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Baroness Noakes: My Lords, the other place rejected amendments which sought to insert new clauses after Clauses 4 and 6 because the law already provides adequately for education, training and research. I believe that that is disingenuous. The law does place a duty on the Secretary of State in relation to facilities for clinical teaching and research in connection with clinical medicine and clinical dentistry. That sounds rather good, but it suffers from serious weaknesses. It is phrased only in terms of clinical medicine and dentistry. But, of course, as we discussed earlier in this House, education, training and research goes far wider than that. Indeed, as the Minister agreed, it needs to cover the education, training and research for all other healthcare professional groups and, indeed, one might say, for every other significant group of staff in the NHS.

In another place it was said that that duty will be delegated to PCTs. But, of course, that is only part of the story. Unless the duty to safeguard and promote education, training and research is held at all levels, it will be ineffective. While, as has already been said, PCTs are enormously important for education, training and research in primary and community care and are also important if they commission services in the acute sector where teaching and research needs to be protected, that duty needs to go beyond PCTs.

The duty does not have an impact on strategic health authorities. Some of us are still bewildered as to what strategic health authorities will, in practice, do. Coherent strategic frameworks do not help some of us to understand that. But, in any event, we believe that they should have the same responsibilities as other parts of the NHS concerning a duty in relation to education, training and research. Of course, trusts also need a duty but at present they have only certain powers.

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Therefore, we have a duty which is imperfect in coverage and imperfect in reach and a patchwork of duties and powers which simply do not cover the whole territory. If we believed that this imperfect legal framework nevertheless caused no problems in practice, we should not be here this afternoon debating this clause. The plain fact is that there are problems in practice. During the passage of the Bill in your Lordships' House we heard from many noble Lords of the type of problem being encountered.

The Minister said that the duty is difficult to define. I find that argument very difficult to follow. The terms "education", "training" and "research" can bear their natural meaning. Of course, the Bill must be interpreted in the context of the NHS because that is what it relates to. The Department of Health will doubtless issue guidance on the practical implications of the existence of a duty. With the department's normal consultative processes, I am sure that ultimately that would not result in any problems so far as concerns a satisfactory understanding throughout the NHS of what such a duty meant and, therefore, what the breach of such a duty meant.

The Minister has sought to seduce us with the prospect of a ministerial review of education, training and research. That is a very interesting idea, although it falls short of the duty which the clauses addressed. We are pleased about the scope of the review in terms of covering all parts of the healthcare professions with regard to education, training and research. That is welcome. But before we on these Benches decide finally what to do about the Commons response to our new clauses, we should like to hear more from the Minister about the review. As the noble Baroness, Lady Northover, said, timing is clearly important. A start date of early 2003 does not sound particularly early. But, perhaps more importantly, when will the review be expected to end? Kicking something into the long grass is not an attractive alternative to our clauses.

Another issue concerns who is to be involved. The Minister talked of a ministerial review. It would be interesting to know which Minister will lead the review. Of course, noble Lords have a considerable respect for the Minister, and it would clearly be a bonus if he were to lead it. But, in addition to Ministers, can the noble Lord say who else is likely to be involved in the review and, in particular, which experts would be expected to work alongside Ministers?

Lastly, there is the question of reporting, which the noble Baroness, Lady Northover, also raised. I ask the Minister to give an assurance to the House that the outcome of the review will be published and, indeed, that the Government will be prepared to have the issues debated in your Lordships' House following publication of the review. I shall listen with keen interest to the response of the Minister.

Baroness Finlay of Llandaff: My Lords, under Section 51 of the National Health Service Act 1977, the

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Secretary of State does, indeed, have a duty to provide facilities for teaching and research. In his reply to the debate on the Bill on 16th May, the Minister reassured the House that powers exist to safeguard education, training and research. Today, the Minister has given most welcome reassurances and words of comfort. Those intentions are fully accepted and appreciated.

I am particularly heartened to have confirmation of the representation on the strategic health authority of someone from an undergraduate education institution concerned with healthcare professionals. I am heartened that the rolling-out of the medical student expansion programme will be monitored, and I am sure that the meeting with the BMA will be important. I have had a very warm meeting with Jane Hutt in Wales and was most reassured by that. She is certainly well appraised of the challenges that exist in education and research. With the reassurances following that meeting, I accept that it would be inappropriate to press for an amendment to appear on the face of the Bill in relation to Wales. However, it does not remove the need to ensure that a duty on those who provide and commission services is clearly spelled out.

The situation on the ground shows worrying trends. The chairman of the Council of Heads of Medical Schools, with whom I spoke today, remains concerned that primary care trusts will not appreciate the relevance of the wider education and research issues in relation to their functions, including primary care placements for medical and other healthcare professionals, the impact of their commissioning decisions on teaching and research in NHS trusts and primary care, and the growing importance of research in primary care for the future quality of healthcare overall.

On 16th May, the Minister reported his discussions with the Council of Heads of Medical Schools and explored ways of implementing and ensuring some of the changes that had been called for in this House. Some of those reassurances have been given in his reply today. However, the need still remains to ensure what safeguards are in place and how they will be audited. Questions have been asked by the noble Baronesses, Lady Northover and Lady Noakes, which I shall not reiterate. That must be attached to the concept of a ministerial review, which is welcome.

Many PCT public consultation documents contain nothing about education or research, suggesting that PCTs may not understand the importance of integrating clinical teaching and research activities, although such documents discussed in full clinical governance issues and therefore training issues. The Minister asked previously about definitions of "education" and "research". I suggest that in this context education is the process of acquiring the knowledge, skills, competencies and attitudes to enter the healthcare professions and therefore is different from training issues. Training issues are essential for the Government's agenda.

Professor Carol Black, president elect of the Royal College of Physicians, has a particular concern that the short-term service pressures and financial constraints

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risk decreasing the quality of care across the board as central forces to meet targets take priority over the research inquiry into and management of less common conditions. The pressures on trusts to deliver against targets are enormous.

Professor Thompson, Dean of Southampton Medical School, has become aware that in his area the trust does not even want the development of new clinical chairs using Higher Education Funding Council for England (HEFCE) funding because it might divert from the model of a district general hospital that the PCTs seem to want in bringing in complex, rare cases. It is possible that that attitude could completely stifle clinical academic development.

There is an underfunding of services by primary care trusts. That has been offset by the service increment for teaching (SIFT) and R&D inflation, which has been used to fund the clinical expansion. The Council of Heads of Medical Schools has been concerned that new and untried systems could refocus the primary care trusts towards a strategy of viewing teaching hospitals as district general hospitals rather than as centres of excellence, although I fully accept the reassurances given today by the Minister about teaching primary care trusts and how those will differ from other primary care trusts.

Research has been shown to have a direct and immediate benefit on the NHS. Current examples include the MRC acute back pain study, which showed that exercise is more effective than rest. The cost savings can be measured in man hours at work, decreased direct and indirect or secondary complication costs, and savings for society overall. Some research findings, such as day case surgery, have been widely implemented.

However, to reach undergraduates it is essential that facilities are available. The erosion is subtle. Education facilities in many district general hospital wards have now been taken for clinical usage needs, such as offices. The new Wythenshawe Hospital provides excellent facilities in its PFI building but is, by common consent, already too small and the academic block is certainly smaller than was wanted. There are similar problems in Manchester in securing a research place in psychiatry. Although there is a good intention, that has never been confirmed in writing because of the pressures which the mental health trust is under.

Professor Anne Louise Kinmonth, professor of general practice in Cambridge, stated that the systems are untried. The educational budgets to which the Minister referred are being brought together under the workforce confederation, which will hold the margin between education, staff development, service and the systems to research developments. The previous service increment for teaching money will be incorporated in a consolidated budget. I ask the Minister how the accountability will be monitored to ensure that the duty of the Secretary of State under the 1977 Act is fulfilled.

The research and education outcomes provide perverse incentives for clinical academia. The need to have high ratings of 5 or 5* to maintain income have

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meant that research pressures take priority over teaching, yet if the ratings are down and academics are lost, the very people who are required to do the teaching are lost to the system.

Thus, the duty on the face of the Bill will ensure that the current duty of the Secretary of State is devolved out to the primary care trusts, NHS trusts and strategic health authorities, where the commissioning decisions are taken. Such an amendment is entirely consistent with the tenor of government policy and with the accountability recommendations of Follett and, indeed, is completely compatible with the reassurances given today by the Minister.

5.45 p.m.

Lord Turnberg: My Lords, while I strongly support the amendment proposed by the noble Baroness, Lady Northover—how could I not support it—it is the case that the Secretary of State already has a duty to protect teaching and research in the NHS. It is also the case that teaching and research are not simply the responsibility of PCTs and strategic health authorities. Universities, funding councils, research funding bodies and charities play dominant roles but inevitably so much of teaching and research goes on within the NHS and by NHS staff that they must play a part in protecting those vital roles.

The Government are unwilling to see that responsibility reiterated on the face of the Bill, which I understand. It is good to hear that the Minister is unequivocal in making clear that all parts of the NHS have not only a responsibility to their patients now but also a responsibility to teach and train future staff and to promote research on which so much of the treatment of future patients depends.

I was delighted to hear about the ministerial review. That is a tremendous response. I hope that there is not a hint of procrastination here because there is a degree of urgency. New medical students will appear in October. Medical schools are at present suffering problems concerning redundant staff. That paradox of more students and fewer staff is one which needs urgent attention. Those are not the direct responsibilities of PCTs or strategic health authorities but part of a much wider picture. I hope that the ministerial review will in practice cover rather more than the elements we are discussing in this amendment.

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