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Baroness Sharp of Guildford: My Lords, I also rise to support the amendment. As the noble Lord, Lord Walton of Detchant, and other noble Lords indicated, it is extremely important that we maintain the high quality of research and development in this area of expertise in the UK, where we have led for many years.

Given present scientific developments, there is an increasing lowering of boundaries between the life sciences, the biological sciences and the medical sciences. Although we have seen some diminution in the proportion of papers produced on the medical sciences, the UK is still highly ranked on the production of papers on biological sciences. We have recently seen an increase in the numbers of papers published in those areas. Nevertheless, the points made by noble Lords on all sides of the House are absolutely correct and we fully endorse them.

Lord Skelmersdale: My Lords, far be it from me to throw rocks into still waters and make them troubled, but I am rather troubled by this particular amendment of my noble friend. Of course, there is no doubt that both medical noble Lords who spoke on this issue in Committee are worried. They are right to be worried because the situation, as the noble Lord, Lord Walton, has just said, is, without a shadow of a doubt, deteriorating. That said, I believe that beggars--or perhaps cobblers--ought to stick to their lasts, which is why I only really welcome two-thirds of this amendment.

Primary healthcare trusts are, after all, going to be concerned with primary healthcare. Training, especially the postgraduate training of doctors into various disciplines, some of which are not truly recognised like stroke medicine or indeed the professions allied to

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medicine--PAMs, or whatever they are called; for example, the various therapists--needs extra input. We all know that there are not nearly enough of them. It is in those areas that the primary care trusts should get involved.

I take issue with the noble Lord, Lord Walton, in going on to expect the primary care trusts to expend money on research and development in the tertiary services. Tertiary services are equally in need of boosting, of extra funding and all the rest. The question is whether it should be done by the health trusts, by central government or some other organisation. I rather suspect that it would not be right for the primary care trusts to do it.

Baroness Masham of Ilton: My Lords, I add my support to the amendment, but I should like to ask the Minister if he can say who will fund the tertiary services. There seems to be concern about that. As other noble Lords have said, the quality of training spreads throughout the country. People who are trained in tertiary units move on. They get married and move down to the primary care services. Therefore, their expertise is spread around the country. The existence of units of excellence encourages nurses from all over the world to train in such places. The training of doctors, nurses and physiotherapists is vital when there is such a shortage.

Baroness Gardner of Parkes: My Lords, I did not understand the point made by my noble friend Lord Skelmersdale about tertiary services. I do not think that the amendment calls for GPs or primary care trusts to support research in tertiary services. It is more concerned with the referral of patients to the tertiary services and, because patients are referred to tertiary services, the tertiary services themselves will carry out the research. Can my noble friend confirm that the training will include newly qualified doctors who often undertake a period of primary care training in general practice? Are they included in the amendment?

Earl Howe: My Lords, with the leave of the House, although that area is important, it was not uppermost in my mind. I was seeking to focus on clinical academic medicine in the medical schools. I believe that that was the principal concern also of other noble Lords, including especially the noble Lord, Lord Walton of Detchant.

Baroness Gardner of Parkes: My Lords, I thank my noble friend for that clarification and strongly support the amendment.

Baroness Hayman: My Lords, we have had a useful debate, following which I cannot be in any doubt about the strong feeling held by noble Lords about the importance of academic medicine. As the Minister in the department with responsibility for research and development, I feel that I am reminded constantly of the areas in which we need to ensure that those interests are properly safeguarded. We recognise the seedcorn that they represent in terms of high quality patient care for the future. We should not lightly neglect that.

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I was grateful for the acknowledgement from the noble Lord, Lord Walton, of what we are trying to do in terms of the amendment that we shall be bringing forward to ensure that, as part of a PCT's duty to make arrangements to secure appropriate professional advice, the local stakeholder must take into account the key area of academic interests, particularly where a PCT commissions services from a teaching hospital.

In terms of the effect of the amendment, the provisions of Schedule 1 will give primary care trusts powers similar to those currently enjoyed by NHS trusts to conduct or commission research and to make offices and facilities available for training purposes. As the House is aware, funding for research and development is achieved through the research and development levy. It is for each trust to put forward research proposals for central funding. The strategic framework for the R&D levy, issued in January 1997, sets out the principles that govern the allocation of NHS funding for research and development. A strategic review is currently under way with the aim of ensuring that the allocation of funding takes full account of the organisation and function of the new NHS and that it continues to improve quality and value for money.

With regard to the short debate which was initiated by the noble Lord, Lord Skelmersdale, we should not think of research and development as something that happens simply in academic medical departments and tertiary centres. One of the opportunities for primary care trusts with regard to their ability to undertake research and development is to ensure that that work is conducted in areas such as nursing, the professions supplementary to medicine and primary care where, after all, the vast majority of healthcare is delivered to patients and where the research base has not traditionally been as strong as in some areas of secondary and tertiary care. There are great opportunities there.

With regard to training, undergraduate and postgraduate training are both funded also through a system of levies, although postgraduate deans contribute to the costs. The arrangements for both are well established for NHS trusts. Primary care trusts will be brought into the same system.

The appropriate level of expenditure on tertiary services will obviously depend on local circumstances. However, I hear the concerns expressed about the importance of ensuring patient access to proper tertiary facilities. I am sure that when we reach Amendment No. 20 we shall have an opportunity to debate some of those issues. The appropriate level of expenditure will vary greatly. The provision of guidance from the Secretary of State would restrict the local flexibility that is required to ensure the most appropriate arrangements for the commissioning and provision of services. I am not sure that it would be appropriate for the Secretary of State to provide guidance on appropriate levels of expenditure on tertiary services, although I recognise the importance of ensuring access to those tertiary services and of the trickle-down effect of that throughout the service.

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With the assurance that PCTs will be brought fully within the existing arrangements which apply to NHS trusts in respect of research and development, training and tertiary services, I hope that the noble Earl will not feel it necessary to press the amendment.

6.45 p.m.

Earl Howe: My Lords, this has been a useful debate and I am grateful to all noble Lords who have participated in it and to the Minister for her response. In my view at any rate, part of the problem is that those who perform work that deals in long-time horizons--that is, in training and research, or in what is sometimes referred to as the "futures agenda"--are inevitably subject to a different kind of culture from those who deal in purchasing and commissioning decisions of a short-term nature. The second culture benefits from the first, but it is an underpinning that allows change to manifest itself only gradually. One day you notice that something on which you relied is no longer there.

One of the less satisfactory features of the proposed system for funding tertiary services is, as I understand it, the emphasis to be placed on historical spending patterns. It is essentially a system that relies on rolling forward what has happened in the past. That may well cut down on the paperwork, but it may also serve to ossify current structures in an unhelpful way. Alongside the protection of the overall levels of funding, one needs to achieve an ability to build up new tertiary concepts where there is the scope to do so. An over-reliance on the past will not allow such flexibility. If the Minister feels that she can elaborate on what she has already said on that point, I should be grateful if she would write to me.

On PCTs, I was trying to make it clear that it is not so much that funding will be voted away from training and research, but that the decisions taken by PCTs, particularly in areas such as tertiary services, will have direct, knock-on implications for those activities, with the resultant consequences in terms of funding over the medium to long term. With that, and with thanks once again to the Minister, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

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