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The noble Lord, Lord Darzi, during the Committee debate, stated that the awards could recognise,

This amendment is intended to build upon that commitment by ensuring that the research and discovery process that underpins innovation is acknowledged in the Bill. I support this amendment.

Baroness Emerton: My Lords, my name is also on the amendment; I support it, along with the eloquent speech made by my noble friend Lord Walton of Detchant. Coming from the nursing profession and professions not so steeped in history in the educational bodies, I would emphasise that we are, as a profession, “out of sight, out of mind”. There is an unfortunate gap between service and education. That gap needs to be closed quickly to cover all the points that have been put in the NHS review by the Minister, concerning compassion and the values of the NHS. If this could be included in the Bill, it would help the universities to see—in undergraduate training, leading to postgraduate training—the importance of the values of the NHS, and to reinforce them. I strongly feel that “out of sight, out of mind” needs to be cleared, and hope the Minister will be prepared to take this on board.

Baroness Finlay of Llandaff: My Lords, my name is also on these amendments, and I would like to speak in their support. I would also like very strongly to support the point made by my noble friend Lady Emerton. The NHS is dependent on the places where people are educated for the supply of its future staff. Therefore, it becomes absolutely crucial that, right from the day of entry into that educational process, students are viewed as part of the continuing spectrum of the workforce of the NHS. They are the potential workforce. The danger is that those who are organising educational courses can often view something such as the NHS Constitution as something extra that they have to include somewhere in their curriculum, rather than making sure that it is in embedded as a theme running through every aspect of the curriculum. I have seen this in some courses, where new pieces of legislation—and the Mental Capacity Act is one of those—have been added on as if they were bolt-ons, rather than underpinning the way every patient is approached at all times. Therefore, it is important to look at educational provision.

I turn to the second of these amendments. I fear that if we do not include original research, along with innovation, it risks being divisive. Original research may be the thing that triggers the subsequent innovation, and whoever undertook that deserves to be recognised for the work they did. It is also very evident that some of the more innovative and service-based research is coming from the healthcare professions beyond medicine, which are nursing and the allied healthcare professions. To encourage them to have a research approach, as well as to innovate in their practice, would foster the whole research agenda and drive forward the frontiers

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of knowledge. Therefore, I cannot see what there is to lose by including the words “or original research” in that amendment, but I can see that we stand to lose quite a lot by not including them.

Baroness Murphy: My Lords, I hope noble Lords will forgive me if I seem to be turning into a legalistic nit-picker here today, because I am exceedingly sympathetic to what they are driving at. I am particularly sympathetic to Amendment 34 about the prize. Of course, it is an NHS prize, meant for the delivery of innovation in NHS care. Quite whether this is the right amendment to ensure that the right people get prizes for research, or whether it would need to be translational research done within the NHS, I am not sure. But I am very sympathetic to this amendment, even though it may be very difficult in practice to translate that into a part of the Bill.

6 pm

The problem with Amendment 6 is that we have a definition of the discharge of NHS functions. Clause 2 relates to the duty to have regard to the NHS Constitution, and states that each of the bodies listed,

Then an NHS function is described as,

In a way, those bodies are already articulated as to who does provide, commission or regulate services.

It all depends on whether universities and FE colleges discharge any NHS function by delivering educational services. Legally, they probably do not under the definition included in this part of the Bill. That of course is a pity, because I would particularly like to support the notion of my noble friend Lord Walton and the comments of my noble friend Lady Emerton about the crucial nature of getting the principles of the NHS Constitution into the training of nursing and other professions concerned with medicine, as well as medicine itself. To do that, those principles of care need to go right back to the beginning of training. This would be a marvellous place in the Bill to put that. It is also true that universities should deliver education and research with regard to healthcare.

I very much support the principles, but the way that the NHS Constitution is worded and who its functions should be discharged by mean that these amendments are not quite right. However, I am very sympathetic to what they are driving at.

Lord Turnberg: My Lords, I apologise for not being here at the beginning, but I heard the vast majority of the debate on the amendments, which I support for all the reasons so eloquently put forward by a number of noble Lords. I know that the Minister needs no lessons from me about the importance of medical research. He is engaged in so much himself. I am sure that I do not need to remind him of the recent study that showed that it is possible to measure not only the value to people and patients, but the economic value, of medical research, whereby for every £1 that one puts in, one gets £1.39 out in economic terms every

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year thereafter, once the results of that research have been put into action. I know that the NHS Constitution refers to research. I am not sure that it refers to it at great length, but it does refer to it. Nevertheless, given that it is vital to future care, it should be included in the Bill, and I hope that my noble friend will agree.

Lord Sutherland of Houndwood: My Lords, I support the eloquence of my various colleagues, my noble friends, who have put forward Amendment 6 in particular. I declare a disinterest; I am not and never have been a member of any healthcare profession, which may not be true of all the other noble Lords who have spoken, but I have some relevant experience as the head of universities which have incorporated medical and nursing schools, and I am an honorary fellow of one of the royal colleges. My experience is that healthcare and relevant education is always better provided the more closely integrated the two processes are. I have no doubt about that. This is perhaps less obviously true in times of plenty, but in times of shortage people disappear into their bunkers and silos, and the more that one can do in real and symbolic terms to integrate these two area, the better. Hence, I support Amendment 6.

Earl Howe: My Lords, with these amendments the noble Lord, Lord Walton of Detchant, has once again hit the nail on the head, and I very much support the case that he has put forward, especially in relation to education and training. There is a fundamental problem here to which the noble Lord alluded in tactful terms and the noble Baroness, Lady Finlay, drew attention to more explicitly. It is that many NHS organisations, if not the majority, do not regard education and training as part of their core business. They may pay lip service to them, they may be able to show that education and training are taking place, but for many organisations whose primary day-to-day preoccupation is to deliver services efficiently and effectively to patients, education and training are not in the forefront of their priorities.

Unfortunately, this is particularly true of foundation trusts. There are some notable exceptions to that generalisation which we could all name, but the letter of the law which states that foundation trusts must include education and training as part of their core mission does not tend to occupy centre stage in the deliberations of foundation trust boards. Nor is it something to which Monitor devotes a large amount of attention. I may be wrong in that perception, but there seems to be insufficient accountability for success or failure in this area.

We remember all too well what happened in 2006 when the NHS budget came under particularly heavy pressure. Trusts were told that they had to break even or do better, no matter what it took. Surprise, surprise, it was the education budget which was cut quite ruthlessly. I have a figure which came from the Nursing Times, which stated that strategic health authorities skimmed more than £70 million from education and training budgets during 2007-08.

The years ahead are likely to give rise to equal, if not worse, budgetary pressures. The education budget is an easy target, because the general public do not

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notice whether it is being spent or not, but the harm that cuts like that do over the long term is considerable. The training of staff is not something that you can abandon and return to from year to year; it is a long-term enterprise. The universities, whose core business is to deliver training, much of it in collaboration with the health service, are placed in an impossible position if the NHS decides to adopt any sort of stop/go policy.

I am told that the problem tends to be worse in trusts that are aspiring to become foundation trusts, because those organisations cut back on their costs to achieve the desired set of financial ratios, and the cutting of costs inevitably means cutting back on people, which in turn impacts directly on supervision ratios at ward level. That kind of economy has an immediate and obvious impact on the quality of training. Anecdotally at least, cuts are said to account for some of the high drop-out rates that there have been in nurse training, for example.

Equally, I am told that in primary care the quality of work placements is on the whole poor. Part of the problem is that doctors’ surgeries have only a limited physical capacity, but the more fundamental issue is that for primary care practitioners, education is not a core part of their mission. There is no measure which impinges on a service provider for a failure to engage with the next generation of professionals. Yet, in a very real sense, NHS organisations owe it to themselves to be mentors and custodians of the next generation. They also owe it to us as patients, and we need to be very careful that this key function of the health service receives adequate recognition in the way that the NHS Constitution is applied. Those responsible for delivering education and training in healthcare must be held to account for their performance.

I hope that with his close knowledge of the NHS, the Minister will want to focus on the concerns which the noble Lord, Lord Walton, has raised, and that the Minister will also want to make sure that the opportunities presented by having an NHS Constitution with rights and duties within it are not missed.

Lord Mackay of Clashfern: My Lords, I strongly support Amendment 6 and the later amendment, not only in relation to the medical or surgical side of the profession but also in relation to nursing. In recent years, much more nursing training has been provided outside the NHS. In the olden days, the training was mainly in hospitals, but it is now in many cases quite substantially provided in universities. This leads to the difficulty that has been mentioned about the listed bodies. In Clause 2(2), we have the list of bodies, but what the bodies are to do is told to us in Clause 2(1), which says:

“Each of the bodies listed in subsection (2) must, in performing its NHS functions, have regard to the NHS Constitution”.

Clause 2(3) defines what is meant by “NHS function”. It means,

I am inclined to think that most universities will be under an enactment of some kind. Under that enactment, they are providing education. That would be part of the provision of NHS services, because the education

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qualifying people to take part would fall into that category. The Bill does not say a health enactment; it just says “an enactment”. I think that universities would qualify.

As an honorary fellow of some of the medical royal societies, I feel that these societies are in more of a difficulty, because most of them are not governed by an enactment; they are usually set up and governed by royal charter. Certainly, that is my understanding. Therefore, there is some slight technical difficulty about fitting them into the list. I have no doubt that, if the Minister was prepared to agree to accept this in principle, his advisers would quickly put in place the necessary adjustment to take account of it. I just mention it in case it might be overlooked—although I do not think that the Minister would overlook it—or looked on as a fundamental difficulty, because I think that it is a difficulty that can be overcome.

If the training of staff who are going to be members of the health service is undertaken by institutions other than NHS institutions, it is important that the spirit and ethos of the NHS and its constitution should be ingrained in them as part of the initial training. Therefore, I am strongly in support of Amendment 6. I also support the amendment on innovation, with which I have not noticed any technical difficulty.

6.15 pm

Lord Darzi of Denham: My Lords, we have heard from many noble Lords. Again, let me declare an interest. I am a university employee and still remain one. I can sympathise with the noble Lords, Lord Walton and Lord Patel, and the noble Baronesses, Lady Emerton and Lady Finlay, who propose that the list of bodies that are under a duty to have regard to the NHS Constitution be extended to include bodies concerned with the education of health professionals and with the support and delivery of medical and scientific research. In addition to this amendment, I understand that the noble Lord believes that it would be appropriate to require the same bodies to be consulted on the 10-yearly review of the constitution.

Amendment 34, which was tabled by the noble Lords, Lord Walton and Lord Patel, and the noble Baroness, Lady Finlay, would enable the Secretary of State to make payments to promote innovation or original research.

Both research and education are the bedrocks of high-quality patient care. I hope that I can provide noble Lords with reassurances in relation to some of the concerns that have been raised today. First, by way of context, I reassure the noble Lord that education and research are vital to the NHS. In 2009-10, £4.6 billion was allocated to strategic health authorities for education and training, and health research commissioned by the NHS has reached £1 billion for 2010-11. High Quality Care for All, on which I reported in July last year, set out our commitments to the establishment of, for example, academic health science centres, which will bring together a small number of health and academic partners to focus on world-class research, teaching and patient care, bringing the NHS and research ever closer in the history of the NHS.



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My report also sought closer working between the NHS and education institutions by proposing the creation of new health innovation and education clusters. These announcements will be made soon. These clusters will bring together many partners, across primary, community and secondary care, universities, colleges and industry. Bringing NHS organisations and higher education institutions together will promote learning and education between their members and will enable research findings to be applied more readily in improving patient care.

The noble Earl, Lord Howe, raised the issue of NHS budgets. We have on many occasions debated how we protect these budgets and, within the contexts of the health innovation and education clusters, some of the policy reforms that we are introducing will create more transparency. I remember on numerous occasions the noble Baroness, Lady Tonge, asking how we protect these budgets. The best way to protect them is to introduce transparency and a tariff system, where a budget will follow a trainee. That is the way in which we hope we will reform our education system, under the guidance and the support of Medical Education England from the medical perspective, and working with nursing colleagues to find a more transparent way in which we can allocate our education and training budgets.

On Amendment 6, I would like first to consider the NHS Constitution. The importance that we attach to both education and research is reflected in the third principle in the constitution, which states:

“The NHS aspires to the highest standards of excellence and professionalism ... in the people it employs and the education, training and development they receive ... and through its commitment to innovation and to the promotion and conduct of research”.

In addition, although we have debated whether this amendment is necessary, I have to make the point that all education and training commissioned directly by the NHS is already covered by the legislation as drafted, as the noble Baroness, Lady Murphy, pointed out. Strategic health authorities and other NHS organisations will have to have regard to the constitution in everything that they do, including education and training. That should be included in commissioning education and training. However, the noble and learned Lord, Lord Mackay, always challenges me when it comes to issues of the law and I take the point that certain colleges, as far as royal charters are concerned, may not be able to do this. I will be more than happy to seek further legal advice and to bring this back when we come to the next phase of the Bill.

I turn now to the new bodies concerned with the support and delivery of medical and scientific research. Primary care trusts and other trusts can undertake, commission and assist in research. Any of this research would be captured, I believe, by the duty to have regard to the constitution in Clause 2. The current definition of “NHS function” in Clause 2(3) refers to,

I believe that this covers patient-facing research, where patients receiving NHS services are involved.



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On consultation on the constitution on a 10-yearly basis, I again reassure noble Lords that many groups involved with research, training and education of health professionals contributed to the production of the final NHS Constitution, such as the General Medical Council, the Medical Research Council and the Academy of Medical Sciences. Their contributions were valuable and we shall of course wish to involve them in any further changes to the constitution, including the 10-yearly review of the constitution and any more minor revisions, where they are affected.

I now turn to the innovation prizes and the spirit in which they have been introduced. As I have said in the House before, I strongly believe that these prizes are intended to get the best minds in this country to focus on some of the challenges that will face us in the future, and those challenges will require major breakthrough discoveries. That is what I am referring to in relation to the prizes. I think that the noble Baroness, Lady Murphy, mentioned Peter Mansfield, who discovered MRI in 1967 in Nottingham. He was not recognised for his research until 2005, when he won the Nobel Prize. Many such discoveries occurred in this country, and their benefits were translated elsewhere around the globe before they had an impact on our NHS patients. Therefore, the drivers behind the NHS innovation prizes are major breakthroughs and major discoveries.

My noble friend referred to innovation prizes and the use of the word “research”. This is a question of semantics. The definition of “innovation” is the successful development and implementation of new ideas, commonly divided into three stages: identification or invention, which is one area that we discussed in relation to research; growth, including adoption, testing and evaluation; and diffusion. However, if noble Lords still believe that we can strengthen the definition, I shall be more than happy to do so. In that respect, I am delighted to report that tomorrow we will be announcing the appointment of Professor Sir John Bell, the president of the Academy of Medical Sciences, as interim chair of the expert panel. I shall be more than happy to discuss the words “research” and “innovation” and to come back to the matter at Third Reading. I think that we all agree about the purpose of these prizes and about the very major role that universities and other higher education providers can play in relation to research.

I hope that I have reassured noble Lords that some of their amendments may not be necessary, but I am happy to seek further legal advice in relation to them and to come back at Third Reading.

Lord Walton of Detchant: My Lords, as always, I am deeply grateful to the Minister for his comprehensive, thoughtful and helpful comments on these amendments. As he said, it is crucial that the interrelationship between NHS bodies and universities is close, as is made evident by the fact that 30 per cent of clinical academic posts in the UK are funded by the National Health Service.

However, there are still considerable anxieties, some of which were pointed out by the noble and learned Lord, Lord Mackay of Clashfern, my noble friends on

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these Benches and the noble Earl, Lord Howe. Despite everything that the noble Lord has said, certain NHS bodies seem reluctant to accept their responsibility in relation to education and research. For example, it has just been pointed out to me that, with regard to training around 95,000 students from this September in nursing, midwifery and the allied healthcare professions, universities have no information about the level of benchmark prizes to be paid by the strategic health authorities, and this is at a time when they are trying to finalise their budgets for the 2009-10 academic and university financial year. Therefore, there are continuing anxieties, although it was extremely helpful of the noble Lord to say that he would look again at the amendment on innovation prizes.

In the light of the Minister’s letter and comments, when I first came to the House today, my feeling was that I should withdraw the amendment. Then, when I heard the speeches of many noble Lords around the Chamber, I thought that in many respects it would be much more sensible to test the opinion of the House. However, with reluctance, but nevertheless with gratitude for the way in which the noble Lord has presented the Government’s case and for his willingness to reconsider the matter at Third Reading, I beg leave to withdraw the amendment.

Amendment 6 withdrawn.

Amendments 7 and 8 not moved.

Amendment 9

Moved by Earl Howe

9: Clause 2, page 2, line 28, at end insert—

“( ) The Secretary of State shall publish guidance providing for the meaning of “have regard to” in this section.”

Earl Howe: My Lords, Amendment 9 is designed to take us back to one of the most perplexing aspects of this whole chapter of the Bill: what exactly it means to require bodies and persons to have regard to the NHS Constitution.


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