National Health Service Reform and Health Care Professions Bill
Mr John Hutton (Minister of State, Department of Health; Barrow and Furness, Labour)
I should express right at the beginning of my remarks the fact that I fully understand the sentiments and concerns that underpin amendments Nos. 2 and 4, which were made to the Bill in another place. In particular, I am sure that we would all wish to ensure that the enormously important contribution that academic medicine makes to the national health service is properly safeguarded and that its international reputation for excellence is properly secured.
Fundamentally, the arguments in favour of the amendments are based on two assumptions, the first of which is that the existing legal framework to ensure that education, training and research is properly underpinned in the NHS is either inadequate or ineffective. I do not believe that to be the case. The necessary statutory powers already exist and help to ensure that a proper focus on education, teaching and research is maintained right across the service.
The second assumption is that the NHS does not take the question of education, training and research seriously enough—that it is too low a priority and that creating a new legal duty in this area will improve matters.
"to secure that there are made available such facilities as he considers are reasonably required by any university which has a medical or dental school, in connection with clinical teaching and with research connected with clinical medicine, or as the case may be, clinical dentistry".
That duty is already delegated to health authorities, and once the changes under "Shifting the Balance of Power within the NHS" take effect—and once the changes under the Bill take effect later this year—it will be delegated directly to primary care trusts across the country. The duty is no less of a duty because it is delegated by the Secretary of State to PCTs. The Secretary of State and, through him, PCTs, will have a duty under the section to ensure the provision of facilities that are necessary for clinical teaching and research.
Under paragraphs 14 and 15 of part 3 of schedule 5A to the 1977 Act, which broadly sets out the powers and duties of PCTs, PCTs are empowered to conduct, commission or assist the conduct of research and to make officers and facilities available in connection with training by a university or any other body providing training in connection with the health service.
Under paragraph 11 of schedule 2 to the National Health Service and Community Care Act 1990, an NHS trust may undertake and commission research and make available staff and provide facilities for research by other persons. Under paragraph 12 of schedule 2 to the 1990 Act, an NHS trust may also provide training for persons employed or likely to be employed by the trust or otherwise in the provision of services under the 1977 Act, and to make facilities and staff available in connection with training by a university or any other body providing training in connection with the health service.
Under section 5(2)(d) of the National Health Service Act 1977, the Secretary of State has the power to conduct, or assist others to conduct, by grants or otherwise, research into matters relating to the causation, prevention, diagnosis and treatment of illness, and into any such other matters connected with any service provided under the 1977 Act, as he considers appropriate.
In addition to those specific powers, if it appears to the Secretary of State that it is necessary under section 17 of the 1977 Act, as amended by the Bill, he has a power to give directions about their exercise of any functions to strategic health authorities, PCTs and NHS trusts. The exercise of all those powers in relation to health bodies in Wales has been devolved to the National Assembly for Wales.
Anyone with a fair mind would regard that description of legal powers and duties as a comprehensive one, which I believe provides a solid legal basis for education, training and research right across the NHS.
The Lords amendment was made with the best of intentions—I am absolutely sure of that—but it would be superfluous to include its provisions in the Bill. As a general principle, we should not legislate unless there is a clear and obvious need to do so. An adequate legal framework is already in place and can, if necessary, be supplemented by directions from the Secretary of State to strategic health authorities, PCTs and NHS trusts about the exercise of relevant functions. There is, in short, no substantive need for the amendment, and that is why we should not accept it. There is another set of difficulties with the amendment. It is too vague to be meaningful. It does not even define education, training or research, or limit the scope of those three concepts to the health sector; nor does it offer any way of measuring whether the bodies concerned are meeting their legal obligations.
The second argument in support of the amendments relates to the concern about whether there is sufficient focus on education, training and research in the NHS. I believe that there is. That is certainly true of resources. On research, the Department of Health has increased its research and development budget from £432 million in 1996–97 to £507 million in this financial year. In relation to education and training, the budget for multi- professional education and training—the new MPET budget—has increased from £1.7 billion in 1996–97 to £2.9 billion this year. Those are significant increases in resources. No one looking at those figures could say that the Government have not focused sufficiently on education and training issues.
The amendments are not necessary to protect the funding for education, training or research. NHS funding for supporting research and development and for education and training is already managed centrally, as I am sure Mr. Burns recalls from his time in the Department of Health. NHS education and training funding is allocated to local NHS work force development confederations, which bring together local NHS organisations, including primary care organisations. Those in turn have the responsibility to purchase NHS-funded education and training from higher education institutions in accordance with local work force requirements, of course taking account of national priorities. NHS trusts can also use their own funds to support education and training where appropriate.
PCTs in particular, therefore, will not be under pressure to spend that money for other purposes. We have no plans to put the funding for research into PCTs' allocations for patient care. The money for research is ring-fenced. Indeed, even the small amount of money that health authorities spend directly on commissioning public health research and development will in future be protected within a ring-fenced central research and development budget.
The argument is not simply about money, however. It is right that we continue to look carefully at how we can improve present arrangements. That is why we will look for an increasingly closer collaboration between universities and research-active NHS bodies to guarantee the quality of research that meets the needs of patients and of staff delivering services at the front line.
We are already putting in place a new network of PCTs that will help to promote high standards of research governance and management across health and social care. The creation of that network by April next year is one of the targets in implementing the research governance framework for health and social care, which my Department published in March 2001. Those PCTs will have research management capacity that they will share with other PCTs around them, encouraging, I hope, a collaborative approach to research. By next April, we will also have in place around 30 new teaching PCTs, mainly in underprivileged and under-staffed areas to provide teaching, research and clinical opportunities for primary and community care professionals to support and improve the delivery of services to local populations. Teaching PCTs will work alongside local universities to provide a learning environment for their own organisation, as well as a local resource for the wider health community.
PCTs will also have the ability and opportunity to enhance the quality of patient care by engaging patients and carers in support of teaching and research; by fostering the special opportunities available in primary care for research and for teaching students across the range of health professions; and by taking full account of teaching and research in their commissioning of local and more distant hospital and specialist services. We expect PCTs to grasp those opportunities to ensure both the long-term success of the NHS plan and the continuing contribution of the NHS to health-related research and education.
To ensure that PCTs are fully equipped to take on their new functions, the national primary care trust development programme has been established. The programme recognises that, in addition to developing the general competencies of PCTs, more detailed work is required over a longer period on specific issues. I am pleased to be able to announce that one of those subjects will be the research, education and training issues affecting PCTs. The national primary care trust development programme will pull together a number of front-line PCTs, and other key individuals and organisations, to help to take that work forward. That will help to support PCTs in discharging their important responsibilities in that sector.
The Government are fully committed to investment in the NHS work force. The NHS plan has made that commitment clear, and our record in office confirms the priority that we rightly attach to education, training and research. Since 1997, the number of nurses has increased by 31,520; in the year between September 2000 and September 2001, the number of qualified nurses employed in the NHS increased by 14,430, or more than 4 per cent. Since 1997, the number of qualified scientific, therapeutic and technical staff has increased by almost 14,000; in the past year alone, the number of such staff has increased by 4,290 or 4 per cent. Since 1997, the number of doctors has increased by 9,550; there are now 99,170 doctors, excluding GP retainers, in the NHS in England. In the past year, the number of NHS doctors has increased by 2,850, or 3 per cent. I am glad to say that there are now 4,320 more consultants than there were in 1997.
The House will probably be grateful if I do not continue to read through that long list of statistics, but overall they are extremely positive. They confirm that we have prioritised that necessary investment, and that it is being made. We are committed to the development of that work through an expanded programme of education, training and research. The NHS plan and the most recent Budget underline those strong commitments. The Government are also committed to a modern NHS that values and makes use of research-based evidence in developing patient services.
Given the legal provisions that are currently available to sustain the proper focus on education, training and research, and the special arrangements that apply to the use of those resources in the NHS, I hope that the House agrees that amendment No. 2 is not necessary. Although I am sure that it is motivated by the best intentions, the circumstances in which we should and should not legislate are clear.
Amendment No. 4 would impose a similar statutory duty on local health boards, NHS trusts in Wales and specialist commissioning bodies in Wales. The position in Wales in respect of legal powers must now take into account the devolution settlement and the Government of Wales Act 1998. The existing powers and duties of the Secretary of State, laboriously described by me this afternoon, as they apply to the NHS in Wales have been devolved to the Welsh Assembly.
In addition, clause 6 confers on the Assembly a new general power both to establish local health boards and to determine their functions and duties. Consultation on the new structures will soon start in Wales. The problem with the amendment is that to a large extent it pre-empts that consultation exercise by establishing on the face of the Bill one of the duties of these new bodies; it is therefore inconsistent with the thrust of clause 6.
Were we to accept the amendment, we would in effect fetter the democratically elected devolved Administration in the exercise of their powers over those policy matters. The form, functions and responsibilities of local health boards are rightly matters for the Welsh Assembly to determine through regulations. Those regulations will be subject to scrutiny through the secondary legislation procedure, which will allow full open debate by Assembly Members. That is the right way to determine the functions of the new bodies in Wales, and that is what clause 6 already provides for. Amendment No. 4 would take us in the opposite direction, and for that reason, we should not agree to it.
Mr Simon Burns (West Chelmsford, Conservative)
I listened carefully to the Minister and I appreciate his acknowledging that the amendments were tabled in all good faith. However, he went on to say that they were superfluous; I do not concur with that aspect of his analysis. As the Minister will know, concerns have been expressed in many areas by a large number of individuals both inside and outside the NHS about the terms of medical education, training and research. The amendments apply to England and Wales; they have the widest possible terms and embrace all aspects of education, training and research relevant to the NHS.
I am sure that we all agree about the importance of education, training and research, but we cannot ignore problems in respect of their delivery, which is at the heart of our disagreement with the Minister. We want to focus on the size of the problem and whether existing NHS structures allow education, training and research to thrive and prosper. No one would disagree that our final goal is to ensure that they do so, but our disagreement or, rather, our change of emphasis, concerns the way in which we maximise opportunities and ensure that delivery goes beyond mere rhetoric and lives up to expectations. The issue at stake is not simply the existence of powers in NHS legislation, but whether they are being used to their full extent to maximise benefits and opportunities, which is why the proposed new clauses use the word "duty" in their titles. Will the Minister explain again why he believes that that word is superfluous, instead of regarding it as a back-up in the armoury of delivery to ensure that we achieve the end that we all seek?
While we all agree about the importance of education and its vital role in the NHS, it is plain to many people, particularly those involved in training and research, that those disciplines are vulnerable and threatened in the NHS. There is abundant anecdotal evidence that teaching and research resources are currently squeezed in NHS trusts. Lecture theatres are used for other purposes; there is a staffing crisis in universities; and doctors are so overwhelmed by day-to-day demands on their time, which affect their health care functions, that there is little or no time for research. It is all too tempting to sit back, secure in the comfort of the extra resources to which the Minister referred this afternoon and the possible extra resources that will emanate from last month's Budget. Citing statistics, however, will not make the problem go away; after all, part of the problem has been the squeeze on finances.
The problem, however, is not as simple as that. It is far from clear that any extra resources will find their way into teaching and research, as the Minister hopes. The crux of the matter is whether all the bodies in the NHS with a role in teaching, research and education will deliver the enhanced service we all hope for. I have doubts, for example, about primary care trusts and their lack of expertise and experience. The Minister may say with some justification that as PCTs bed down and gain experience, that problem may be minimised. The fact is that, as we made abundantly clear in Committee, the time scale for the introduction of PCTs was rushed; there will be problems with the new bodies' lack of experience and their ability to cope with their heavy responsibilities.
I have no doubt—and I hope that no doubts arise—that PCTs will build up experience and that the fears and concerns expressed in the initial stages of their creation will be removed. None the less, experience is a problem in the early stages, as it will be in any new organisation. The trusts have been asked in these early days to concentrate on identifying and providing acute care and other health services. However, if all their time and effort is concentrated on the delivery of health care—everyone would agree that that is their main function—problems may arise if they have to cut corners in the early stages because of those demands.
Education, training and research are a classic issue that PCTs will always feel they can pick up on later while seeking now to minimise the other problems concerning health care provision. Another problem is that the trusts' natural orientation is towards primary care. For those reasons, I do not believe that there can be certainty that PCTs will commission so as to promote and safeguard education, training and research to the extent that we would have hoped and expected them to do, especially in their early days.
The safeguarding of those elements of the health service, on whose importance we all agree, is still not addressed by strategic health authorities. The Government have stressed the role of SHAs in terms of the performance management of PCTs that fail to achieve what the authorities believe they should achieve on education and research. I am deeply sceptical, however, about whether the introduction of such loose structures and untried processes at this stage of the reforms will solve the problem.
Nevertheless, there is one sure way we can safeguard the three critical areas in question and put beyond any doubt the responsibility of NHS bodies for those vital elements, which are crucial if our health service is to continue to make improvements and enhancements and to deliver quality treatment. That solution is for the Minister to think again and accept the amendments introduced by another place—a place that is renowned for being not the partisan and highly political body that this House often is, but a more reflective body, which in debates about the Bill has drawn on the expertise of people who have spent a considerable proportion of their professional lives in the health service and in health and research in general. It would be unwise not to heed their wise words and reflective views and to seek to reverse a measure that was introduced into the Bill not to cause trouble but to strengthen, encourage and enhance training, research and education.
In the light of the reasonable way in which I have tried to convince the Minister of the argument, I hope that he will understand in an equally reasonable way that as we are considering such a crucial matter it would be wise to strengthen and reinforce the message by agreeing to the amendments, instead of deciding that they are superfluous and relying on the provisions as they stood before the Bill was amended.
Dr Evan Harris (Oxford West and Abingdon, Liberal Democrat)
I speak in support of the Lords amendments and against the motions to disagree on the basis of, first, a series of problems that exist at the level of academic medicine and teaching and research; secondly, an additional problem caused by Government policy, which puts more pressure on primary care trusts not to deal with the problem; and thirdly, a question mark over whether there is any problem with introducing the amendments. The Government may suspect that they will not be effective, but I do not believe that they would do any harm.
There are significant problems in education, training and research. There are also significant numbers of vacancies in academic medicine, and that situation is not getting any better; if anything, it is getting worse. Without the people to do the training—and, indeed, the people to train the trainers—we shall not have a work force in the future. A briefing provided by the British Medical Association tells us that the number of medical academics as a proportion of the work force has fallen from 11 to 8 per cent.
That fall is partly the result of an increase in the numbers of staff, but I would argue that there is an a priori reason for the proportion to stay the same, because as we recruit new staff they will initially be at a junior level, and we are still not seeing enough resources going to provide either the trainers or the trainers for the trainers. The significant problems in the recruitment of medical academics are often due to the pressures on them, and the lack of resources they feel they have in terms of time, equipment, hardware and space to do the teaching that is required.
A further component of the need to ensure that resources are allocated to this area is the desperate need for consultant expansion. If resources were spent on education and research because of the amendment that has been made in the House of Lords, the side effects would be that a significant amount of that money would be extra funding, and that extra priority would be given to consultant expansion. I have said to the Government—and to the Minister who is speaking for them today—on many occasions since 1997 that they must safeguard consultant expansion and ensure that resources go into enabling senior-level consultant staff to do high-quality work, research and training, rather than allowing the expansion of sub-consultant and non-consultant career grade posts, which, for all their merit, are almost by definition not involved in the training of the next generation of specialists; they are almost entirely service-related posts.
Until the Government can do something about the explosion of such posts, I will have little faith in their ability to ensure that there will be sufficient numbers of people to do important work such as the research that is led—although not exclusively carried out—by consultants, and the training that ought do be done almost entirely by fully trained specialists. Were the Government to introduce, through separate legislation, the means of controlling this explosion in sub-consultant grades and non-consultant career grades, we would be much more inclined to support the position that they are taking here and—I suppose that this is what counts for the Government in terms of the size of their majority—in another place. The Minister will accept that I have raised this issue several times; I have never had a satisfactory answer. Perhaps, with this Government, I never will.
Dr Andrew Murrison (Westbury, Conservative)
Does the hon. Gentleman agree that a lot of what he is saying has to do with semantics, because what were once senior registrar grades are now, effectively, consultant grades, as we have recruited consultants who are younger and less experienced?
Dr Evan Harris (Oxford West and Abingdon, Liberal Democrat)
I fear that I do not understand the hon. Gentleman's question, and I would hesitate to guess at what he means. The easiest thing for me to do might be to restate our position, which is that we need—and the Government have said that they wish to see—a consultant-provided service for the treatment of patients and for the education and training of the next generation of the work force, and a consultant-provided, or at least consultant-led, research service. This applies to the other health care professions as well; I am using this as an example, but I am keen not to be seen to be concentrating on this one aspect.
If I have misunderstood the hon. Gentleman I apologise, but what we have seen instead is an explosion of jobs being created that are not to do with education and training. They are purely service jobs, including staff grades and associate specialists or, worse, non-mainstream trust grade doctors who are there to do the service work that trusts feel under pressure to do. Their numbers have expanded enormously. The Minister has heard me say before that many of the people filling those posts have not been treated well by the health service, often on the basis of their background or race, and that there are significant issues to address in this area.
We need to expand consultant opportunities and increase the number of people being trained for that specialist status. In the absence of a Government policy to guarantee that, this amendment, which would put a duty on the commissioners of services who provide the funding for those posts, would provide a mechanism for applying pressure for consultant expansion, although it would not be enough in itself. I hope that by setting out my position I have addressed the hon. Gentleman's point.
The Minister said that the Government recognise the importance of research and try to base their policy on it. I question that, as I have before, because of some of the health policies that the Government are pursuing, such as giving priority to the two-week wait policy for cancer patients, which for all its merit is certainly not based on evidence of clinical outcomes. If the Government are saying that they support research so that it can inform their policies, they must "want"—to coin a phrase once used by another hon. Member—more research evidence, because I am not satisfied that that is happening.
My main concern is the pressure on primary care trusts and budget-holders arising from the distortion of priorities caused by the welter of Government targets, which are based, at best, on sensible service provision and, at worst, on aims that have little significance for, or impact on, rational patient outcomes. We know that education and training will always suffer when the commissioners of care are faced with compulsory targets.
If the Government withheld from setting some targets or at least adopted a more rational approach to target setting, I would be more likely to support their position that there is no need for the Bill explicitly to defend and protect less glamorous areas of the NHS. They may be less glamorous, but what is significant in this discussion is that they are not outcome-measured like many of the other initiatives that the Government have forced on primary care trusts. We have the tyranny of appraisal and the measurement of outcomes, and anything that does not have a hard outcome is deprioritised. That is why placing this duty on primary care trusts, although it is not the optimum solution, is a useful approach.
I turn finally to ring-fencing. The Minister knows my view that ideally we would have proper devolution of funding. Local commissioners would not be hidebound by ring-fenced pots or targets but would be in a position to allocate funding as they saw fit, according to local priorities, with a recognition of services that are not affordable through explicit rationing.
The Minister seeks to defend his position by saying that funding for research and education is ring-fenced, but at the same time he claims that the Government are devolving responsibility for decision making to primary care trusts, and that is not wholly consistent. The Government must decide once and for all whether they are in favour of full devolution of spending decisions or whether they are in favour of a ring-fenced approach. We could then examine that policy in more detail.
The time of people in education and training is not ring-fenced. They find that increasingly even their unpaid overtime is being eaten into by service requirements, some of which are reasonable and some of which are merely target chasing. It is to protect their ability to do their job and to avoid causing them to leave the NHS in disgust, which would create an even greater manpower problem, that we should agree with the Lords in their amendment and allow the duty to remain in the Bill.
Mr John Hutton (Minister of State, Department of Health; Barrow and Furness, Labour)
I shall try to deal with the points raised by the hon. Members for West Chelmsford (Mr. Burns) and for Oxford, West and Abingdon (Dr. Harris). Both made thoughtful and well argued cases for the amendment, but none of their arguments confronted the issues as I see them. They did not deal with the inescapable logic that we should consider the legal basis of how these matters are currently regulated in the NHS. They also failed to deal with my remarks about our commitments and our allocation of resources. Listening to those contributions, one would think that education, training and research budgets were being cut because of service pressures elsewhere. That might well be an accurate description of past times, but it does not describe where we are today. Education, training and research projects are all growing substantially—a fact that provides the right context for the discussion that we should be having about these issues.
The hon. Member for Oxford, West and Abingdon raised some important points, and I agree with much of what he said about non-consultant service grade doctors and so on. There is little doubt that some of the growth in those grades constituted a reaction by trusts to the problems—as they perceive them—arising from the working time directive. To find solutions, we need to address that issue and to engage with the service urgently. It is not in the long-term interests of patients, doctors or the NHS itself to trap a large number of doctors in service grades in which they will be unable to use their full potential and skills. Frankly, such posts would not seem attractive or easy to fill in any case, even if it were right to set them up.
There is one aspect of the hon. Gentleman's argument that I find slightly difficult to understand. How would placing such a duty on primary care trusts deal with the problem? I accept that, in essence, we are talking about service issues that relate to resources. We need to look at medical, education and training issues in the round, and that is what we are doing. For example, we are considering senior house officer training, and there is a very strong case for reconsidering other grades, particularly non-consultant grade 2. Education, research and training are not—as the hon. Gentleman and the hon. Member for West Chelmsford have suggested—at the bottom of a list that prioritises issuing targets, and so on. Such issues are a priority, because fundamentally the national health service is a knowledge-based service. It is based on, and driven by, science and evidence.
The key to growing capacity—the biggest challenge that the NHS faces—is to invest in the NHS work force. We must train the new doctors, nurses, therapists and other grades of staff that the NHS needs for the future. We would be daft to compromise its ability to meet the NHS plan's challenging targets by taking a penny- pinching approach to education, training and research. We are simply not going to do that.
Dr Evan Harris (Oxford West and Abingdon, Liberal Democrat)
The Minister knows I accept the argument that he has just made, and I recognise that funding is available to begin the expansion of various aspects of the health service that we all want to see. I welcome his comments on non-consultant career grades, and perhaps we can pursue that issue later. However, I should stress that I am arguing not that the amendment would resolve the problem, but that—in terms of the need for consultant expansion, rather than service grade expansion—it would offer a protection, until we can see the fruits of the Government's thinking. Such thinking is reassuring, but we need to see the fruits of it.
Mr John Hutton (Minister of State, Department of Health; Barrow and Furness, Labour)
If I genuinely thought that that were so, I would take a different view, but I simply do not believe that the amendment would achieve the hon. Gentleman's aim, and it certainly would not achieve mine.
There is also a wider context, to which the hon. Gentleman referred, that we should keep in mind. On the broadly philosophical question of the balance between earmarked funding and general allocations to NHS organisations, I hope that he recognises the fact that we are earmarking unified general allocations to NHS trusts less and less. However, education and training is a separate issue. The hon. Gentleman, his Liberal Democrat colleagues and the hon. Member for West Chelmsford have identified the importance of such investment. We can secure prioritisation in an effective way without fundamentally compromising the thrust, the spirit or the letter of our policy on devolution.
The work force development confederations that receive the new training and education resources on behalf of the NHS are constituent organisations, consisting of local acute trusts, primary care trusts and so on. They are the organisations best placed to take such decisions. In distributing training and education resources to the confederations, identifying such resources carefully, and ensuring that they are spent on the purpose for which they were intended—a point that the hon. Member for Oxford, West and Abingdon raised in support of the amendment—we are in no way conflicting with our overall position on the devolution of power to the NHS front line.
This is probably one of those debates in which, despite having all the arguments on my side, I will not persuade the hon. Member for West Chelmsford and the Liberal Democrats to take a different stance. They supported the amendments in the other place and I fully understand why they did so. In asking the House to disagree with the Lords amendments, I am in no way trying to downplay the importance of education, training and research. We differ about how the goal can best be achieved.
I am absolutely sure that the Secretary of State, the Department of Health and the NHS recognise the importance of education, training and research. We have shown that commitment in the way that we have dedicated significant additional resources to challenging some of the problems that we face and dealing with the capacity constraints that we inherited in the training of nurses, doctors and other therapists.
We are getting on with that job. The best way that we can do that is to continue in the direction that we have set, and not legislate unnecessarily. We would be doing that, and ineffectively as well, if we accepted the amendments. The Government will continue to attach the highest priority to education, training and research across the national health service.