HL Deb 18 March 2002 vol 632 cc1101-23

3.8 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath)

My Lords, I beg to move that the House do now resolve itself into Committee on this Bill.

Moved, That the House do now resolve itself into Committee.—(Lord Hunt of Kings Heath.)

On Question, Motion agreed to.

House in Committee accordingly.

[THE CHAIRMAN OF COMMITTEES in the Chair.]

Clause 2 [Primary Care Trusts]:

Baroness Noakes

moved Amendment No. 36: Page 3, line 5, leave out "It is" and insert "From 1st April 2003, it shall be The noble Baroness said: In moving the amendment, I shall speak also to Amendment No. 52. Both amendments concern the readiness of primary care trusts for the responsibilities envisaged for them in the Bill.

Amendment No. 36 is a simple one. It defers the responsibility of the Secretary of State under Clause 2 to create PCTs covering the whole of England until 1st April, 2003. The Government's current intention is to ensure that all PCTs are in place by this October. Many of them will, in fact, exist by this April, only a couple of weeks from now.

The Minister may well say that, as most PCTs will exist legally next month, the amendment is of no practical effect. However, there may be a small number of PCGs that will not have completed the transition to PCT status next month. I remind the Minister that his predecessor, the noble Baroness, Lady Hayman, assured the House that no PCTs would be imposed and that progression to trust status would be, driven locally, based on local views".—[Official Report, 25/2/99; col. 1268] We know that most of the conversions have not been made in that way. They have been driven by the centre, with a fig-leaf of local involvement.

Will any PCGs not have been converted to PCT status on a so-called voluntary basis by the beginning of April 2002? If so, will the Minister say how many, and where they are located? Will conversion to PCT status be enforced under this Bill, if it becomes law, even if local views—including, importantly, the views of local health professionals—are against it? Will he say whether enforced conversion represents an adequate foundation for a PCT to take on the major new functions envisaged in the Bill?

We on these Benches do not agree with the policy of forced conversion of PCGs to PCTs but we recognise that the Secretary of State is hell-bent on reconfiguring the NHS to his own design. Amendment No. 36 at least seeks to provide a more dignified timetable to allow the hard-pressed NHS to adapt.

Amendment No. 52 is more complex and, in practical terms, more important. It requires the Commission for Health Improvement to investigate the preparedness of PCTs, both before a PCG becomes a PCT and, importantly, before the PCTs are given the new functions envisaged for them in the Bill. If in either event CHI believes that a PCG or a PCT is not ready, it must make a special report which would defer the creation of the PCT or the transfer of functions for one year. In that way, even if there are no PCTs still to be created when the Bill becomes law, the amendment would require a report from CHI on all PCTs' readiness to receive their new functions.

This will be particularly important given the continuing concerns about the ability of PCTs to cope. I am sure that the Minister has listened to the concerns of organisations such as the British Medical Association as to whether, for example, the necessary clinical and managerial staff have been recruited for the role envisaged for future PCTs. I am sure that he will also be aware of the King's Fund tracker survey last year which reported many problems in commissioning, in health improvement and in partnership working, as well as concerns about managerial capacity and information deficiencies.

I am sure that the Minister is aware of the findings of district audit during its visits to PCGs and PCTs during 2001. Unsurprisingly, it found a marked variation in the degree to which those bodies were prepared for their new roles. It found specific risk areas in corporate governance, in information management, in partnerships, in commissioning, in control of prescribing costs and in arrangements for personal medical services.

The Minister may also have read an article in the Health Service Journal last week about a survey of primary care groups and primary care trusts in the south-western region. That found that many were still relying heavily on their health authority for commissioning. It concluded that the proposal to allocate 75 per cent of NHS funds to PCTs by 2004 will be unrealistic in some areas.

Can the Minister say whether the 300 or so PCTs that will be operational next month currently have a chief executive who has the competencies required for the new PCT responsibilities and an appropriately qualified finance director who will be able to cope with the new financial requirements involving 75 per cent of total NHS spending? In this connection, the King's Fund tracker survey found last year that one in seven had no finance staff at all. A cursory glance at the recruitment pages of the Health Service Journal will show that many, many posts remain to be filled.

Will the PCTs have an appropriately qualified public health specialist capable of pursuing the public health agenda that the Government envisage for PCTs, including the development and delivery of health improvement plans? Will they have appropriately qualified staff to handle the whole range of functions, including, most importantly, commissioning and the new revalidation and regulatory requirements in relation to primary care? Will they have adequate information systems? And last but not least, will they have adequate budgets to pay for all of this? These requirements are not in the "nice to have" category; they are essential if the planned additional functions are to be delegated to PCTs.

Does the Minister accept that there are major gaps in readiness among PCTs—gaps so great that it is unrealistic to think of a commencement date of October this year? If he does accept that there are gaps, what do the Government intend to do about them?

We on these Benches are profoundly concerned about the preparedness of PCTs, on whose shoulders so much of the burden of delivering the Government's aspirations for the NHS will rest. That is why we believe that the implementation of the new PCT functions should not take place until there has been an independent examination by experts. The Commission for Health Improvement seems to fit that Bill but an alternative could be to use the Audit Commission, which is even more independent.

We urge caution until it is clear that the requisite capabilities demonstrably exist. It may well he that some PCTs are, in the Government's view, ready to proceed, but I hope that the Minister will not claim that that is the position of all PCTs because all of the available evidence is against that. If the Government insist that the change must be on a 100 per cent basis rather than a more cautious, phased approach, we believe that the pace of the slowest must prevail. Will the Government now consider a phased approach? I beg to move.

3.15 p.m.

Lord Clement-Jones

We on these Benches support the two amendments, particularly Amendment No. 52, to which I have put my name. As the Minister knows, in an ideal world we would prefer a scheme whereby, as agreed under the Health Act 1999, health authorities would determine the point where PCGs had enough capacity to become PCTs. It would be a local decision and the duties would be assigned to PCTs according to their capacity at the time. Under the Bill, there will be an almost compulsory changeover to PCT status and then an assignment of duties to those PCTs in a completely nondiscriminating way in terms of whether or not they have the resources and the capacity to take them on.

The Minister will he well aware that there is considerable doubt and uncertainty as to whether PCTs across the board will be in a position to assume those roles and responsibilities. It is particularly notable how common that view is in the area of commissioning. Later this week, seven all-party groups will gather to talk about this issue—the All-Party Parliamentary Groups on AIDS, on Cancer, on Health, on Maternity, on Men's Health, on Mental Health and on Primary Care and Public Health. A fairly considerable degree of concern is being expressed by all those involved in those all-party groups. The Minister would have to be insensitive not to understand that there is great concern about the capacity of PCTs in these circumstances.

We on these Benches agree with the BM A that PCTs are new organisations and the demands being placed on them by the Bill may be beyond their existing capacity. Indeed, as the noble Baroness, Lady Noakes, pointed out, the reorganisation is virtually there in advance of the Bill. Whether or not they have the capacity and resources, the Secretary of State has, in effect, anticipated the outcome of the Bill. He has shown a degree of confidence that Ministers do not normally possess.

As the noble Baroness, Lady Noakes, explained, PCTs are already experiencing difficulties in recruiting clinical and managerial staff who are able and willing to participate in the roles to which they will be assigned. It has been explained in the Commons that PCTs will be up and running by October this year or next spring, but even that date is ambitious given that there are many primary care groups which were insufficiently prepared in the first place for the move to PCT status.

PCTs will be responsible for assessing the health needs of their local communities and for preparing plans for health improvement, and a strengthened public health function will be needed for PCTs to provide this needs assessment function. As the Minister is aware, the public health function is an area where there is grave uncertainty about whether PCTs will have the capacity, resources or expertise to handle their new functions.

In addition to the public health function, the Government want PCTs to be the lead NHS organisation in joint working with local authorities and others as part of local strategic partnerships. Together with the BMA, we are concerned that while advances in health may not be related to the healthcare system, the primary responsibility of PCTs must be to provide a proper and adequate healthcare service. The emphasis of PCT activities must be on that core activity. But what we now see happening is that the Government are loading them with other functions which may mean that those core functions are not going to be properly carried out.

There is the national PCT development programme. I should like the Minister to give an absolute assurance that PCTs will be in a position to carry out their functions and that they will have the resources and the expertise. That requires a considerable degree of confidence from the Minister. I very much look forward to hearing what he has to say.

Baroness Carnegy of Lour

When the Minister replies, will he specifically answer the question of my noble friend Lord Howe? Can he assure the Committee that each primary care trust will have a competent chief executive in post and a competent finance director, somebody who is a specialist in public health and also other professionals who are able to deal with the various functions? The Committee needs a precise answer to that question because it is quite clear to anybody. whether they know about the detail of the trust functions or not, that without such people the changeover should not be made.

Lord Hunt of Kings Heath

I find myself somewhat disappointed by the tone of the remarks made in this debate so far about primary care trusts. In our very enjoyable debates on Clause 1 for the whole of last Thursday, the theme of the criticism of the Government was that we were adopting an over-centralist approach. Before us this afternoon there is evidence of the Government's decentralist approach and our aim to ensure that primary care trusts decision-making is as close as possible to GPs, primary care and the patient. Here we come forward with exciting ideas to get decision-making down to that level and the reaction of Members of the Committee who have spoken is shock, horror and, "You can't do this. We are very worried".

I make no apologies for being an absolute enthusiast for primary care trusts. Of course, I accept that there are tremendous challenges for them to take on and that there are those who are expressing some uncertainty about the ability of PCTs to do that. In the main they are not primary care trust themselves, but various pressure and interest groups which normally seek to influence the Government to take a highly centralist approach and wish the Government to continue to do so.

I say right at the outset that my experience in meeting primary care trusts and talking to general practitioners and the staff involved leads me to believe that they are very well able to take on the extra responsibility which they have been given. It is worth remarking that the first primary care trusts were established on 1st April 2000. Subsequent waves of primary care trusts have been established. In April 2001 we had 164 primary care trusts delivering healthcare to 47.7 per cent of the population.

The fact is that there is a great deal of enthusiasm out there for becoming primary care trusts and that is why we have received over 150 proposals from primary care groups and others who wish to become operational on 1st April 2002.

As regards the question asked by the noble Baroness, Lady Noakes, at present it is anticipated that only one primary care group will remain as at 1st April 2002. From that date we expect that there will be 303 operational primary care trusts. The one primary care group which we believe will remain at 1st April 2002 is Braintree which proposes to become a care trust from October 2002. There is one other primary care group, Crosby and Maghull, which is part of proposals to create a South Sefton primary care trust. That is currently subject to a submission to Ministers. If that were not to approved it would become a subcommittee of Bootle and Litherland primary care trust. Therefore, there would be two primary care groups left as at April 2002.

I completely deny that primary care groups have been dragooned into becoming primary care trusts. I have visited any number of such groups and trusts over the past few months. I am absolutely convinced that there is enthusiasm for getting on with the task and being given the enormous responsibility that they have. I am sure that primary care trusts will enable this crucial inter-relationship between the decisions of GPs and primary care to be pulled together in the work they will do on commissioning, which I am convinced will lead to a much better balance of services between primary care, secondary and tertiary care.

To suggest that those primary care trusts are incapable of managing these changes underestimates enormously the calibre of managers, primary care leaders and clinicians within the National Health Service. Already within PCTs which have been established we are seeing better support practice, better support to individual clinicians, better integrated and effective services and better access and design.

As the noble Lord, Lord Clement-Jones, has suggested, we have established a very good development programme to help primary care trusts prepare for operation. They include a co-ordinated development programme, a comprehensive self-assessment toolkit, an integrated whole systems package of development for each strategic health authority community and a robust infrastructure for all key stakeholders to have appropriate influence and to ensure that PCTs are equipped to deliver on the Government's objectives.

At local level, primary care trusts are being encouraged to develop and work collaboratively, to pool knowledge and to share capacity and expertise. I make no apology for that. For some particular functions primary care trusts will need to work together with others. But that does not detract at all from the individual ability of each primary care trust to work effectively. No one has ever suggested that each primary care trust would be totally self-sufficient. But I have no doubt whatever that co-operative arrangements which we determine locally will work effectively.

I was asked about the position of executive appointments. My understanding is that as of 11th March, chief executive appointments had been made in all except six primary care trusts. Clearly, they are crucial appointments. Once the chief executive has been appointed it will then be possible to get on with the appointment of other senior officers. No one could say that as at 1st April every primary care trust will have every senior officer position filled. However, I expect the NHS to have the arrangements in place to ensure a seamless process of transition of responsibility from health authorities and primary care trusts and that health authorities will support primary care trusts to ensure that there are no particular gaps.

Having said that, I turn to Amendment No. 52. It would require the Commission for Health Improvement to investigate whether primary care groups are properly prepared to become primary care trusts and whether they are ready to take on functions under this Bill. While I understand why the noble Baroness, Lady Noakes, makes this proposal, I do not believe that it is a proper function for the commission. CHI's responsibilities are quite specific. It may already carry out investigations into the management, provision or quality of healthcare, for which primary care trusts have responsibility under the Health Act 1999. Under this Bill we are extending the responsibility of CHI, particularly to carry out general reviews of any aspect of NHS services.

The independent review of services by the CHI is of a different order from that proposed in the new clause. It is not appropriate for the CHI to make the decisions envisaged in the new clause. The decision on whether a primary care group should become a primary care trust or whether a primary care trust should take on functions is surely for the Secretary of State to make. In making that decision, the Secretary of State needs to be satisfied in four key areas: the benefits of what will be achieved, the degree of support for the proposal, the fitness of the proposed organisation to deliver and the impact on other organisations.

Having been involved in approving a number of applications for organisations to become primary care trusts, I can confirm that the decision is taken only after the fullest consideration. Careful analysis is undertaken and Ministers ensure that the key questions that need to be asked are posed. We have to be satisfied that the proposed primary care trust can take on the responsibilities that it is to be given.

I understand why questions have been asked about the preparedness of primary care trusts. They are being given an enormous responsibility. However, I am confident that they can take on that role. I have been impressed in my visits to primary care trusts. They do not need delay and uncertainty; they need to press on. I am confident that they can do so.

3.30 p.m.

Baroness Noakes

I thank the Minister for that response, which was not a big surprise. We on these Benches are not against the proposals to devolve functions to primary care trusts; we are against the premature delegation of functions and transfer of responsibilities before those trusts are ready. That was the purpose of my questions to the Minister.

The Minister has said that he has met a lot of enthusiasts. That often happens to Ministers. They do not necessarily meet a representative selection of opinion in the NHS. I am afraid that that is a fact of life.

Lord Hunt of Kings Heath

Health Ministers meet all shades of opinion. I assure the noble Baroness that I have met health authorities, in particular, that have expressed concerns about the transition of power to primary care trusts. However, there is self-interest in some of those concerns. My whole experience of the NHS is that at the end of the day it always rises to the challenge.

Baroness Noakes

I do not doubt the sincerity of the Minister's views, although he has taken an unnecessary swipe at those organisations that have reported lack of preparedness. One would not suspect the King's Fund or district auditors of having a particular agenda.

I asked the Minister whether each of the 300 or so bodies would have a chief executive w ho had the competencies for new PCT status. He replied that there would be a chief executive in all but six. Will they all be chief executives selected for the competencies of the new PCTs, or will they be chief executives who were in post under the old arrangements, who were not expected to have the competencies of the new roles of PCTs? I understand that there has had to be a reappraisal of those already in post to see whether they are capable of undertaking the role for the new PCTs. However, that deals only with chief executives. I understood the Minister to say that we would then move on to other posts. I asked about qualified finance directors, public health specialists and the staff who will handle functions such as commissioning, as well as the underpinning requirements of money and information systems. I must press the Minister on what progress has been made on those posts. It is all very well to say that chief executives will come in and see to the rest, but there is an awful lot to do if all those posts are not in place or substantially in place by now. Perhaps he will comment on that.

Lord Hunt of Kings Heath

It is difficult for me w say the extent to which each of the 303 primary care trusts has filled each position. I can make two specific points. The chief executives, who will be in place in all but six primary care trusts, will be a combination of those who were already in post in the existing primary care trusts and chief executives who have been appointed as a result of the new primary care trusts coming into being on 1st April.

I certainly accept that we now envisage PCTs taking on a great deal of responsibility that might not have been envisaged by some primary care trusts when they appointed their chief executives. It will be for each primary care trust to consider those responsibilities and assess the strength and calibre of its existing management team. Equally, the development programme that we have put in place will enable the NHS to give support and encouragement to existing post holders as well as new post holders.

The chief executive is the key appointment to be made for primary care trusts that come ini o being on I st April. Once the chief executives are in place in the new organisations, they can work with the chairs and the non-executives to get on with filling the other senior positions. We hope that that will be done as quickly as possible. My point in my original response to the noble Baroness was that I expect there to be interim arrangements in place to ensure that primary care trusts are ready to go live on 1st April. That is one aspect of the responsibilities of health authorities in providing the support required by PCTs in the interim period.

Baroness Noakes

I thank the Minister for that. Who determines whether a PCT is ready? The Minister said that it was for PCTs to consider whether their chief executives were strong enough for the roles that they would have to carry out. Is he saying that at the time that the Secretary of State makes the delegation of functions to primary care trusts, he will not have carefully considered the preparedness of the individual trusts? The Minister explained the process and the matters that were considered in the creation of PCTs. I am sure that he accepts that there will be a lot of gaps in the capabilities needed on day one, when the functions are delegated. I am very unclear as to what information flows will be coming to the department before the button is pressed on the responsibilities falling on the shoulders of PCTs. What processes does the department have—or is it expecting to leave the matter entirely to the PCTs?

Lord Hunt of Kings Heath

In the assessment that is made in agreeing to the establishment of new primary care trusts, the department takes a number of factors into account before Ministers are asked to make a decision. One of the criteria for making a decision is whether there is sufficient evidence to indicate that the proposed primary care trust is fit for the purpose. That includes consideration of whether the application identifies effective governing and leadership arrangements and whether those arrangements will deliver the local primary care trust's vision.

The noble Baroness also asked about existing primary care trusts. That is a matter for local decision. If a primary care trust is taking on more responsibilities, the board of that trust needs to see whether the management arrangements and the calibre of its leadership cadre are up to new responsibilities. The same would apply to any other NHS organisation.

In addition, we debated the role of strategic health authorities last Thursday. It is also the case that strategic health authorities will want to ensure that leadership within primary care trusts is effective, and that is also part of its performance management function. I should be surprised if the noble Baroness were suggesting that the Secretary of State should adopt a highly centralist approach to judging the capability and performance of each primary care trust chief executive. We have in place a sufficient process to ensure that judgments can be made about leadership capability as well as development programmes to help those leaders show just what they are capable of.

Baroness Carnegy of Lour

Before my noble friend continues—I apologise to her for confusing her with the noble Earl: I do not know why I did it, but I do know the difference—what the Minister is saying will not do. I am very shocked at this, as I am sure others are. In order for the Government to be able to say that they are decentralising and how enthusiastic they are about it—some of us are doubtful about the extent of this decentralization—they are prepared to let bodies take on enormous responsibilities when their chief executives may or may not continue at the moment. It is impossible to say when the finance director will take over, because he does not at present exist in a number of trusts. The Health Service cannot be asked to do that just to get political will across to the nation. The Government should ask themselves whether we need to hurry so much. People will accept a short delay until the whole matter is put in order. They are making a great mistake, and I should have thought that politically it will be disastrous for the future.

Lord Hunt of Kings Heath

If the noble Baroness were to ask primary care trusts whether they would like another year to potter around trying to reach the state of preparedness that she suggests they have not yet reached, they would say that that would be the worst possible thing that could happen to them. They know that they have to take on the challenge of major responsibilities, but they want to get on with the job.

The assessment criteria under which we have judged the effectiveness of primary care trusts to take on their responsibilities, combined with a development programme and the overseeing role of health authorities to ensure that things are done correctly, that there are no gaps, that the infrastructure is in place, give me confidence that the NHS is well able to take on the new structure from 1st April this year, and I believe that it should be allowed to get on with it.

Baroness Noakes

Having listened to what the Minister has said, I am left profoundly unconvinced. We are told that an assessment is made of leadership. That is all very well, but leadership does not necessarily deliver a fully functioning organisation on the ground. There is a big gap between an assessment of leadership over the past few months and knowing, when the Secretary of State comes to make the delegation, that these organisations are ready and able to take on those functions. I do not believe that it is centralist to have a proper assessment of the new organisations. The new organisations may be jumping up and down, saying that they are ready, but that does not mean that they are ready. That is why Amendment No. 52 was designed to put an independent assessment into the process.

I had expected the Minister to inform me of the comprehensive and robust procedures that the Department of Health will adopt to ensure that PCTs are not given their new functions unless they are sure that they are completely ready. When referring to this amendment, the Minister said that he thought the CHI was not up to the job, which I found rather surprising—

Lord Hunt of Kings Heath

I am grateful to the noble Baroness for giving way. I hesitated to read out to the Committee the criteria for assessment because I thought it would extend our debate for many more minutes than that. Perhaps it would help the noble Baroness if I were to write to her, setting out the criteria for assessment. If she sees the extent and range of those criteria, she may feel somewhat reassured.

3.45 p.m.

Baroness Noakes

I should be most grateful to receive that information. However, at this stage I remain sceptical about whether or not anything that has been said today has met the point of whether or not, first, PCTs are currently ready for their new functions and, secondly and perhaps more importantly, anyone in the Department of Health will know in October, or whenever the new functions are delegated, that that is the case. I am sure that we shall want to return to that matter at a later stage. Meanwhile, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

[Amendments Nos. 37 to 40 not moved.]

Clause 2 agreed to.

Schedule 2 agreed to.

Baroness Northover

moved Amendment No. 41: After Clause 2, insert the following new clause "DUTY OF PRIMARY CARE TRUSTS REGARDING TEACHING AND RESEARCH Primary Care Trusts shall have a duty to foster and safeguard teaching and research. The noble Baroness said: Amendment No. 41 requires primary care trusts to foster and safeguard teaching and research. This amendment should hardly be necessary. It should, of course, be a "given" that teaching and research should be integral to the Health Service at every level. However, with the pressure to meet targets, deadlines and budgets, it has become clear that teaching and research can too often be squeezed out. Therefore, only by enshrining in the Bill a duty to foster research and teaching will it be protected. The NHS has an outstanding record in both, yet we know that both are currently under threat.

The noble Lord will doubtless recall that on 21st November 2001 the noble Lord, Lord Walton of Detchant, introduced an important debate on the issues now confronting medical teaching and research. That debate highlighted most acutely the problems facing those areas. If we are to have joined-up thinking, we need to remember those problems as we consider this Bill. As we heard then, the requirement to teach students, treat patients and conduct research means that clinical teachers have impossible demands made on their time. For a number of years the recruitment and retention of clinical academics has been a major problem.

According to a recent BMA survey, the heavy pressure of NHS work leaves little time for vital research. Comments in the survey include: The NHS has turned its back on research", and, the clinical work runs away with the show". Until the serious problem of recruitment and retention of medical teachers is addressed, the Government's plan to educate and train extra doctors for the NHS will not succeed. But that is not just a problem at secondary or tertiary level. The ethos of teaching and research must run right through the NHS. The public has much greater contact with primary care than with secondary care. There is a role for the PCTs in a wider teaching brief—teaching public awareness. PCTs should have a key role in preventive care. They should also play a part in promoting research among the public, helping to persuade people that it is in the wider public interest to participate in research and trials. If they do not take such a lead, distrust of research may well become unstoppable.

In teaching future doctors and other health professionals, PCTs clearly have a vital role to play. Those working in this sector must not be so overburdened that they cannot do that. Therefore, it has to be clear to those in administration, government and the Department of Health that they need to look to the wider picture. Much research would be better carried out at primary level if only the infrastructure were there. For example, in programmes such as screening, GPs often play the key role in compliance—hence those instances in which letters sent to patients supposedly from the GP are in reality drafted and sent by the hospital co-ordinating the trial. The poor GP has no time to play much of an active part. That is surely in no-one's interest.

If we are to see a shift of emphasis within the National Health Service to PCTs, it is vital that their aims should be clear. Teaching and research should be integral to those aims. Given that PCTs are still in their infancy, it is important that this is written into their brief. I would like to be sure that it is and I would like to know how we can be sure that research and teaching will not be squeezed out as currently happens. I beg to move.

Lord Walton of Detchant

I am very grateful to the noble Baroness and to the noble Lord, Lord Clement-Jones, for tabling this amendment to which I give my warm support. I do not wish to go over the ground covered in the debate last December, to which the noble Baroness referred. However, from the inception of the National Health Service, there has been an agreement, never fully enforced, that clinical academics, appointed and paid by the universities, should be able to devote six sessions weekly—six half days a week—to clinical service in the National Health Service. Five sessions should be devoted to teaching and research. Under the old knock-for-knock agreement, that was co he compensated for by the teaching given by National Health Service consultants, who were not employed by the universities. That particular agreement has been breached to a remarkable extent.

The BMA survey, to which the noble Baroness referred, has demonstrated that there is a massive recruitment problem of clinical academics. Over 70 chairs and more than 200 clinical lectureships or senior lectureships are vacant for lack of suitable applicants. At a time when the Government are committed to training 6,000 medical students annually, rather than the present 4,200, it is absolutely vital that this sector should be expanded and increased and that the time available for teaching and research should be preserved.

The same survey found that practically no clinical academic was spending less than 40 hours a week in service commitments to the National Health Service. Some were spending as much as 48 to 50 hours a week, leaving little or no time available for teaching and research. This is a huge disincentive to recruitment of clinical academics. In many instances, it has been due to managerial pressure on clinical academics to see ever more patients and help fulfil the Government's commitment to bring down waiting lists for outpatient appointments and inpatient care. Therefore, it is absolutely vital that a clause with this kind of intent should be included on the face of the Bill.

Baroness Pitkeathley

I understand that some primary care trusts have teaching responsibilities which would address some of the concerns raised by Members of the Committee who have already spoken. When my noble friend the Minister replies, he may be able to give figures.

Baroness Cumberlege

I believe that to be the case. The Minister will tell us the definitive answer. As I understand it, there are designated primary care trusts that are specific for teaching. The amendment of the noble Baroness, Lady Northover, is to try and get teaching throughout the whole of the National Health Service. I very much support that.

In Committee, probing amendments are sometimes put down. Other amendments can be teasing or have a wider aim, but some are very serious. This is a serious amendment to which I give my full support.

I chair the medical school council of St. George's Hospital. Much of the research in primary care there is conducted by GPs. Despite the pressures, they do carry out research. The British Medical Journal devotes a complete section to research carried out by general practitioners. I hope that that continues.

I should like to look at undergraduate education and how that currently works. If we are to do ever more in the community, it is essential that the people who provide that service have teaching built in at an early stage. Fifteen to 30 per cent of the experience of undergraduates is in primary care. Around 203 practices are involved. It is a huge commitment from general practice.

The graduate entry programme that St. George's undertakes is for graduates with any degree—50 per cent have a science degree, 50 per cent other degrees. This is a marvellously innovative way of educating doctors for the future. We shall have better doctors as a result. In the first week, their entire experience is in general practice. That is important if we are to reshape the way we give clinical care in the future.

In both adult and paediatric nursing courses, 10 to 25 per cent of time is spent in placements. In mental health, it is 20 to 35 per cent. This will be an enormous commitment on behalf of primary care and community services. Placements, teaching and research are all going on in primary care.

There are enormous pressures on the National Health Service. The spirit of this amendment is absolutely right. We are not asking for rights; we are asking for information and discussion. We are asking for an awareness of the responsibilities needed in primary care if we are to deliver this new curriculum.

A deep concern of researchers is that if PCTs decide they wish to change their placement of future contracts, it could derail an entire research project. That could have a disastrous impact on new research that is coming forward. It is essential that PCTs, in their commissioning, recognise what those contracts will do.

We know that the Minister has exemplary skills in avoiding amendments and skirting round them. I hope that he will reconsider this amendment and make it a duty of primary care trusts to have regard to teaching and research.

Baroness Finlay of Llandaff

I strongly support the amendment. I declare my interest as a vice-dean of an undergraduate medical school. The noble Lord, Lord Walton of Detchant and the noble Baroness, Lady Cumberlege, have outlined many issues. I shall not repeat them.

It is crucial that we look at the benefits of teaching and research from direct patient outcome. There is good evidence that all patients entered into clinical trials, even those on the placebo arm, do better than patients not entered into trials at all. There is good evidence that standards of clinical care in teaching practices rise—even in those practices which might be considered to be providing care at a slightly suboptimal level. The standard of such practices can be pulled up by their becoming involved in teaching. They become involved in reflective practice; they audit what they are doing. A questioning student will often provide as much teaching as a so-called teacher.

Duties of a doctor, a GMC document, outlines teaching and research as a core duty of every doctor; but such duties do not exist for managers. There is presently no obligation on managers to ensure that teaching and research take place in the area over which they have responsibility. Time needs to be allocated to clinicians; but they also need rooms, facilities, computers, and a library online. Those who teach and those who receive teaching need to be able to access simple things such as paper, photocopying and secretarial support. Those must be built in to the ethos of the system that is delivered.

Research evidence is needed on the patterns of healthcare delivery. The Health Services Management Centre considers that there is no research evidence to support the changes currently proposed in the reorganisation of the NHS. We are desperate for good research evidence for different systems of management within the NHS, quite apart from clinical research and clinical teaching.

If we are to recruit healthcare professionals into primary care in the future—and there is present evidence that people are walking away from primary care—we must ensure that the teaching and research environment is valued and that that becomes a statutory duty of managers.

4 p.m.

Baroness Emerton

I support the comments of the noble Baroness, Lady Finlay. I suggest that we also extend the requirement to other healthcare professionals. Teaching in the community is much more difficult than it is within the environs of a hospital. Clinical supervision is yet another difficulty that is experienced in the community. It is important to ensure that teaching and research is included for all healthcare professionals in the primary healthcare field, particularly when new patterns of care are being experienced. I refer to hospitals such as the one near my home, where there is a multi-professional team approach. That is where research comes in and can prove that this is essential. I support the amendment.

Earl Howe

I, too, am pleased that the noble Baroness has tabled the amendment. I fully share the concern that underlies it. I shall not repeat what has been said, except to underline one of the main worries that have emerged from this short debate. The difficulties currently being experienced in medical teaching and research as a result of the acute shortage of clinical academics are of the highest importance for the health service. So important are they, that we must not for one minute allow ourselves to lose sight of them amidst the upheaval in the NHS that is heralded by the Bill.

PCTs are new creatures. Even those which exist have not been going very long. Others have yet to come into being. Much of their expanded remit is new territory for them. Many of the staff will be new, and systems will be bedding down. While I worry about the burdens of acclimatisation that the Government are imposing on NHS staff, I worry also that, without great care being taken, functions that are not central to the delivery of healthcare to local communities will simply fall out of view. The money will be directed to where it is most urgently needed.

No one is saying that PCTs should suddenly be granted a vastly enhanced role in the commissioning and delivery of medical teaching and research. That responsibility lies elsewhere. I dare say that the strategic health authorities will have a duty to oversee medical teaching and training at a local level. But it will be the PCTs, with 75 per cent of the NHS budget, that will have the financial muscle and will play a key role. There is a need to ensure that that element of the teaching and research budget currently being shouldered by health authorities and trusts and by general practice is not squeezed out by other, more immediate and visible pressures. Indeed, there is a need to ensure that it is valued. I particularly identified with the noble Baroness's remarks about maintaining the ethos associated with research and making sure that GPs and clinicians in the community are fully on board.

I hope that the Minister will be able to reassure the Committee and tell us that the Government have these concerns very much in mind. I hope that he will be able to explain how they are being addressed.

Lord Turnberg

I must apologise for entering the Chamber too late to hear the noble Baroness, Lady Northover, introduce her proposal. However, as an ex-dean of a medical school and as vice-president of the Academy of Medical Sciences, I am desperately keen to see research and teaching fostered and safeguarded. It is in desperate need of that. The Academy of Medical Sciences is about to produce a report which highlights many of the difficulties facing academic medicine, teaching and research. These activities are under great threat at a time when we are keen to enhance them.

The principle behind the amendment is entirely laudable—were it not for the fact that primary care trusts will have a big load on their shoulders. It is important that they are involved in research and teaching in the ways described. However, to expect them to have a prime responsibility in this area may be going a little far. This is not necessarily just a local problem; it is a matter of national importance. The responsibility for ensuring that research and teaching are fostered should lie not only with PCTs but also with strategic health authorities in particular, which will be in place in areas where there are medical schools and universities and will have an important role in encouraging relationships with the universities. To that end, I hope that when my noble friend responds he will consider how the functions of research and teaching can be encouraged, perhaps by members of the university and the medical school becoming members of strategic health authorities to ensure that there is a link at that level. This should foster what goes on at PCT level.

Although I like this idea, I am not sure that this amendment will meet the bill. Nevertheless, I hope that my noble friend the Minister will take it on board.

Lord Rea

As a former primary care physician, I strongly agree with the points made on all sides of the Committee. However, I am not absolutely sure that such an amendment is necessary on the face of the Bill or is the right way of doing things. I hope that my noble friend's response will reassure all Members of the Committee who have spoken as to the importance that the Government place on research and teaching in primary care.

Baroness Masham of Ilton

Drugs are one of the biggest items of cost in primary healthcare. Therefore, to find out which drugs are most effective, there must be research. The pharmaceutical industry needs that data. Primary healthcare is having more and more put on to it. It is vital that areas of the profession work together. Therefore, I support the spirit of the amendment.

Baroness Carnegy of Lour

In replying, will the Minister tell the Committee what the spread will be under the new arrangements of research ethics committees? Will there be an ethics committee in each strategic health authority which will look at research in the local area?

Lord Hunt of Kings Heath

This has been an extremely interesting debate, and one with which I have a great deal of sympathy. Clearly, it is very important that we have effective arrangements in place for teaching and research functions within the National Health Service. Indeed, I would argue that it has been one of the great strengths of the NHS since its foundation that we have built up such strong links. I also accept that there are concerns about the recruitment of clinical academics and more generally about the pressures on clinicians within our teaching hospitals in terms of the amount of time that they have for teaching and hard clinical practice.

The Department of Health is very much apprised of the challenges and issues that we face. Some months ago, the noble Lord, Lord Walton, introduced an interesting debate on those issues. At the time I talked about some of the proposals that the Government were taking forward, particularly in partnership with the Department for Education and Skills, such as the individual higher education institutes and the higher education funding councils. At a time when we see a massive expansion in the number of medical school places in our universities, it is important to ensure that we are able to attract clinical academics who can provide the kind of teaching and research that is evidently required. We must also ensure that the medical schools, in their expansion of places and the development of new medical schools, are able to attract people of the highest calibre. I assure noble Lords that it is in the interests of the National Health Service and the Government to ensure that we address some of the problems that noble Lords have raised in the debate.

Having said that, I am entirely sympathetic to the general comments made by noble Lords, although I am not sure that the amendments tabled by the noble Baroness are necessarily the right approach to this issue. The Secretary of State already has powers to support teaching research activities that have been delegated to health authorities and, through them, to primary care trusts. Primary care trusts also have their own directly conferred powers to conduct research and to make offices and facilities available to universities. By keeping that as a function of the Secretary of State, we are allowing maximum flexibility to involve all health service bodies

My noble friend Lord Turnberg raised a number of important issues. He asked whether a university representative would be appointed to a strategic health authority board. The Health Authorities (Membership and Procedure) Amendment (England) Regulations 2002 were laid before Parliament on 11th March to come into force on 1st April. They state that in relation to health authority membership, One of the non-officer members to he appointed to an Authority shall be a person who holds a post in an institution within the higher education sector which provides education enabling students to fulfil criteria necessary for". It then lists professions, including the medical profession, the dentistry profession, the pharmacy profession, the nurses and midwifery profession and professions covered by the Health Professions Council.

That appointment will be an extremely important one in terms of the role of the strategic health authority in ensuring that some of the issues raised by noble Lords are, in effect, carried out. I remind noble Lords that strategic health authorities will have the role of performance-managing primary care trusts and so they will be in a position to ensure that primary care trusts contribute what is necessary to enhance teaching and research within the National Health Service.

We have developed what we describe as work-force development confederations. Their responsibility within each local health community is to decide how money on education and training should be spent. Primary care trusts will be constituent members of those confederations and the performance of the confederations will be managed by strategic health authorities. As part of the strategic role of each strategic health authority, I see a particular responsibility for ensuring that the conditions are right for enhancing teaching and research.

The noble Baroness, Lady Finlay, pointed to the positive impact of teaching practices. I echo that. The experience of the NHS is that the teaching practices that are connected to university medical schools have an enormously positive role to play in the training of medical students and specialist registrars who are attracted to primary care. They also have a positive impact on the development of high quality practice within primary care.

In Birmingham the links between the medical schools and teaching practices in the inner city areas are seen as one positive way that we can overcome some of the recruitment and retention problems in inner city primary care practices. In the future we will want to enhance and to encourage that. I would expect primary care trusts themselves to see the value of much stronger links between constituent primary care practices within their primary care trusts and universities.

Part of the responsibility for ensuring the right conditions for teaching and research is having the right research governance framework so that research can be conducted properly. In March 2001 the Department of Health published a research governance framework that recommended framework agreements between organisations that collaborate on research work. The NHS Regional Research and Development Forum, the Medical Research Council and the Department of Health are co-ordinating discussions to develop a model framework agreement by April 2002.

It sets out that each primary care trust will have responsibilities related to research governance for research and development in primary, community and social care. By April 2003 there will be a national network of primary care trusts to act as host for shared research governance and management capacity.

Clearly, it is important that we are as encouraging as possible to research and to clinical trials. My work in the joint task force between the Government and the research-based pharmaceutical industry has identified a number of issues that need to be addressed to ensure that one has robust research governance, and that the arrangements whereby clinical trials and research can take place are as straightforward and as non-bureaucratic as possible. Within that I would expect primary care trusts to play their full part.

The noble Baroness, Lady Carnegy of Lour, asked me about research ethics committees. They will remain until October 2002 at health authority level and we are still discussing how, after that date, they can effectively be brought under primary care trust responsibility. A suggestion that may emerge is that one lead primary care trust within each strategic health authority area takes on a lead responsibility, but we are still working on those arrangements.

The noble Baroness, Lady Masham, asked me about drugs. Of course, we are keen to ensure that the most effective drugs are used within primary care. That is one reason that we have prescribing advisers who have been successful in advising individual. GPs on their prescribing responsibilities. We also set up the National Institute for Clinical Excellence to give advice on what are the most cost-effective and clinically-effective drug treatments.

My noble friend Lady Pitkeathley asked about the development of teaching primary care trusts. In March 2001 my right honourable friend the Prime Minister announced that £25 million over a three-year period had been made available to develop a number of teaching primary care trusts across the country. That is a very exciting development. Those teaching primary care trusts will provide teaching and clinical opportunities for primary and community care professionals to support and improve the delivery of services for the local population. Their importance relates not only to individual primary care trusts; they will also stress to primary care generally the importance with which we regard teaching and research.

4.15 p.m.

Lord Walton of Detchant

if the Minister ultimately feels unable to accept this amendment, is it possible that, with his characteristic ingenuity, he could at least find a way of including the words "teaching and research" somewhere in the Bill? It is remarkable that a Bill of this magnitude and scope does not even mention those particular words of great importance to the future of the NHS.

Lord Hunt of Kings Heath

I am not as yet convinced that the words "teaching and research" need to be included in the Bill, partly because the reference to teaching and research is already fully included in other NHS legislation. For example, Section 5(2)(d) of the National Health Service Act 1977 provides the Secretary of State with the power to conduct or assist others to conduct research into any matters relating to the causation, prevention, diagnosis or treatment of illness.

Under Paragraphs 14 and 15 of Part III of Schedule 5A to the 1977 Act, primary care trusts are empowered to conduct, commission or assist the conduct of research and to make officers and facilities available in connection with training by a university or any other body providing training in connection with the health service. Under Paragraph 11 of Schedule 2 to the National Health Service and Community Care Act 1990, an NHS trust may undertake and commission research and make available staff and facilities for research by other persons.

Under Section 51 of the 1977 Act, the Secretary of State has a duty to exercise his functions so as, to secure that there are made available such facilities as he considers are reasonably required by any university which has a medical or dental school, in connection with clinical teaching and with research connected with clinical medicine, or as the case may be, clinical dentistry". Paragraph 11 of Schedule 2 to the 1990 Act states: An NHS Trust may provide training for persons employed or likely to be employed by the trust or otherwise in the provision of services … and make facilities and staff available in connection with training by a university or any other body providing training in connection with the health service".

Earl Howe

I cannot help but notice that, in that very helpful list which the Minister has just react out, many of the powers, apart from those that he related to the Secretary of State, are permissive only. They are not duties. I think that that is the concern that has been expressed. There may be the power to do all these things at a local level, but will this function in practice be squeezed out?

Lord Hunt of Kings Heath

The short answer to that is no, because the NHS and the Government cannot allow teaching research to be squeezed out.

Baroness Finlay of Llandaff

I am grateful to the Minister for giving way, and I should like to build on the previous comment. As the dates of the legislation which the Minister cited demonstrate, the desire to incorporate teaching has existed for well over 10 years. A paper from Freeman & Sweeney is entitled, Why general practitioners do not implement evidence: qualitative study, and an article in this week's BMJ calls for primary care organisations to create learning environments that capitalise on the wealth of knowledge. I fear that, unless the Government seriously consider including these requirements in legislation, they will continue drifting on the matter as they seem to have done for many years.

Baroness Cumberlege

What is very good about this amendment is that it uses the words "a duty", and therefore imposes an obligation. I n his reply, the Minister seems to have rested his case on the fact that the strategic health authorities will do the monitoring. However, is that not trying to put right something once it has happened? It is very difficult to do that in research because research has to be continuous and, in research, one is working with a defined patient population. I think that, in research, the danger lies in the PCTs' contracting and commissioning work. In teaching, I think that the danger lies in the pressure on the service, in that, as I explained, so much of teaching today has to be done in primary care.

Lord Hunt of Kings Heath

I fully accept what the noble Baroness has just said. However, it does not seem to follow that simply including this amendment in the Bill would necessarily lead to any specific change.

The question surely is this. Is teaching research important to the National Health Service? If it is, how can we ensure that due recognition is given to that fact not only at government level but at the NHS local level? I believe that teaching research is critically important: it is important to the quality of services and to the quality of research in this country. Moreover, it is important not only to the National Health Service; it is important also to UK plc in terms of our science base and future investment in research and development. I do not believe that the House should have any doubt at all that the Government regard the proper support of teaching research as critically important. I am simply saying that amending the Bill as proposed would not be helpful when the powers that I have read out are clearly available for use by the NHS. I do not expect strategic health authorities to interfere and inhibit the role of primary care trusts.

Primary care trusts have a prime role to play in ensuring—first through the workforce confederations—that sufficient teaching places are commissioned and that the conditions are right for research and teaching. The point about the strategic health authorities is that they are there to check and to ensure that things are not going wrong. As I said last week in ourdebate on strategic health authorities, if there were a specific case in which an individual primary care trust was not prepared to play ball, we would have the lever of performance management as a means of intervening.

My general expectation, however, is that primary care trusts will wish to support teaching research. The impact of the increasing number of training practices has in itself had such a beneficial impact on the overall performance of primary care and the quality of services that I believe that a great swathe of primary care and primary care trusts will see the benefit of supporting teaching and research. As I said, the establishment of teaching primary care trusts is in itself a visible sign of primary care commitment to teaching and research.

I have no doubt that all the points raised by noble Lords are extremely important. They are important to the Government. We wish to ensure that effective teaching research does take place. However, I doubt whether the amendments in this group really would lead to a difference in approach or a real improvement in the way in which teaching research is dealt with. Although it is a major challenge for the NHS, it has to be dealt with effectively by means of the type of mechanism I have discussed.

Baroness Masham of Ikon

Before the Minister sits down, perhaps I may point out that Amendment No. 41 is not grouped with other amendments but stands on its own. Does it not emphasise the need to include research in the Bill. What harm could that do?

Lord Hunt of Kings Heath

The noble Baroness is quite right: the amendment is not grouped but separate. Surely there are three points here. First, even if that were in the Bill, it would have to be interpreted by the department in terms of its meaning for individual organisations. That is no different from the current position. Secondly, it would apply only to primary care trusts. Although one may wish to go down that path, I doubt that there is any specific reason to single out primary care trusts. Thirdly, as I have made clear, current NHS legislation already very comprehensively covers the issue of teaching and research.

Baroness Northover

I thank the Minister for his reply and noble Lords for their contribution to this mini-debate. I seem to have struck a chord. I may not have written this amendment quite as it should be. No doubt I shall have to revisit it, but revisit it we will need to do because there is clearly a lot of concern about this.

What has motivated me is what we have seen happen at secondary and tertiary levels in terms of teaching and research. They are not a key priority for those who are trying to fill financial black holes. The noble Earl, Lord Howe, hit the nail on the head. If this is a duty, then in a way that gives a power to those who are trying to ensure that teaching and research at PCT level is given its due emphasis. If it is not, then when the question is raised as to how resources are to be spent it will simply be pushed aside. I therefore disagree with what the Minister has said. There is a purpose in having something like this built, as a duty, into the list of priorities of PCTs.

I am very struck by what noble Lords have said about the situation at all levels of the health service: for example, the fact that we do not even have ethics committees in place. No decision has been made about that. Clearly there has been a decision within the Department of Health that it is not a key priority; that they need not address it yet; that other things have to happen first.

Lord Hunt of Kings Heath

I am most grateful to the noble Baroness for giving way. I thought that I had said that we have decided to keep the research ethics committees based at health authority level up to October this year. They will then be picked up by primary care trusts. We are now holding discussions on how best those arrangements might then be conducted at primary care trust level. I do not see how it follows that the Government regard it as an unimportant issue.

Baroness Northover

It seems to me that, if it were a high priority, and given that the PCT has to play such a key role in the health service so very soon, it would have been taken somewhat further forward.

Lord Hunt of Kings Heath

I am grateful to the noble Baroness, but I must confess that I find myself somewhat confused. Last Thursday the Government were accused by the Liberal Democrat Benches of taking a far too prescriptive, centralist approach; yet, in the debates this afternoon, I am being invited to take a centralist, prescriptive approach by those very same Benches. It would be interesting to know which hat the Liberal Democrat Benches are now wearing.

Baroness Northover

I have heard this argument before. What the Minister has said, however, is that he will be laying down guidelines from the department as to how PCTs should play their full part; that decisions should follow on from that. What he has not done, therefore, is to devolve this to local level. He has not set down the framework within which PCTs have then to carry forward that duty.

I would consider it appropriate that this should be part and parcel of drawing up the guidelines for PCTs. PCTs then have a duty to implement and carry that out; not the Department of Health, if they feel like it, advising that they might.

The very fact that extra money has gone to some PCTs in order to take this forward shows that the Government do not have the confidence that, without it, research and teaching would be taken forward. That seems to belie what the Minister has said about this happening automatically.

I agree, as I think everyone does, that teaching and research are vital for the NHS and that the future of the NHS depends upon them. Just wishing that to be the case, however, is surely not sufficient. More needs to be done to ensure that PCTs play their full part in this matter and that it is therefore given to them as a duty to carry this out, not simply as a power.

I have listened to what the Minister has said. I am sure that we can revisit this matter and we undoubtedly need to do so, in order to draw up something which would gain some consensus. At present, I beg leave to withdraw this amendment.

Amendment, by leave, withdrawn.

Lord Filkin

I beg to move that the House he now resumed.

Moved accordingly, and, on Question, Motion agreed to.

House resumed.