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Earl Howe: My Lords, this is one of those occasions where I am left feeling somewhat redundant after so many excellent speeches in which almost everything has been said. The noble Lord, Lord Turnberg, has spoken with great authority and clarity, as he always does, and I feel that all that is left for me is to add some points of emphasis.

The first point of emphasis is very easy. We should be in no doubt of the importance of the issue. I take a very simple view of clinical academics. They are that essential cog without which none of the constituent parts of the NHS engine can begin to function. Upon them depends not just the teaching of our future doctors but also, in a very real sense, the maintenance of those standards of clinical leadership which have always put the UK in the front rank of specialist medical excellence. And, as we have heard so eloquently expressed, upon them depends the maintenance of that vital bridge—the bridge between the expanding state of our knowledge about the basic mechanisms of disease and the development of new
 
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treatments which are of direct benefit to patients. Without clinical academics the NHS cannot advance or function. That is why the steep decline in their numbers over the past few years is a cause of deep concern.

Perhaps my second point of emphasis ought to be a tribute to the Government. They are quite clearly taking this problem seriously. The creation of the UKCRC; the substantial new money for NHS R&D; and, most recently, the Walport report, which has led to the creation of new academic clinical fellowships and new clinical and senior lectureships, are, in anybody's language, just what the doctor ordered.

As with so many problems in life, money alone will never be enough. Problems associated with the decline in clinical academic numbers concern much more than that. If you ask many clinical academics what oppresses them in their professional lives, they say that it is all too much. It is like doing two or more jobs simultaneously. As well as that, the constituent parts of the job have become unbalanced, with NHS priorities—the clinical pressures—squeezing out the time available for research. There is frequently an unspoken feeling that research is a bit of a bolt-on extra to the real task of doctors in hospitals, which is to treat patients. Somehow, that unspoken feeling must be banished. That is an issue for management as much as clinicians themselves.

All the time, everyone needs to remind themselves that effective treatment of patients is about more than just using tried and tested techniques. If we are to call ourselves a world-class health service, it is also about creating sufficient capacity in the system to evaluate new tools coming our way from academia and industry. Only by careful evaluation of those interventions will they become usable. As that happens, patients get early access to novel therapies; clinicians become familiarised with their benefits; and the standards of clinical practice move ahead. We are talking about fostering and maintaining a culture—a culture of inquiry—that the UK has always had but which many people are saying has started to ebb away.

The noble Lord, Lord Parekh, was absolutely right about what drives that culture. Young trainee doctors are enthusiasts for what they do. Many may be fired up by the idea of small-scale clinical research in which they can personally play a part. In the past, that sort of early exposure to research was what so often led to a trainee wanting to follow a research-based career. But enthusiasm is quickly dampened by the regulatory hurdles; the shortage of time spent at the bedside of patients during training; and by the difficulty of attracting grant funding, other than for large research groupings. In that context, the announcement of the new academic clinical fellowships was particularly welcome.

However, it is not enough to make the career pathway more attractive in the abstract. We need to ensure that nothing in the system acts as a barrier to innovation in any given discipline. The recent proposal to set up a linked group of academic medical centres may well have potential, but I am worried that that
 
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may unreasonably disadvantage other centres of excellence and that there will simply not be the necessary capacity to pursue high-quality research in some key specialties. We often hear it said about the research assessment exercise—the RAE—that, for all its merits, it does little to help struggling schools improve and that, for the reasons given by the noble Lord, Lord Winston, it often may not accurately reflect the quality of the research being carried out. We hear of staff being reconfigured and research themes being re-jigged simply to notch up high RAE scores. One casualty is career stability. Another is the quality of teaching, for which there is already little enough incentive.

Worthwhile patient-based research can be a long-term business. Somehow, we need to reverse the decline of the past few years in research relating, for example, to public health, pathology and a number of the so-called craft specialties, such as anaesthetics, obs and gynae and radiology—many of them, ironically, key priorities for the NHS. Universities do not want their hands tied on the areas of medical research on which they focus, but there is a good case for having some mechanism to ensure that there is national coverage of all relevant specialties. Will the RAE in 2008 take those issues to heart?

The NHS is currently a cauldron of change in which service provision is the main driver. Amid all that change, teaching and research can all too easily be afterthoughts. The pattern of commissioning by PCTs, not least to independent operators, may restrict the pattern of research conducted in NHS teaching hospitals. The rise in student numbers—welcome in itself—can serve only to put yet more pressure on clinical academics and, in so doing, may dilute the quality of training and research. We need to be alert to those risks.

The proposals put forward in the recent consultation paper, Best Research for Best Health, may not be right in every particular, although I think that they are very promising. But, alongside the Walport report, they represent a golden opportunity to turn the tide, which must be followed through if there is to be any hope of resolving the grave problems to which the noble Lord, Lord Turnberg, has drawn our attention.

5.25 pm

The Minister of State, Department of Health (Lord Warner): My Lords, I join other noble Lords in congratulating my noble friend Lord Turnberg on providing us with the opportunity to discuss this important topic. As a government concerned with ensuring that the UK has a knowledge-based economy and committed to continuing to improve our NHS, we recognise the important contribution that clinical academics make to research, teaching and patient care. This is why we are determined to secure a strong academic base to support both research and the expansion of medical and dental education. The noble Baroness, Lady Finlay, rightly identified the economic case for a strong research base. We share many of the concerns expressed by noble Lords about the decline in
 
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numbers of clinical academic staff, which is why we are acting. But, without being complacent, we are pleased that the Council of Heads of Medical Schools and Council of Deans of Dental Schools in their June survey show a slowing in the rate of clinical academic decline—a "spring shoot" in trying to move forward into the future with more success.

My noble friend Lord Rea was right about the need for the UK to be competitive in attracting clinical research to this country. Universities need to reflect on that in what they charge pharmaceutical companies. Those are issues that we all have to reflect on. I recognise that clinical academics play a crucial role in teaching, research and patient care, but we must also remember that NHS consultants and other professionals do the bulk of practice-based teaching. Since 1997, there has been a 30 per cent increase in consultants in England with honorary contracts to do teaching and/or research in the education sector, which is up from 1,685 to 2,184 in 2003. None of that is to diminish the contribution of clinical academics, but it is important to recognise this other and growing teaching resource.

Let me say something about how we are responding to the challenge that my noble friend Lord Turnberg and other noble Lords have set out so well. I am grateful to noble Lords for the acknowledgement that we are acting in that area. In England, we are investing nearly £33 million over 2004–05 and 2005–06 to support the extension of the new consultants' contract to clinical academics. I remind the noble Baroness, Lady Cumberlege, that another £3 million is specifically to support senior academic GPs—so we are putting money into that area. As a number of noble Lords have said, in the 2004 Budget, we announced an extra £25 million in each of the next four years to strengthen clinical research in England. I will certainly write to my noble friend Lord Rea and other noble Lords about the detail of that development.

We are undertaking a major reform of postgraduate medical training through our Modernising Medical Careers initiative. This has proved a timely opportunity to promote academic medicine by offering trainees more academic placements and dedicated academic specialist training programmes. The first phase of Modernising Medical Careers saw the introduction in August 2005 of two-year foundation programmes, which replace the pre-registration house officer year and the first year of senior house officer training. We announced funding earlier this year for academic placements for 5 per cent of all foundation trainees, which will provide early experience that should stimulate interest in and recruitment to academic medicine.

Modernising Medical Careers has joined the UK Clinical Research Collaborative, which a number of noble Lords have mentioned, in developing new academic training programmes for post-foundation trainees. The joint Academic Careers Sub-Committee, under the excellent chairmanship of Mark Walport, again to which a number of noble Lords have drawn attention, reported in March proposing solutions to problems in academic medicine with the goal of
 
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improving all aspects of academic careers for medically and dentally qualified researchers and teachers. I announced on its publication in March this year that the Department of Health would provide funding of £2.5 million to start as quickly as possible new programmes under Modernising Medical Careers for clinical academics. I did this so that we could make a start on implementing the Walport recommendations, conscious that inevitably we would have to do more work on mapping out the detail. But I thought it important to make a start, which I hope is reassuring to my noble friend Lady Warwick, who asked about long-term financial planning and stability.

As a result of taking action quickly, we have been able to begin the process of enabling more academic clinicians to follow their chosen career path. On 6 October the UK CRC launched a competition for an integrated academic training programme for doctors and dentists in England and Wales. The first fellows will start in 2006, and programmes will provide up to 250 clinical fellowships and 100 clinical lectureships each year as part of the specialist training stage of an academic medical career. Once fully established, these programmes will support around 750 academic clinical fellows and 400 clinical lecturers. We are currently planning for full establishment by 2010.

The noble Baroness, Lady Cumberlege, asked about the long-term commitment to funding. She knows the rules around governments and future commitments outside the current spending review period. My response to her is this: judge us by the action we have taken so far. We are committed to taking this programme forward energetically.

The first phase of the integrated clinical academic training programme, academic clinical fellowships, supports those in specialist training, while the second phase, clinical lectureships, provides opportunities for post-doctoral research career development or higher educational training and attainment of the certificate of completion of training. These will help to alleviate the problems so clearly identified by a number of noble Lords.

Additionally, the Higher Education Funding Council for England is committing up to £50 million over 10 years to support up to 200 "new blood" senior clinical lectureships, in partnership with the Department of Health. There will be five annual rounds of awards following the competition launch this month, with the first lectureships commencing in 2006.

In addition to government departments, healthcare organisations and universities along with several major UK medical research charities have joined this important opportunity to revitalise clinical academic training. The British Heart Foundation, Cancer Research UK and the Arthritis Research Campaign will be promoting expertise in specific clinical disciplines through focused investment. The Health Foundation is making a new investment of £5 million to support up to nine talented clinical academics over five years. Applicants for its clinician scientist
 
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fellowships will come from those working in identified national shortage disciplines; namely, radiology, pathology, anaesthesia, surgery, psychiatry and public health. In tackling the problem, we are seeing the kind of partnership approach that we tried to promote when we established the UK CRC in early 2004.

We continue to work with NHS employers and the Universities and Colleges Employers Association to implement contracts of employment for clinical academics which deliver the joint planning and appraisal recommended by the Follett report, encouraging staff to enter clinical academia and gain fulfilment from all aspects of their role.

The noble Baroness, Lady Finlay, also raised the subject in the context of VAT. I have some good news for the House on this issue. The Government have been taking action on the VAT implications of the Glasgow ruling. A form of contract has been devised which satisfies the contractual requirements of Her Majesty's Revenue and Customs so that clinical academic posts will remain outside the scope of VAT. A joint meeting of Her Majesty's Revenue and Customs, the Department of Health, DfES, NHS employers and the Universities and Colleges Employers Association is being convened to formalise this solution in the near future.

It is encouraging that universities are maintaining good teaching quality at the same time as they are expanding student numbers by making strategic links across university departments. This brings together, for example, physics and chemistry lecturers to support the core scientific elements of the curriculum, thus allowing a more focused use of the particular skills of clinical academics. It is worth remembering that medical school intake has increased by 2,870 places since 1997. We have opened four new medical schools and five new centres of medical education associated with existing medical schools. We have been able to do this because we have been more creative about the way in which we use the talent around in universities, as well as clinical academics, to take on some of the important roles of teaching.

Dental education is experiencing the biggest programme of investment since the inception of the NHS. Additional recurring funding, rising to £29 million a year by 2010–11, is providing 170 additional undergraduate training places. So we are expanding in dental schools as well as medical schools.

I shall try to answer in the time available a number of noble Lords' questions which I have not already answered. My noble friend Lord Turnberg asked about the new money for research registrars: what would happen to the 75 per cent and would it be forthcoming from post-graduate deans? For the academic clinical fellowship programme, that 75 per cent will come from the usual sources that currently pay for clinical training. The post-graduate deans are part of the organisational partnerships that submit the applications of the programme, so they have to be fully signed up to the training programme and for their responsibilities under it.
 
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A number of noble Lords have raised issues concerning the research assessment exercise. The revised HEFCE-led research assessment exercise has been designed to recognise excellence in applied research and in fields crossing traditional discipline boundaries. The changes include the appointment of people with experience of commissioning and using research from industry and the public sector. This should ensure that practice-based research conducted by clinical academics is better recognised. We expect this to be demonstrated in the 2008 research assessment exercise.
 
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As to the issue of the Healthcare Commission and standards, I am afraid that I do not have time to respond to the questions of noble Lords but I shall write to them about it.

Once again I thank my noble friend Lord Turnberg for giving me the opportunity to demonstrate the continuing commitment of the Government to clinical academics and the vital role they fulfil. We accept that there are still problems but we are trying to tackle them on a partnership basis, and with vigour, to overcome them.


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