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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 to be 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

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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.

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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 sub-optimal 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

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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.

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