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Baroness Cumberlege: My Lords, I thank the noble Lord, Lord Turnberg, for initiating the debate. Given his remarkable, distinguished contribution to education, medicine, science and public health, I could spend seven minutes talking about the noble Lord, but that is not the purpose today. However, there could be nobody better fitted to introduce this debate.
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I declare an interest: I chair St George's University of London, a medical school in south-west London, established 250 years ago, and I am on the board of the Brighton and Sussex Medical School, which was established just three years ago. I mention that because I have been struck by how similar the problems are in both medical schools, which are both very successful. They are so different in their character and geography yet they have the same difficulties in academic medicine. As the Government are well aware, in some specialties clinical academics are as rare as hen's teeth and much needs to be done.
The noble Lord, Lord Turnberg, has mentioned already the UK Clinical Research Collaboration and the sub-committee of Modernising Medical Careers. Like others, I rejoice that much is being done; quite embarrassingly, I have to congratulate the Government on that. I look forward to the Minister's reply, as I am sure that he will tell us more about that, and particularly to hearing what the long-term commitment is to funding the Walport recommendations. The long term is essential to remedy some of the mess that we are in.
Given the shortage of doctors, I am sure that the Minister will welcome the fact that, for next year, St George's medical school has attracted 11 applicants for every student place and Brighton and Sussex 20 students for every place. Yet neither institution can attract a professor of surgery. It has not been for want of trying; there just have not been any credible applicants for those posts.
Surgery is not the only specialty in trouble, as the noble Lord, Lord Turnberg, has mentioned. Nationally, we know through the Council of Heads of Medical Schools, last year alone, anaesthetics lost 15 per cent of clinical academics, pathology has lost 40 per cent, radiology 30 per cent, occupational medicine 60 per cent and both paediatrics, and gynaecology and obstetrics have lost 11 per cent.
My first question is: who will teach those bright, aspiring young doctors, when there is such a shortage of clinical academics? With 208 vacant senior posts, 91 of which are professorial chairs, there is a lot to make up. Secondly, with so much of the curriculum delivered in general practice and a decline in clinical lecturers since 2003, how does the Minister propose to remedy the situation in the short term, as it will take quite a while for the initiatives to produce results, and will he address the discrepancy between consultant clinical academics' pay and that of senior academic general practitioners? Thirdly, the introduction of multiple providers further complicates the position. What measures will the Government put in place to ensure that there are sufficient training places for students in those environments?
I shall now deal with the NHS. Recently, I received a letter from Sir Iain Chalmers, who, as noble Lords will know, is a founder of the Cochrane Collaboration and editor of the James Lind Library. He wrote to me in my capacity as chair of the working group for the Royal College of Physicians on its report on medical professionalism, which we will release next week.
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"Over the past 30 years, there has been collective uncertainty about whether patients admitted to hospital with acute traumatic brain injury should be prescribed systematic steroids. This uncertainty has been reflected in dramatic variations in practicesome doctors have given steroids, guessing that they were useful; others have withheld steroids, guessing that their risks were likely to outweigh any benefits. It was not until very recently that this collective uncertainty was addressed by doctors around the world who agreed that acquiescence in this ignorance was incompatible with responsible professional practice. Thanks to these doctors, we now know that this treatment has been killing patients for 30 years. This is just one example of many that I could cite".
As a lay person, I find that chilling. If ever there was a case made for clinical academics, surely it is that one. We need them not just for patient safety but for more than thatfor more than being the translators of science into medicine. We need them as leaders and teachers, and we need them now. Yet the NHS appears to have a disincentive to employ these people.
There is no financial incentive for a thrusting foundation hospital or a trust on the margins of fiscal viability to employ a consultant academic. They are a complication; they have two employersthe trust and the university; they are expected to deliver high quality teaching, carry out internationally respected research and do their clinical work. Some would say that that workload, executed to a high standard, is the equivalent of three full-time jobs, and without protected time, it is undo-able. Yet we know that this combination is extremely powerful in improving the care of patients and making the UK a world leader in academic medicine and the education of doctors.
Of course, SHAs and foundation trusts are expected to make allowances and support all these activities but when pressurised to fulfil targets and achieve more stars, it is the service that always wins the day. With the full implementation of payment by results, there is likely to be an even greater reluctance not only to decrease the number of patients seen and treated but to increase costs through employing staff with research sessions. I do not think that job plans are the answer.
It is disappointing that the Healthcare Commission did not include education and research within its core standards. High quality research should be recognised as essential in the delivery of high quality care. My fourth question to the Minister is: will the Government ensure that the Healthcare Commission explicitly recognises research and education as a trust's responsibility in its performance assessment? Lastly, what guidance will he give to PCTs in their commissioning role?
The decline in the numbers of clinical academic staff is striking and also worrying. As my noble friend pointed out, since 2000 there has been a 12 per cent drop in the number of clinical academics, amounting to as high as 42 per cent among the clinical lecturers. This drop is particularly high in certain disciplines
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28 per cent in the case of psychiatry, 50 per cent in pathology, 13 per cent in surgery and 9 per cent in medicine. It is also worrying with regard to dental schools. In 2004, we had 30 fewer dental academics than in 2003. I am also a little worried that 50 per cent of clinical academics today are over the age of 45, and the number of young medical graduates going into academic medicine is not rising proportionately.
In the light of all this, there is a reason to worry. But I am delighted that the Government are fully aware of the situation and have taken a number of major initiatives. The Chancellor has given high priority to medical research. There is increased funding for NHS research and development, going up to £100 million by 2008. There is also a proposal to encourage research collaboration with other agencies and I am particularly pleased that the Government intend to establish 250 academic clinical fellowships and 100 clinical lectureships per year. The Department of Health consultation document, Best Research for Best Health is also full of interesting ideas.
All these initiatives amount to one of the most progressive steps forward in the past two decades and I want to salute the commitment and conviction of the Government. However, no government alone can tackle a problem of this magnitude. Other institutions also have an important role to play, such as the universities, the General Medical Council, NHS staff and Wellcome and other generous foundations. In the next five or so minutes I want to briefly suggest a few ideas for non-governmental agencies and also a couple for what the Government could do in this area.
First, the NHS culture must change profoundly and clinical research must be seen as an integral part of it. That has two important implications. Consultants and others should see their roles not only as providers of clinical services. They should also be willing to undertake and participate in academic research. It also implies that clinical researchers are seen and accepted as an equal part of the NHS staff as much as the doctors and healthcare professionals.
Secondly, it is important that the training of doctors and dentists in our medical and dental schools should involve research as an integral part. Students should be exposed to clinical academic research and imbibe the spirit of intellectual excitement and acquire basic methodological training. They should see themselves not simply as people who are going to acquire certain skills which they will then apply, but also as reflective and creative minds who will not only be applying their skills but accumulating knowledge and contributing to the growth of medical science.
To digress for one moment, this can also happen to some very talented students. In my own case, two of my sons went to Oxford to read medicine and I had hoped that they would become doctors. Tremendously excited by the sheer prospect of creating something new, both of them became distinguished scientists and one of them is now a professor of cardiovascular physiology at the University of Oxford. I say that not so much to talk about myself, although that is what I have inadvertently done, but to make the point that
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the excitement of research is something that can be implanted and cultivated in students. Unless we do that, we will not have a large number of new graduates wanting to do medical research.
Thirdly, it is extremely important that there should be greater co-operation between basic biological research and clinical work. Although pure research is important, medical science has increasingly moved in a direction where clinical collaboration with fundamental medical research is extremely important. After all, it was the collaboration between Frederick Banting and Charles Best which allowed them to discover insulin.
Fourthly, it is worrying that the representation of women and ethnic minorities among clinical academics is so small. Women represent only 12 per cent of clinical academics and ethnic minorities barely 2 per cent. Steps need to be taken to increase their representation either by addressing the factors that deter them from moving into this area, or by earmarking a percentage of fellowships and lectureships that the Government contemplate for women and ethnic minorities, or at least by making flexible and part-time working arrangements.
Fifthly, the research assessment exercise has acted as a disincentiveI can say that from my own experience as a professor, but also by looking at what has happened in the field of clinical medicine. Clinical research takes a long time to result in academic publications. The productivity of clinical academics therefore tends to be rather low, and their departments get low RAE ratings. That inevitably puts pressure on universities to reduce investments in certain disciplines, as we have seen in the case of so-called craft disciplines such as surgery, cardiology, radiology, obstetrics and gynaecology and, of course, anaesthesia. It is very important that promotions are not delayed, and that tends to happen if the RAE rating of an individual is not up to scratch, not because of his fault but because the publications take a long time to come through.
Sixthly, unlike medical staff, clinical academics lack a clear route of entry and a transparent career structure. There are disparities in pay and working conditions. As the BMA cohort report of 1995 clearly shows, some very talented medical graduates refuse to go into an academic discipline because they feel profoundly devalued, or because they are in danger of earning less pay or because they find few higher academic posts to which they can aspire. Equally important, they are afraid that by going into an academic discipline, they are in danger of being deskilled and might not be able to return to mainstream hospital or general practice medicine, if they fail as academics.
Finally, I shall emphasise a neglected point. Clinical academics need to develop greater international contacts and undertake co-operative international research. That should involve not only our European partners but also the Commonwealth. We have unique advantages in this country, as nearly one-third of our doctors come from Asia and Africa and have close
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links with hospitals and research institutions in those countries. We shall also be able to understand better our own ethnic minority population's medical problems if we keep in touch with researchers in other countries. Therefore, I very much hope that clinical research in our country does not remain merely confined to the NHS trusts, universities and so on, but becomes more entrepreneurial and reaches out to other countries.
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