higher funding level than ourselves—issues to do with patient involvement and consent and issues in relation to the undoubted pressures that there are on many of our health professionals.

Although the right reverend Prelate the Bishop of St Albans warns us of statistics, I believe that there is convincing evidence that considerable progress is being made—the national standards arising from National Health Service frameworks and the focus on quality and outcomes. Ten years ago there was great concern that quality and issues to do with standards hardly rated a mention by trust and health authority boards. The whole issue of quality and standards is now right up there as the number one concern of all NHS organisations.

For the first time in 30 years extra beds are being brought into commission. I listened with great care to the noble Lord, Lord Walton, when he referred to a number of PFI schemes. He said that the bed numbers had been reduced. The process that we adopt for a new capital proposal is that there is a projection of the number of beds before any decision is made about whether it should go down the PFI route or the public finance route.

Our latest PFI hospital, the Norwich and Norfolk, which is truly magnificent, successfully increased its required number of beds during the contract. Overall, more beds are being opened in the health service. It is not just a question of capacity increase; we must give patients choice. I accept the point raised by the noble Lord, Lord Walton, that we cannot have a culture of blame in the health service. We need to decentralise decision-making in the health service.

The noble Lord, Lord Clement-Jones, is always accusing the Government of micro-management. But, shifting the balance, the process of change we are seeing now is designed to move away from such micro-management, to have more focus on a limited number of priorities and to have much more frontline decision making. Seventy-five per cent of the NHS budget by 2004 is to be decided upon at the primary care level.

It is not a matter of either capacity or structures. I accept the point raised by the right reverend Prelate the Bishop of St Albans that of course we have to look at the personal needs of patients. He asked whether the NHS is wholeheartedly committed to recognising the spiritual needs of our patients. I say that we are. I recognise that in some places we have not been able to do all that we need to do. However, I can assure him that the Government are ever willing to discuss with the Churches and other faiths ways in which we can improve that spiritual care for those patients who wish to receive it.

The right reverend Prelate the Bishop of Portsmouth asked for a reality check and referred to the gap between high-tech equipment on the one hand and waiting on the other. A number of other examples were given. We need to equip ourselves with high-tech equipment. The NHS has run for far too long on out-of-date, old-fashioned equipment. But the key to dealing with waiting is to increase overall our capacity; and the key to that is staff.

We have an ambitious programme for increasing the number of staff. I believe that we shall meet the target of 10,000 extra doctors by 2005. As my noble friend Lord Rea pointed out, a key plank is the increase in medical school places. Between 1997 and 2005 over 2,000 medical school places will have been created in England, with four new medical schools and three new centres of medical education.

The noble Lord, Lord Patel, asked whether there is a problem with regard to the number of applicants to medical schools. The latest figures for the 2001 entry are 8,438 applicants, with 5,869 accepted. For the 2002 entry, 9,018 applicants—a large increase over last year—have been received. I have no indication whatsoever that the quality of those applicants is any lower than in past years.

A number of noble Lords made important comments about the curricula. I do not disagree with those comments. The noble Lord, Lord Colwyn, referred to complementary and alternative medicine; and the noble Lord, Lord Rix, referred to learning disabilities. He put forward a persuasive case and I noted the support of Dame Deirdre Hine. The pressure on deans and medical schools to ensure that they cover so many different parts of the curricula is very great. While I would encourage medical schools to think widely about what should be in the curriculum, we need to recognise the pressures on them.

I say to the right reverend Prelate the Bishop of St Albans that I believe we shall meet those targets. We believe that we have enough specialist registrars in post to deliver the bulk of the 7,500 consultant targets. But we shall look further to boost their numbers by action to reduce delays in training throughput and international recruitment.

We have already announced the first 300 of the extra 1,000 specialist training places we plan. Those will be in place by April. Further increases will be supported by full funding of new posts from this year and all posts from next year.

Let me address the issue of international recruitment. The right reverend Prelate the Bishop of Portsmouth and my noble friend Lord Rea expressed some concern. I want to make it clear that we are recruiting only from countries where there is a clear surplus of either doctors or nurses; and that we are doing so with the encouragement and agreement of the governments of those countries. I believe that that is the right approach. As I mentioned earlier, we think that by changing the arrangements for training we can ensure that in some cases we can speed up the training programme. I want again to respond to the right reverend Prelate the Bishop of St Albans by saying that this is being done by eliminating some unnecessary delays and dead time. It is not fast tracking in the way he suggested.

The noble Lord, Lord Chan, asked about refugee health professionals. I recognise that there is a community of people who could be used in the National Health Service. We are working with the Refugee Council and the BMA. We have also set up a steering group to allocate funding for projects targeting the needs of refugee health professionals. I understood the point that the noble Baroness, Lady Masham, made. We are conscious of the need to make the best use of doctors in the UK.

It is important to recognise nurses' contribution to expanded capacity in the National Health Service. We have seen a massive increase in the number of nurse training places. That will give us confidence to ensure that we will meet the targets we have set in relation to the nursing staff we require for the future.

One cannot discuss the NHS without talking about resources. Many noble Lords have recognised that we are putting in considerable extra resources and that we now have the fastest-growing health service of any major European country. It is true that we have a long way to go to catch up with many of our European partners. The scale of increase—it is 6.7 per cent in real terms—for this financial year is impressive. I am not convinced that there are magical alternatives to the current funding regimes. The right reverend Prelate hinted at social insurance as used in parts of Europe. But that is not always an advantage. Many companies in Europe are concerned about the cost to them of their contribution to that social insurance scheme. In many ways one can think of social insurance schemes as a tax on jobs.

The noble Lord, Lord Walton, encouraged by the noble Lord, Lord Patel, wished me to be brave in standing up to the Treasury in relation to hypothecation. It is true that I had a briefing from the Treasury on this matter but I failed to understand it. I am not convinced of hypothecation. In the end it is still part of the general taxation picture. When government make a decision about the general level of taxation I am not convinced that the NHS would do any better than at present. My right honourable friend the Chancellor has asked Mr Derek Wanless, previously of Nat West Bank, to undertake a long-term assessment of the trends which may affect the UK health service over the next 20 years and to identify key factors which will determine the financial and other resources required to ensure that the NHS can provide a publicly funded, comprehensive health service. I understand that his recommendations will inform decisions to be taken in next year's Budget. I believe that in the meantime the amount of resources that we have put into the health service are very significant indeed.

The noble Baroness, Lady Northover, and my noble friend Lord Turnberg, raised concerns about progress in relation to Section 60 of the Health and Social Care Act. I well understand the issues they raise. I would be concerned about "research blight" as it has been described. I understand that membership of the advisory group will be announced shortly and that the regulations will be made as soon as possible. I have taken notes of the comments raised. I shall make sure that the matter is drawn to the attention of those responsible for ensuring that those proposals are up and running.

This question is related to teaching and research. The research infrastructure in this country is of a high order. In partnership with the Wellcome Trust, we are now investing an extra £1.75 billion in the research infrastructure, much of which supports biomedical research in the universities. I accept that we need to consider whether investment in research, especially when we examine the trends in the past few years, ought not to relate only to medical research.

I listened with great interest to the remarks of the noble Baroness, Lady McFarlane, who was a distinguished nurse academic in her own right at Manchester University. She put forward a convincing case with which I have every sympathy. We have not seen the consortium report, but we shall read it with interest. I have made the point in my discussions with Sir John Pattison, the department's director of research and development, that we need to consider research in relation to nursing and the other non-medical professions.

I turn to a number of the specific issues that have been raised in relation to clinical academics. I can tell the noble Baroness, Lady Northover, my noble friend Lady Warwick and the noble Lord, Lord Walton, that there is no doubt that there has been long-standing anxiety about the recruitment of clinical academics. Those concerns have been further fuelled by the increase in medical students and the need to have a sufficient quality and quantity of clinical academics to teach that growing number of students.

I was interested in the references made to current vacancies. I understand from the CHMS survey on clinical academic staffing that there are 73 professorial vacancies but that 45 were being filled at the time of the survey. With regard to lecture posts, the figure is 322 vacancies, but 180 of those are being filled. I am not suggesting that that is particularly comforting. I recognise that there are enormous pressures in the universities to ensure that those places are filled. Certainly the Department of Health via the academic and research sub-group of the Advisory Group on Medical Education, Training and Staffing has the long-term aim of developing a comprehensive database of clinical academics and is embarked on a project to conduct it. In addition, the sub-group of AGMET, as it is known, is responsible for taking forward the recommendations from the report of the Academy of Medical Sciences to address perceived disincentives to an academic career in medicine.

The noble Earl, Lord Howe, was right to refer to Sir John Savill's report. We are keen to ensure that the lessons from that report are fully learnt. The noble Earl may know that as a result of that report. we created a clinician scientist scheme jointly funded with research interests. I understand that eight of those posts have now been filled and eventually we wish to see 250 posts. This is an exciting scheme that offers new career pathways for the real academic high flyers.

Since the Savill report, the Academy of Medical Sciences, whose work in this area has been outstanding, has commissioned Sir Peter Morris to review and make further recommendations. The academy has highlighted particular areas that it views as a priority for action. I am not sure whether the report has been published yet, but some of the results have been shared with the department. The conclusion of the report is that concerted action by all stakeholders is required to highlight the seriousness of the current position. The academy has commented that, as one of the key stakeholders, the department has already made good progress in taking action to address concerns. We shall want to work with the academy on these issues, and I understand that action has already been taken on one of Sir Peter's recommendations with joint work between Universities UK, the BMA and involving the Department of Health to develop joint appraisal arrangements for clinical academics.

That brings me to the report of Sir Brian Follet on appraisal, disciplinary and reporting arrangements for senior NHS and university staff. It is extremely relevant to remarks made by the noble Earl, Lord Howe. Follet recommends better joint supervision of clinical academic staff. By March 2003 all researchers not employed by the NHS will hold an NHS honorary contract, which includes both research governance procedures and responsibilities if they are to react with individuals in a way that has a direct bearing on the quality of care.

Follet arose from the problems at Alder Hey hospital. The Redfern report identified difficulties in relation to accountability for clinicians who have joint appointments. Follet will be important in sending us in the right direction. I noted the comments of my noble friend Lord Turnberg about the need for a flexible approach, and I shall take that on board. The noble Baroness, Lady Greenfield, talked about the importance of attracting public/private partnerships and the need for workshops, and we shall consider those suggestions carefully.

I am also aware of the career choices facing young doctors. Some may have seen disincentives in opting for academic medicine as they saw rewards more quickly available by pursuing a clinical service-based path. The noble Lord, Lord Chan, made that point. I assure noble Lords that part of our response to the Follet review is to look at the recognition available to clinical academics through the new consultant reward scheme. Outstanding contributions by clinical academics and research workers will be recognised within the new schemes. There is clearly a need to increase rewards for service achievement without diminishing the recognition of university and MRC based consultants. That review should be completed in the spring and we want to see coming through from that the potential to reward academic excellence of clinical teachers.

My noble friends Lord Turnberg and Lady Warwick asked about liaison between my department, DIES and Universities UK. We have received proposals from Universities UK and the chairs and chief executives of teaching hospitals. I assure the House that my right honourable friend Mr John Hutton will be listening carefully to those proposals. We certainly accept the need for close collaboration.

The clock ticks away and I shall conclude my remarks by saying how confident I am that the NHS is up to the tough challenges that it faces. I am sure that we need good quality teaching and research to help us to do that. The NHS is one of our finest assets which we must support and cherish. We are determined to do so.

8.38 p.m.

Lord Walton of Detchant

My Lords, we have had a fascinating and, at times, outstanding debate. I must say how grateful I am to all noble Lords who have contributed to it and who have made so many important and valid points. In particular, I echo the remarks of congratulation made to my noble friend Lady Greenfield on her electrifying, inspiring, lucid and outstanding maiden speech. I trust that we shall hear a great deal more from her in the future.

I should love to comment on every contribution that has been made in the debate, but I am conscious of the fact that not very long ago I was gently but firmly rebuked by the Chief Whip for spending too long on my closing remarks at the end of such a debate.

The noble Lord, Lord Turnberg, talked about the 10 key principles, which, in this collaboration between Universities UK and the NHS, must be maintained. The noble Lord, Lord Colwyn, referred to integrated medicine; the noble Baroness, Lady Northover, spoke about the importance of epidemiological research; the noble Baroness, Lady Greengross, talked about the crucial importance of examining the problems of an ageing population; and the right reverend Prelate the Bishop of St Albans highlighted the crucial importance of a multi-faith society, the hospice movement and palliative care.

As one would expect, my noble friend Lord Rix talked about the importance of training in the care of patients with learning disabilities. The noble Baroness, Lady Warwick, spoke about widening participation in medical education, while my noble friend Lord Patel referred to the important role played by doctors trained overseas. I hope that the Minister will take note of one matter of importance arising from his comments and those of my noble friend Lady Masham. The GMC is most anxious to introduce a single form of registration for all overseas doctors. The present process of registration creates barriers to many doctors, for example, refugees who come to the UK, as my noble friend Lord Chan said. I hope that that will be examined very carefully.

The right reverend Prelate the Bishop of Portsmouth, in one telling phrase, said that there was a narrow gap between aspiration and reality of which we must be very well aware. The noble Lord, Lord Rea, referred to primary care and the crucial importance of increasing the number of general practitioners, while my noble friend Lady McFarlane of Llandaff spoke very forcibly and effectively about research in nursing.

I am very grateful for the support that I have received in this debate from the noble Lord, Lord Clement-Jones. He referred to many issues, for example bed blocking, the importance of community hospitals and residential care beds. The noble Earl, Lord Howe, stressed the need for the NHS Plan and targets to take fully into account the crucial importance of clinical academic medicine and research in the university/NHS interface.

In his gracious and courteous response, the Minister carried his bruises manfully. He referred to international comparisons. There are many problems in healthcare systems across the world. If one talks to people in France, there are very few in that situation. The French healthcare system is very properly regarded as an outstanding example. Obviously, it costs very much more than the present provision in the UK. I was glad to hear the noble Lord say what he hoped to do about removal of the culture of blame and increasing not only bed capacity but the number of health service staff under an ambitious programme. I also appreciate his comments on resources and hypothecated taxation.

The Deputy Speaker (Baroness Hooper)

My Lords, I regret that the time allotted to this debate has now elapsed. Does the noble Lord wish to withdraw his Motion?

Lord Walton of Detchant

My Lords, I simply suggest to the noble Lord that if he did not understand the briefing from the Treasury he should try a little harder in future and proceed with the implementation of the Saville and Follett reports, which he so wisely commended, through the Academy of Medical Sciences. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.