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Baroness Finlay of Llandaff: My Lords, I, too, am most grateful to the noble Lord, Lord Turnberg, for having secured this important debate. Indeed, there is an urgent need to ensure that medical academics are recruited and retained, for three cogent reasons, which other noble Lords have already covered but which I believe bear reiterating.

First, Britain has punched above its weight in research for many years, and that research benefits patients directly. It also brings in investment to the country through pharmaceutical companies, devices and equipment manufacturers and through patents, which earn money for the university in which a discovery was made, thereby ploughing profit back directly into the academic sector.

Secondly, the next generation of doctors needs to be taught and to learn the critical appraisal skills and the integrative thinking that is best taught by the intellectually and research-active clinical community, for there is cross-fertilisation between good researchers and good teachers in that community. Yet the teaching of students is threatened by the increasing move to private sector clinical providers, who do not have an obligation to ensure that students are exposed to clinical problems. The commissioning does not seem to impose an obligation on such providers to support teaching and research, so even with the service increment for teaching money—the so-called SIFT—we will not be able adequately to recruit teachers from the service to meet the needs of the increasing numbers of healthcare students.

Thirdly, there is the issue of patient care itself. Just as common things occur commonly, rare things occur rarely; yet for the patient with the unusual presentation or the complex rare problem, it is the intellectual rigour of the academic centre that has always been brought to bear to establish an accurate diagnosis and then plan an appropriate treatment. So it is the practice of clinical academics that directly benefits patients, particularly those with rare disorders—the so-called orphan diseases. There is evidence that patients appreciate that a teaching environment directly benefits them and others because the standard of clinical care is driven up by the teaching environment.

In my own department, we have recently published our findings that patients are not harmed by students learning oncology from them. Far from it, patients reported a wide range of benefits from having a student allocated to them—including appreciating someone else that they could talk to about their illness,
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who could give them information as well. So with the proven benefits that accrue, it seems odd—as the noble Baroness, Lady Cumberlege, has already highlighted—that the Healthcare Commission did not include teaching and research as part of the core standards.

The number of clinical academics has fallen by 12 per cent since 2000, despite medical student numbers increasing. Although the consultant posts have increased in the UK by 24 per cent since 2000, 90 per cent of the research in the NHS is undertaken by clinical academics. Among those in academic posts, the number of women has not risen, as noble Lords have said, despite the huge in numbers of women in medicine. There is only one woman dean of a medical school. Only 20 per cent of medical academic post-holders are women, with the proportion tapering with seniority. Only 12 per cent of the clinical professorships are held by women. At lecturer grade, a third overall are women, but several women at senior lecturer grade and above report being discouraged from pursuing an academic career, feeling that there is a glass ceiling, even if the concrete roof is beginning to crumble. Yet these very bright research juniors do not have role models for how to have a baby and be a professor, and do both successfully.

Now, however, an even greater threat to academic medical posts is emerging. The NHS funds 39 per cent of all such posts—as it should, as it is the NHS that benefits from their clinical role. For example, society takes it for granted out there that Professor Roger Williams was the person who oversaw the clinical care of George Best, as well as undertaking the liver unit research for which King's is famed as a department. Such clinicians in academic posts have honorary consultant contracts with the NHS with fixed clinical sessional commitments, and they often work way beyond their contractual obligations. Since the Follett report they are appraised by both the NHS and the university, they are answerable to the NHS for their clinical activity, and they are effectively jointly employed. For salary purposes their pay is processed through the university, and it needs to be, for the research assessment exercise returns to reflect accurately the work done by the academic members in the university.

However, this longstanding tradition of joint NHS and academic posts is seriously under threat from the revenue collectors, otherwise known as the VAT man. The Minister will be aware that a tribunal in Glasgow recently ruled that VAT should be levied at the standard rate on the salaries of NHS-funded clinical academics at the University of Glasgow. This verdict has serious implications if it is not revisited. Sir Nigel Crisp has recognised the size of the problem, and in October this year he informed the Council of Heads of Medical Schools, on which I sit as an observer, that if this became more general,

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The additional cost to "DH" from this VAT bill is likely to be around £60 million per annum. This will completely undermine the Walport money that has been put aside to stimulate the career progression of the rising stars in clinical academia. We certainly need to bring these bright medics on, otherwise their potential will be unrealised or they will emigrate. What steps are being taken to address this? It could clearly negate any good done through implementation of the Walport report.

The universities and NHS trusts believe that the issue should be addressed nationally, and that there is a way forward. There needs to be an agreement that the salaries of such staff fall outside the scope of VAT by virtue of the tightly integrated nature of a clinical academic's work. I have already explained that teaching, research and service delivery are entirely interdependent, and that the joint job-planning and appraisal that now takes place as a result of the new consultant contract—and of Follett implementation—essentially means that these NHS-funded clinical academics hold a joint employment contract. However, there is a great deal of uncertainty and disquiet in the sector at present, arising from the local initiatives of Glasgow's HM revenue collection officers.

I do not expect the Minister to be able to reassure me today—that would be too much to ask on an issue as complex as this—but, given the circularity of the financial flows, all out of public money, I hope the Minister will seek to provide clarity and ensure that the posts are deemed to be outside the scope of VAT, to avoid academic posts being destroyed.

4.44 pm

Baroness Warwick of Undercliffe: My Lords, I join other noble Lords in congratulating my noble friend Lord Turnberg, on proposing this important debate. He has drawn the attention of the House to an issue that is becoming increasingly pressing. I declare an interest as chief executive of Universities UK. Universities are of course responsible for the education of our clinical academics as well as our medical students.

Since 2000—and I am repeating a statistic that will probably be a death knell for the Minister—there has been a 12 per cent decrease in the number of clinical academic staff. During that period, the number of medical students has increased by 40 per cent and four new medical schools have opened. The expansion is set to continue. Medical schools are currently bidding for an additional 100 student places in England, and we expect further increases to follow. In the past two years alone there has been a 17 per cent drop in the number of clinical lecturers. In dentistry, clinical academic numbers reached a 10-year low in 2003 and have since declined still further from 473 in 2003 to 444 in 2004. That is at a time when the Government are seeking increases in dental student places too.

That has an impact not only on teaching but on research, in which the UK is recognised as second only to the United States. The research conducted by
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clinical academics is highly marketable and it supports patient care in the NHS. Some 90 per cent of NHS research is conducted by clinical academics. A reduction in the research capacity of the UK in this field would compromise our ability to innovate and lead the way in all areas of healthcare.

Take, for example, one of the subjects referred to by my noble friend Lord Turnberg—pathology. An understanding of the basic underlying cause, nature and origin of disease is critical to all medical practice and is at the forefront of medical research. A shortage of academic pathologists at all levels will compromise medical training as well as the UK's research capacity. There are now only 12 clinical lecturers in the whole country, and they are concentrated in just six schools. Four years ago, there were 64 clinical lecturers, which means that 80 per cent of the medical schools in the UK are without clinical lecturers in pathology.

The reasons for the shortages are mixed, depending on the specialism. Various factors—such as the length of time needed to train; short-term and temporary appointments with limited career prospects; more attractive career opportunities and pay in other sectors—all play a part in leading talented individuals to conclude that the demands on clinical academics are excessive and that the pressure to maintain clinical activity, research and teaching all in one role is simply not possible.

Governments have been aware of this problem for at least 10 years. Successive reports have highlighted the staffing problems in teaching and research. Most recently, the Department of Health and the Department for Education and Skills Strategic Learning and Research Advisory Group commissioned work on the development of the workforce. The resulting report, Developing and Sustaining a World Class Workforce of Educators and Researchers in Health and Social Care, identifies some possible solutions. The report makes recommendations for government, for higher education institutions and for the health service, particularly about career planning and development, to ensure that we have the workforce that we need for teaching and research in both sectors. While partial funding has been made available for a limited number of lectureships and fellowships in medicine only, the effects will none the less take some time to feed through into the wider health and education sectors, and the nature of the funding mechanism proposed is not stable. So I hope that the Minister will be able to say something about stability and sustainability of funding.

However, it is important that we should not only be concerned about the strength of the teaching workforce for doctors and dentists. In nursing and the allied health professions there is a need for a much more far-sighted workforce-planning role to support students in practice and to address the expected increase in retirements from those professions over the coming years. The Government should consider how they can make the best use of all healthcare
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professionals, as new types of practitioner emerge in the health service and the mix of skills required continues to change.

If the UK is to reduce its dependence on qualified medical professionals from overseas, particularly those from nations that can least afford to lose such personnel, we must take steps to ensure that we can be self-sufficient. Expanding the number of medical schools and increasing the number of available places is part of that, but without suitable staff to teach the students and placements for clinical practice, we are unlikely to make the advances that the public have every right to expect.

There are many powerful reasons why the Government should take action—to enable us to deliver expansion, for the sake of the international development agenda, and because high-quality teaching and research are essential to the provision of high-quality healthcare. I therefore hope that the Minister will recognise the importance of collaboration between the higher education and health sectors, and of providing greater support and encouragement for that collaboration. I also hope that he recognises that the underpinning education and research that sustains health professionals needs stable funding, a longer-term perspective, and careful planning.

4.51 pm

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