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Lord Winston: My Lords, I, too, am grateful to my noble friend Lord Turnberg for introducing this very important debate. Governments, including this one, have successively talked up how they value the National Health Service as a unique and wonderful institution, but the key to its quality is very much the medical education that has been provided in this country and particularly the accent on specialist care, because specialist care provides a model for so much teaching and research.

Academic medicine has been threatened for a long time. The threat was critical with the development of the internal market under a previous government, and it is a great pity that we did not abandon it. The internal market has prevented teaching hospitals concentrating on a large series of patients, which is good for teaching and research, and in consequence training has been less good. I need to make it clear that I am going to be talking about teaching and training as different issues in academic medicine.
 
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The accent on primary care trusts as the chief funders in the health service has not always been helpful to academic medicine. A key problem of serious importance in medical education at the moment—one to which other speakers have referred—is the impact of the research assessment exercise. Most people who speak about the RAE often speak with sour grapes, having not scored highly in the RAE themselves. I point out to the Minister that I speak from an institution, a unit and a laboratory that has had the highest possible score on the RAE on each successive assessment, so I do not think that that claim can be laid in my court.

The RAE is severely corrosive in all sorts of ways. It is widely criticised in all universities for causing the skewing of research activity; for the loss of good teaching, particularly in the new universities, which now, of course, cannot provide research activities to attract good teachers; for questionable metrics on impact; and on the issue of innovation—not an immediate cause for this debate. The worst effect undoubtedly has been in the health service and in the medical schools, which have suffered the most.

I point out to my noble friend that the modern clinical academic is required to do four different jobs. First, he has to demonstrate excellence in practice, which has become increasingly critical, quite properly, with better clinical governance and better records. I never thought that, at the age of 65, I would be happy to retire from the health service. I did not believe that that would be possible with the kind of contact that I have had with my patients over many years, but this year I feel that a great weight has been lifted off my shoulders. That is a problem with so many clinical academics. Many of them are seeking to retire as early as possible, something that will have a serious impact because often they are the most capable of good teaching, even if their hands shake too much to do good surgery. I note the smile of the noble Lord, Lord McColl of Dulwich, sitting on the Front Bench opposite. I bow, of course, to my colleague's great experience in surgery.

Secondly, there is research. It is absolutely true that research has been skewed in the academic sector of medicine. Increasingly, it is almost entirely focused on non-clinically relevant areas. In my laboratory, we go for research that is likely to score highly in the research assessment exercise but is unlikely to have much impact on clinical medicine. So, for example, my team would far rather publish in Nature or Science, but almost no medic will read those journals and so the research will have little impact on clinical practice. We do not go for the clinical journals because, if we did, we would not receive the score that maintains the income needed to maintain an academic department.

Unfortunately, very little clinical research is taking place in so many medical schools. As my noble friend Lord Turnberg said, heavy regulation is another disincentive. I want to give, as he did not, two examples of that. One is in an area in which I applied for a simple research project using embryonic stem cells—waste material. They are embryos that cannot be given to patients and which patients are freely
 
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giving for other research. That application has been held up for eight months by the research ethics committee over a trivial matter, partly because it has such a pressure of work that it cannot get through it quicker. We now have to go to the HFEA, and it will be interesting to see how long it takes us to go through that regulatory body. With my animal research, I waited 13 months for a licence to carry out one injection into the testicles of six pigs. That seems to me to be undesirable in an area in which we are trying to compete with our American colleagues across the sea.

Thirdly, teaching is low-rated, but it is a key to excellence. It is also a key to morale and to influence throughout the health service. Finally, something as important as teaching is training. We cannot do all three of the previous exercises and train young doctors as well. It is impossible to take them through surgical procedures, for example, with the attention that is needed. My noble friend will understand that many young consultants are appointed who would have needed more training in my day, so much so that my surgically based colleagues commonly complain that they are called out by new, younger consultants who have never seen a relatively common operation before and need some assistance. That is not satisfactory for patients, and it is a real problem.

In my last minute, I must briefly talk about obstetrics and gynaecology, the discipline in which I trained. It is craft-based, and considerable exposure is needed to acquire and maintain clinical skills. The RAE has had a disastrous effect on it. The recent editorial in Volume 112 of the British Journal of Obstetrics and Gynaecology points to that; I can give the Minister the reference if he wishes to see it. It is increasingly the case in most universities that O&G is hardly a subject for RAE purposes because of the risk of there being weaker activity. The decline in the number of lectureship posts by one-third has hit O&G in my university particularly hard. The number of lectureships has been cut down to one, and that post is vacant. Typically, the post that I held before I retired, as a clinical professor with one of the busiest jobs at Hammersmith Hospital, is now vacant, and it will be filled, as is so often the case, by a non-clinician because that is nowadays the only way of maintaining the research assessment exercise. We need research in pregnancy, and, if we do not have it, there will be a massive problem.

Finally, I draw the Minister's attention to my concern about R&D funding in the health service. Spending 1 per cent of the total output of the health service on R&D is insufficient, particularly when there is a good case for suggesting that a great deal of the current R&D function does not go towards research but towards propping up the health service in many teaching hospitals.

5.12 pm

Lord Smith of Clifton: My Lords, I am also grateful to the noble Lord, Lord Turnberg, for initiating this timely debate. It is interesting that during the debate, optimism has been expressed in the future tense, but gloom and foreboding have been expressed in the past
 
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and present tenses. As the noble Lord, Lord Rea, said, we will see how successful the innovations that the Government have outlined are in the event.

The medical employment field is full of problems at the moment. Recruitment, deployment and retention, in particular, raise a series of concerns to which many noble Lords referred. They have also mentioned the four new medical schools that have been created to increase the number of doctors. That is all very well, but it is endangered by the concurrent changes in the career pathway for hospital doctors, who will be the consultants of the future, and has caused a shortage of junior training grades. Many recent medical graduates are finding great difficulty in getting a foot on the ladder. It may be a glitch at the moment, but it will have adverse consequences for the future.

The medical curriculum has undergone radical changes. The age-old concept of pre-clinical training has been all but exorcised. I am advised that there are coherent reasons for that, and that it is important that medical students should be introduced to patients from the outset of their studies. There may be a cogent case for this very radical departure, but I cannot avoid the suspicion that it conveniently disguises the fact that in recent decades, as many noble Lords have pointed out, it has proved to be extremely difficult to fill posts in the established pre-clinical subjects: physiology, anatomy and biochemistry. That was largely due to the fact that academic salaries lag considerably behind those of hospital doctors. As a consequence, pre-clinical teaching is very patchy in quality and I worry how well versed future doctors will be in the basic subjects of their calling. Moreover, the problem has been compounded in clinical teaching where many chairs in clinical medicine remain unfilled, as many noble Lords have said, because of the disparity in the salaries and workloads of academics and consultants. Neither of those factors is to the advantage of British medicine.

There are two further concerns. First, most of the pioneering research in medicine is undertaken by medical academic staff. The reduction in their numbers puts this in serious jeopardy. It is short-sighted in itself and, furthermore, impacts directly on the quality of the practice of medicine in hospitals and GP surgeries. In my view—and this was referred to by the noble Lord, Lord Parekh, and other noble Lords—not enough of the university medical sciences score 5A ratings in the research assessment exercise to guarantee that the UK stays in the forefront of medical advance.

Secondly, this alarming picture on the research side is paralleled by the growing reliance on private contractors to provide hospital services—again a fact to which many noble Lords have referred. I accept the need for a mixed economy in such services if waiting lists and so on are to be reduced and services improved, and there are other related benefits. But there are also two very serious disbenefits. First, private hospitals recruit graduates from medical schools to which they make no financial contribution. Secondly, they invariably make no provision for training placements. Other noble Lords have referred to that. On both
 
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counts they are the beneficiaries of a system for which they pay nothing. They are classic free riders. The growth of private medical provision, which continues apace, has serious implications for the next generation of doctors.

The situation regarding dental academics also causes concern. There have been reductions in the number of dental academic staff, as has been noted, there are a number of unfilled vacancies, and those in post are an ageing cohort. The creation of a new dental school, which the Government propose, without adequate resources, will further exacerbate the problem. I declare an interest as a resident in the region, but I trust serious consideration will be given to attaching the new dental school to the Hull and York medical school: there is a chronic shortage of NHS dentists in the region.

This debate has highlighted the parlous state of academic medical and dental teaching and research. There are serious medium and long-term consequences unless the situation is rectified. We must hope that the Government's new initiative will do that. In the short term, as many noble Lords have said, there are immediate problems that need to be addressed by government. I select two of the most pressing and ask the Minister for his response.

First, following the remarks of the noble Baroness, Lady Finlay, what concordats will the Government enter into with private hospitals to allow for training placements for junior staff? Secondly, as the noble Baronesses, Lady Cumberlege and Lady Murphy, and the noble Lord, Lord Winston, have said, what guidelines will the Government issue to ensure that hospital trusts, foundation hospitals and primary care trusts make adequate provision for sustaining academic medical research and teaching? I should be grateful if the Minister in closing would address these questions.

5.17 pm


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