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Earl Ferrers: My Lords, can the noble Lord give an assurance that, as part of his responsibilities for looking after London Underground, the Mayor of London will not introduce traffic-calming arrangements on the Underground as he has done disastrously and inconveniently on the streets of London?
Lord Filkin: My Lords, what an interesting question. That is not in my brief. I believe that there will be traffic-calming in the sense of improved safety and automatic train protection, but I suspect that the noble Earl was not referring to that. We shall consider the matter further, and I shall even discuss it with him if I meet him.
National Health Service Reform and Health Care Professions Bill
3.31 p.m.
Baroness Northover moved Amendment No. 1:
- After Clause 2, insert the following new clause—
The noble Baroness said: My Lords, the arguments over this area of the Bill have been well rehearsed and cogently argued. That is, no doubt, why everyone is leaving the Chamber. I shall therefore be as brief as I can.
We all agree that education, training and research are vital for the future of the NHS. The Government's plans to expand the number of doctors, nurses and other staff makes that even more important. We know that all is not well at present. On Report I highlighted the fact that Guy's, King's and St Thomas' schools of medicine are now shedding clinical teaching staff on a vast scale.
However, this matter does not only concern medical schools—far from it. It concerns the whole of the health service. If it works effectively, devolution within the health service should produce a massive shift to local areas and their needs. Of course, much of that is to be welcomed.
But national standards and national needs must also be addressed. We have expressed our concerns about that elsewhere in the Bill, and we shall return to the issue when looking at specialist commissioning. Clearly, giving a high priority to education, training and research is exactly one such area. It may not seem a pressing need at local level, given all the other competing claims, but it is what will underpin the future of the health service. We all agree on that.
This debate turns on the difference between the words "may" and "must". We say that at all levels of the service, research, education and training must be supported. The Government seem to believe that "may" is enough. In Committee the Minister said that,
At Report stage, the Minister pointed out that,
The Minister said that he accepted that,
I take another case in point. The Government announce increased expenditure on cancer. Does it reach the areas that it is supposed to reach? It does not—to the enormous frustration of patients and clinicians, as the Minister knows.
The Minister is, and knows that he is, overly-optimistic if he believes that permitting the support of research and teaching, as opposed to ensuring such support, will be adequate. We know how much pressure there is on administrators to ensure each year that they achieve their various targets, not least financial ones. Education, training and research must not be squeezed out by such pressures.
The amendment is very simple. It says that in the interests of the future of the health service and, therefore, of patients, trusts and strategic health authorities must have a duty to safeguard and promote education, training and research. I beg to move.
Baroness Noakes: My Lords, we on these Benches support Amendment No. 1. The issue of safeguarding and promoting education, training and research was debated thoroughly both in Committee and on Report. The noble Baroness, Lady Northover, has summarised the key concerns that were raised on all sides of the House. Those concerns were largely expressed in terms of medical education, training and research, but the amendment is rightly drawn in the widest possible terms and embraces all aspects of education, training and research relevant to the NHS.
I do not believe that there is any disagreement in this House about the importance of education, training and research, or about the fact that there are currently problems in delivery. The disagreement focuses on how big that problem is and how well the existing structures of the NHS will allow education, training and research to thrive and prosper.
At earlier stages of the Bill, the Minister referred to the powers that exist in NHS legislation. I do not believe that the existence of the powers has ever been suggested to be the issue. The issue is whether the powers are being used. That is why the amendment includes the word "duty". The Minister has never explained why he believes that there should not be a duty on the face of the legislation. He has rightly pointed out that what is important is what happens in practice, and we have heard many fine aspirations about teaching and research. I doubt that anyone in the NHS or, indeed, in your Lordships' House would not sign up to those aspirations.
However, it is plain to all those involved that teaching and research in the NHS are vulnerable and threatened. In practice, the process simply does not work well enough. There is ample anecdotal evidence that teaching and research resources are squeezed at NHS trusts. For example, lecture rooms are used for other purposes; doctors are so overwhelmed by the day-to-day demands placed on them that little or no time remains available for research; and there is a staffing crisis at universities.
The Minister has expressed considerable confidence that central earmarking of funds for teaching and research means that those funds are spent on those matters. But, as the noble Baroness, Lady Northover, said, many in the NHS do not believe that.
It is tempting to think that the extra resources being put into the NHS as a result of the recent Budget will make the problem go away. Part of the problem has,
The heart of the question is whether all the bodies in the NHS with a role to play in education, training and research will, in fact, deliver. Many of us have doubts about PCTs, both in relation to their lack of preparedness for their responsibilities and their natural primary care orientation. Both those features mean that there can be no certainty that PCTs will commission in a way that promotes and safeguards education, training and research.
I have already mentioned the concerns that exist at the level of NHS trusts. That leaves strategic health authorities. On Report the Minister told the House that there would be health and education sector partnerships at the level of strategic health authorities. In Committee, he laid stress on the role of strategic health authorities in performance managing PCTs if they do not achieve what those authorities believe that they should. One must have great faith in the efficacy of loose structures and untried processes to believe that that will solve the problem. It is clear to me that the responsibility of NHS bodies for education, training and research needs to be put beyond doubt. That is why we support the amendment.
Lord Walton of Detchant: My Lords, I have had the privilege of being involved in clinical practice in the NHS since its inception. For many years I was involved in teaching medical students and in clinical research. It is generally acknowledged that the standard of medical education in this country over all those years has been second to none. It is also generally acknowledged that clinical research, much of it conducted in the National Health Service, in the hospitals and in the community, has been responsible for enormous developments in patient care.
The National Health Service Act 1946 included a requirement that teaching and research should be supported from the beginning. At the start of the health service there was a knock-for-knock agreement, by which it was agreed that clinical academics working in and employed by the universities should devote six half days a week of their time to clinical service and five half days in a week to teaching and research. The other part of that agreement required NHS staff, including consultants, to give teaching services to medical students and to other staff. Many years ago that agreement was eroded. Evidence from the heads of medical schools—the Council of Heads of Medical Schools—clearly indicates that many clinical academics are spending a minimum of 40 hours a week and some as much as 58 hours a week in clinical practice to the detriment of teaching and research.
One outcome has been that many young clinical academics, due to a lack of research productivity, have not been able to persuade the research assessment exercise of the Higher Education Funding Council that they are involved as sufficiently in research as they should be, in order to improve the funding of their particular medical schools. The consequence has been
Another reason why I do so is that there is a shortage of recruits into clinical academic medicine. That is not surprising. There are 73 vacant chairs and almost 300 vacant clinical lectureships because the attractions of academic work and of teaching and research have been steadily eroded, often by pressures from managers in the NHS trying to compel members of staff to see more and more patients in order to reduce out-patients' and in-patients' waiting times and many other factors.
The Minister has been kind enough to tell me that he has had discussions with the Council of Heads of Medical Schools. I agree with what has been said already, that there is a difference between a permissive power within an Act, which gives the right or the opportunity of health service bodies to support teaching and research and a requirement that they must do so. For the life of me, I cannot see why there can be any objection to an amendment of this nature being put on the face of the Bill. I hope that the Government will use its good offices, in consultation with the universities, and with the health service bodies, to make certain that the clinical practice of clinical academics will be reduced and that their time for teaching and research will be preserved. I support the amendment.
Baroness Cumberlege: My Lords, throughout its passage I have consistently tried to get the word "duty" on to the face of the Bill. I was delighted to hear the noble Lord, Lord Walton, say that the Minister has had talks with the heads of medical schools. I understand that the Minister may give noble Lords some words of comfort, which to some extent I welcome. Words of comfort can evaporate in the mists of time. We want the word "duty" to be incorporated into the Act so that there is a "must do", a requirement and so that there is no ambivalence.
At Report stage I gave your Lordships an example of where I felt a duty was important. I mentioned my son, who had a penchant for motorbikes. He was very reluctant to use a crash helmet. In the language of the young, he felt that it was not cool. But a law was introduced, so as a parent, I had authority to say to my son, "You are not going on that motorbike without a crash helmet". What I did not tell your Lordships on that occasion was that about two months later the splendid East Sussex Ambulance Service scraped him off the road. I and the Ambulance Service have no doubt that the crash helmet saved his life, or at least saved serious brain damage.
I am anxious to avoid serious brain damage for United Kingdom plc. Without a doubt, I agree that there is a crisis in academic chairs and young lectureships, as mentioned by the noble Lord, Lord Walton. I have heard others say that in this country we excel in the quantity and the quality of our medical research. The noble Lord said that he believed it was the best in the world; I have heard that it is the second best in the world because the United States is a little better than us. That is not surprising as the United States is very large and very rich.
Not only do we excel in quantity and in quality, but we also excel in our cost-effectiveness. We are innovative. We are good at thinking up new ways of doing things. One has only to look at the Cochrane collaboration which is now being replicated all over the world. That is one man's vision and one man's inspiration. Sir Ian Chalmers conceived that and has firmly established it.
I believe that we have real strength and more. Amazingly, we have so many opportunities: new opportunities in epidemiology, in tracking disease and in finding cures because we have a unique patient database that we can use. As primary care develops—I have much sympathy with what the Government are doing to try to strengthen primary care—we can build further on much of the research and, more importantly, on joint training in primary care and in the community. In the future, teamwork will deliver the services.
We can also involve patients more directly in understanding science and research. In that context there is a mission. It is less threatening to understand a research project in which one is invited to take part when it is explained to one in the familiarity of a GP's surgery rather than in some remote, cold, clinical hospital. In this country we have a huge communications problem in promoting the public's understanding of science and research. For decades the Royal College of General Practitioners has promoted and encouraged research in general practice. When reading the BMJ it is encouraging to see how much of that journal is dedicated to publishing peer-reviewed research carried out by GPs and occasionally by nurses and other health professionals working in community medicine.
That is a terrific picture. We really excel. Enormous achievements are being made, but I share the grave concerns of the noble Baroness, Lady Northover, and my noble friend Lady Noakes. Against the background of all that achievement, many of us fear that the enormous pressures now being exerted on primary care teams, GPs and other staff to meet targets will erode what we have achieved so far. I work intimately with primary care trusts at present, which is rewarding and interesting, but the pressures on them are huge. There are targets for waiting times in surgeries and referrals, national service frameworks, health improvement programmes, patient involvement, GP assessment, cancer plans and the need to balance the books, recruit staff and so on.
I am certain that research and training is not at the top of the list—it is going continually down the list as more pressures are placed on trusts to deliver. My noble friend Lady Noakes and the noble Lord, Lord Walton, talked about commissioning, so I shall not go into that, but I point out that primary care trust boards are not only commissioners but managers. They are in fear of a visit from the Commission for Health Improvement and are having to learn about all their new work as managers as well as commissioners. That is why they should also have a duty in respect of research and development.
One of the great hallmarks of your Lordships' House has been its championing of research and scientific endeavour. I remind your Lordships that it was this House that in 1992 persuaded the government to introduce the post of Director of Research and Development in the Department of Health. That was strongly resisted at the time, but it was eventually conceded. That post, which was the result of an initiative from your Lordships' House, has made a marked difference to how the National Health Service now invests in and carries out research.
I suggest that we hold to that which we know to be true, eschew the warm words of comfort that I suspect that we shall hear from the Minister and support this cross-party amendment with some of the same determination that the House exercised 10 years ago.
"DUTY OF PRIMARY CARE TRUSTS, NHS TRUSTS AND STRATEGIC HEALTH AUTHORITIES REGARDING EDUCATION, TRAINING AND RESEARCH
Primary Care Trusts, NHS trusts and Strategic Health Authorities shall have a duty to safeguard and promote education, training and research."
"it is in the interests of the National Health Service and the Government to ensure that we address [those areas]",—[Official Report, 18/3/02; col. 1117.]
Indeed!
"primary care trusts are empowered to 'conduct, commission or assist in the conduct of research'",
and that they can,
"'make officers and facilities available in connection with training'".
That is, they can, but they do not have to.
"there is an issue [here] in regard to power and duty".
That is, indeed, the point. He spoke of dedicated funding streams for teaching and research, adding,
"I do not believe that primary care trusts will be under pressure to spend that money for other purposes".—[Official Report, 29/4/02; col. 507.]
I trust that noble Lords will excuse my scepticism here. On Report I quoted a case where administrators had sought to redirect money from research and teaching into a black hole by the tactic of increasing the levy charged for allowing their premises to be used. There are ways and means of tapping into such money.
3.45 p.m.
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