Clinical Academic Staff

– in the House of Lords at 4:10 pm on 1st December 2005.

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Photo of Lord Turnberg Lord Turnberg Labour 4:10 pm, 1st December 2005

rose to ask Her Majesty's Government what steps are being taken to reverse the decline in numbers of clinical academic staff.

My Lords, I am delighted to have the opportunity of introducing this debate on a cold Thursday afternoon, but never has there been a more important moment for us to discuss investment in medical research. I should declare my interests as a former professor of medicine and a Fellow of the Academy of Medical Sciences.

Enormous opportunities are now opening up for us and we are poised to enter a golden age of medicine. Every day we read of advances in research which offer the potential to prevent heart attacks, cure cancer and the like, and undoubtedly we are living longer and healthier lives. A child born today will live two years longer than one born 10 years ago. We gain two years in every 10, and it is reckoned that around 50 per cent of that gain in longevity is due to advances made in medical science.

But all the marvellous new insights in molecular biology, immunology, biochemistry and new technologies become of practical value only when they can be applied to the care of patients. Let me give an example of what I mean. Many years ago a substance was discovered in the body called tumour necrosis factor, TNF. It was found to have wide and important effects in biology, especially in the immune system. Enormous amounts of research were done on how it works and what it does, but it was only when TNF was applied to treating human disease that it was found to be of great clinical value. Workers at the Kennedy Institute in London did all the clinical research that was necessary and showed that antibodies to TNF could be used safely in patients with rheumatoid arthritis. This has revolutionised the treatment of the disease. For carrying out that work, Professors Maini and Feldman won the Lasker prize.

The point I am making is that it is only the application of basic science to patient care at the end of the line, where the clinical research has to be done and where paradoxically we are currently lacking the key figures to pursue the sort of research which Maini and Feldman did so successfully. At a time when basic science is marching ahead, clinical research is faltering. At a time when we have probably the best clinical laboratory in the world in our single, comprehensive healthcare system, with its common goals and infrastructure, we are failing to take advantage of it. And while there are many reasons for this state of affairs, it is the fall in the number of those who engage in clinical research, the academic clinicians, which has been so damaging.

Let me give some rather disturbing data which have been collected by the Council of Heads of Medical Schools over the past few years. At a time when we have seen the creation of four new medical schools and an increase of up to 50 per cent in medical student numbers—a time when one might expect the number of medical academic teachers to increase at least a little—we have seen a considerable fall instead. Between 2000 and 2004, there was a fall of 42 per cent in clinical lecturers and of 11 per cent in senior lecturers. In some disciplines the falls have been extreme. In pathology, where there were 64 lecturers in 2000, there were a mere 12 by 2004. Psychiatry experienced a fall from 114 to 40; public health from 62 to 22 and surgery halved from 98 to 50. Although the number of professors has risen a little, there remains an overall drop of 12 per cent. Similar patterns can be seen in academic dentistry, and there are also difficulties in academic nursing. There is clearly a gross mismatch between the needs of young students to be taught and the number of clinical academics available to do so, to say nothing of the falling prospects for clinical research.

The reasons for these falls are multiple and well recognised. They include such pressures as the prolonged time it takes to train a clinical academic in both clinical practice and in research; their poorer financial rewards, research and teaching being squeezed out by the care of patients which always comes first; and the heavy regulatory burdens on researchers. Is it much wonder that many are turned off and take the easier option of going into primary care or consultant practice rather than take on this uphill struggle for smaller rewards?

It is against this background that a number of recent initiatives by the Department of Health have been extremely welcome and should go some way to addressing the balance. First, the clinician scientist fellowship scheme set up four or five years ago has seen the appointment of a small number—so far about 80 out of 250 proposed—of elite, young clinical academics with protected time to undertake research. Secondly, the creation of the UK Clinical Research Collaboration, the CRC, is a very important initiative, with funding promised to allow a number of developments. But perhaps the major initiative has come through a CRC sub-committee, headed by Mark Walport of the Wellcome Trust, which has come out with some excellent proposals, the majority of which, I am happy to say, have been taken up by the Department of Health.

The intention is to appoint 250 academic clinical fellows and 100 clinical lectureships each year, and that once up and running for three or four years these programmes will support as many as 750 fellows and 400 clinical lecturers. Funding for these is, of course, key, and this is promised for 25 per cent of the salaries of the fellows and 100 per cent of the lecturers. It is a remarkable and very welcome indication of the Government's commitment to medical research.

On top of all this, the Higher Education Funding Council for England has committed to fund 50 per cent of 200 new-blood senior lectureship posts over 10 years and apparently has agreed to provide £50 million in partnership with the NHS.

Finally, the NHS R&D Directorate has recently released a consultation document, entitled Best research for best health, outlining a new NHS research strategy which bodes well.

You might ask, therefore, "What is the problem when all this frenetic activity is going on which seems to be the answer to every academic maiden's prayer? Why look this set of gift horses in the mouth?". Well, it is always wise to check whether the gift horse has teeth in the right place, and it is here that I would like to seek reassurances from the Minister about a number of aspects.

The new money for research registrars is said to cover 25 per cent of the costs of their salaries so that the lucky ones can spend a quarter of their time in research. But is the 25 per cent really new money? Will the postgraduate deans, who are responsible for at least the clinical training of these doctors, be able to take on board this influx with dual training requirements, both research and clinical? Will the new clinical lectureships be taken on by the universities, which, after all, are responsible for academic appointments? There is not much mention in the consultation document of university or medical school involvement in the appointment of these posts. The major issue is whether the new money proposed for these welcome initiatives continue to be forthcoming over the next few years as promised? I hope it will, but it would be nice to have it confirmed by my noble friend.

Of course all these developments are extremely welcome and for the first time in many years there is a sense of optimism that medical research will be given the attention it deserves. But, even though it may seem churlish of me, I have to say that to make a career in academic medicine an attractive option for all these new lecturers we are hoping to see come in, we will have to correct some of the disincentives I hinted at earlier.

The first is the heavy regulatory burden facing clinical researchers. Much has been done following the review of research ethic committees, which the Minister initiated and have done so well, but there are many other regulatory bodies which need similar attention. There are now so many different types that it is the multiplicity of regulatory bodies which poses the burden. I hear from researchers that delays of six months are the norm, and 12 months not uncommon, because of the need to jump so many regulatory hurdles. Many active research groups have to employ staff specifically even to understand the regulations, let alone respond to them. I hope the Minister will bring his renowned skills at bureaucracy-busting to bear on these bodies too.

Then there is the issue of the very large number of women coming through medical schools. Sixty per cent or more of new medical graduates are now women and we are ill prepared to meet the needs of this tidal wave, a veritable tsunami, of women coming through the ranks of medicine. I know the noble Baroness, Lady Finlay, will expand on this issue and I look forward to hearing more from her.

We are at an extremely exciting time, when the returns from investing in clinical medicine are considerable, and not only in health. Calculations made in the United States demonstrated that for every dollar put into medical research, they got a return of $5 to the overall economy. There is a fivefold economic return on investment in medical research. I expect that we could get similar rates of return here, quite apart from the advantages gained from research on better health.

We must be clear that, for the NHS, research is not an add-on, an optional extra, but an integral part of what the health service should be all about. We must take full advantage of the initiatives now taken by the department. They provide a golden opportunity, but only if they are delivered as proposed and continue to be delivered over the next few years.

Photo of Baroness Cumberlege Baroness Cumberlege Conservative 4:20 pm, 1st December 2005

My Lords, I thank the noble Lord, Lord Turnberg, for initiating the debate. Given his remarkable, distinguished contribution to education, medicine, science and public health, I could spend seven minutes talking about the noble Lord, but that is not the purpose today. However, there could be nobody better fitted to introduce this debate.

I declare an interest: I chair St George's University of London, a medical school in south-west London, established 250 years ago, and I am on the board of the Brighton and Sussex Medical School, which was established just three years ago. I mention that because I have been struck by how similar the problems are in both medical schools, which are both very successful. They are so different in their character and geography yet they have the same difficulties in academic medicine. As the Government are well aware, in some specialties clinical academics are as rare as hen's teeth and much needs to be done.

The noble Lord, Lord Turnberg, has mentioned already the UK Clinical Research Collaboration and the sub-committee of Modernising Medical Careers. Like others, I rejoice that much is being done; quite embarrassingly, I have to congratulate the Government on that. I look forward to the Minister's reply, as I am sure that he will tell us more about that, and particularly to hearing what the long-term commitment is to funding the Walport recommendations. The long term is essential to remedy some of the mess that we are in.

Given the shortage of doctors, I am sure that the Minister will welcome the fact that, for next year, St George's medical school has attracted 11 applicants for every student place and Brighton and Sussex 20 students for every place. Yet neither institution can attract a professor of surgery. It has not been for want of trying; there just have not been any credible applicants for those posts.

Surgery is not the only specialty in trouble, as the noble Lord, Lord Turnberg, has mentioned. Nationally, we know through the Council of Heads of Medical Schools, last year alone, anaesthetics lost 15 per cent of clinical academics, pathology has lost 40 per cent, radiology 30 per cent, occupational medicine 60 per cent and both paediatrics, and gynaecology and obstetrics have lost 11 per cent.

My first question is: who will teach those bright, aspiring young doctors, when there is such a shortage of clinical academics? With 208 vacant senior posts, 91 of which are professorial chairs, there is a lot to make up. Secondly, with so much of the curriculum delivered in general practice and a decline in clinical lecturers since 2003, how does the Minister propose to remedy the situation in the short term, as it will take quite a while for the initiatives to produce results, and will he address the discrepancy between consultant clinical academics' pay and that of senior academic general practitioners? Thirdly, the introduction of multiple providers further complicates the position. What measures will the Government put in place to ensure that there are sufficient training places for students in those environments?

I shall now deal with the NHS. Recently, I received a letter from Sir Iain Chalmers, who, as noble Lords will know, is a founder of the Cochrane Collaboration and editor of the James Lind Library. He wrote to me in my capacity as chair of the working group for the Royal College of Physicians on its report on medical professionalism, which we will release next week.

Sir Iain writes:

"Over the past 30 years, there has been collective uncertainty about whether patients admitted to hospital with acute traumatic brain injury should be prescribed systematic steroids. This uncertainty has been reflected in dramatic variations in practice—some doctors have given steroids, guessing that they were useful; others have withheld steroids, guessing that their risks were likely to outweigh any benefits. It was not until very recently that this collective uncertainty was addressed by doctors around the world who agreed that acquiescence in this ignorance was incompatible with responsible professional practice. Thanks to these doctors, we now know that this treatment has been killing patients for 30 years. This is just one example of many that I could cite".

As a lay person, I find that chilling. If ever there was a case made for clinical academics, surely it is that one. We need them not just for patient safety but for more than that—for more than being the translators of science into medicine. We need them as leaders and teachers, and we need them now. Yet the NHS appears to have a disincentive to employ these people.

There is no financial incentive for a thrusting foundation hospital or a trust on the margins of fiscal viability to employ a consultant academic. They are a complication; they have two employers—the trust and the university; they are expected to deliver high quality teaching, carry out internationally respected research and do their clinical work. Some would say that that workload, executed to a high standard, is the equivalent of three full-time jobs, and without protected time, it is undo-able. Yet we know that this combination is extremely powerful in improving the care of patients and making the UK a world leader in academic medicine and the education of doctors.

Of course, SHAs and foundation trusts are expected to make allowances and support all these activities but when pressurised to fulfil targets and achieve more stars, it is the service that always wins the day. With the full implementation of payment by results, there is likely to be an even greater reluctance not only to decrease the number of patients seen and treated but to increase costs through employing staff with research sessions. I do not think that job plans are the answer.

It is disappointing that the Healthcare Commission did not include education and research within its core standards. High quality research should be recognised as essential in the delivery of high quality care. My fourth question to the Minister is: will the Government ensure that the Healthcare Commission explicitly recognises research and education as a trust's responsibility in its performance assessment? Lastly, what guidance will he give to PCTs in their commissioning role?

Photo of Lord Parekh Lord Parekh Labour 4:28 pm, 1st December 2005

My Lords, I, too, thank my noble friend Lord Turnberg for initiating this very timely and important debate with characteristic understanding and passion.

The decline in the numbers of clinical academic staff is striking and also worrying. As my noble friend pointed out, since 2000 there has been a 12 per cent drop in the number of clinical academics, amounting to as high as 42 per cent among the clinical lecturers. This drop is particularly high in certain disciplines— 28 per cent in the case of psychiatry, 50 per cent in pathology, 13 per cent in surgery and 9 per cent in medicine. It is also worrying with regard to dental schools. In 2004, we had 30 fewer dental academics than in 2003. I am also a little worried that 50 per cent of clinical academics today are over the age of 45, and the number of young medical graduates going into academic medicine is not rising proportionately.

In the light of all this, there is a reason to worry. But I am delighted that the Government are fully aware of the situation and have taken a number of major initiatives. The Chancellor has given high priority to medical research. There is increased funding for NHS research and development, going up to £100 million by 2008. There is also a proposal to encourage research collaboration with other agencies and I am particularly pleased that the Government intend to establish 250 academic clinical fellowships and 100 clinical lectureships per year. The Department of Health consultation document, Best Research for Best Health is also full of interesting ideas.

All these initiatives amount to one of the most progressive steps forward in the past two decades and I want to salute the commitment and conviction of the Government. However, no government alone can tackle a problem of this magnitude. Other institutions also have an important role to play, such as the universities, the General Medical Council, NHS staff and Wellcome and other generous foundations. In the next five or so minutes I want to briefly suggest a few ideas for non-governmental agencies and also a couple for what the Government could do in this area.

First, the NHS culture must change profoundly and clinical research must be seen as an integral part of it. That has two important implications. Consultants and others should see their roles not only as providers of clinical services. They should also be willing to undertake and participate in academic research. It also implies that clinical researchers are seen and accepted as an equal part of the NHS staff as much as the doctors and healthcare professionals.

Secondly, it is important that the training of doctors and dentists in our medical and dental schools should involve research as an integral part. Students should be exposed to clinical academic research and imbibe the spirit of intellectual excitement and acquire basic methodological training. They should see themselves not simply as people who are going to acquire certain skills which they will then apply, but also as reflective and creative minds who will not only be applying their skills but accumulating knowledge and contributing to the growth of medical science.

To digress for one moment, this can also happen to some very talented students. In my own case, two of my sons went to Oxford to read medicine and I had hoped that they would become doctors. Tremendously excited by the sheer prospect of creating something new, both of them became distinguished scientists and one of them is now a professor of cardiovascular physiology at the University of Oxford. I say that not so much to talk about myself, although that is what I have inadvertently done, but to make the point that the excitement of research is something that can be implanted and cultivated in students. Unless we do that, we will not have a large number of new graduates wanting to do medical research.

Thirdly, it is extremely important that there should be greater co-operation between basic biological research and clinical work. Although pure research is important, medical science has increasingly moved in a direction where clinical collaboration with fundamental medical research is extremely important. After all, it was the collaboration between Frederick Banting and Charles Best which allowed them to discover insulin.

Fourthly, it is worrying that the representation of women and ethnic minorities among clinical academics is so small. Women represent only 12 per cent of clinical academics and ethnic minorities barely 2 per cent. Steps need to be taken to increase their representation either by addressing the factors that deter them from moving into this area, or by earmarking a percentage of fellowships and lectureships that the Government contemplate for women and ethnic minorities, or at least by making flexible and part-time working arrangements.

Fifthly, the research assessment exercise has acted as a disincentive—I can say that from my own experience as a professor, but also by looking at what has happened in the field of clinical medicine. Clinical research takes a long time to result in academic publications. The productivity of clinical academics therefore tends to be rather low, and their departments get low RAE ratings. That inevitably puts pressure on universities to reduce investments in certain disciplines, as we have seen in the case of so-called craft disciplines such as surgery, cardiology, radiology, obstetrics and gynaecology and, of course, anaesthesia. It is very important that promotions are not delayed, and that tends to happen if the RAE rating of an individual is not up to scratch, not because of his fault but because the publications take a long time to come through.

Sixthly, unlike medical staff, clinical academics lack a clear route of entry and a transparent career structure. There are disparities in pay and working conditions. As the BMA cohort report of 1995 clearly shows, some very talented medical graduates refuse to go into an academic discipline because they feel profoundly devalued, or because they are in danger of earning less pay or because they find few higher academic posts to which they can aspire. Equally important, they are afraid that by going into an academic discipline, they are in danger of being deskilled and might not be able to return to mainstream hospital or general practice medicine, if they fail as academics.

Finally, I shall emphasise a neglected point. Clinical academics need to develop greater international contacts and undertake co-operative international research. That should involve not only our European partners but also the Commonwealth. We have unique advantages in this country, as nearly one-third of our doctors come from Asia and Africa and have close links with hospitals and research institutions in those countries. We shall also be able to understand better our own ethnic minority population's medical problems if we keep in touch with researchers in other countries. Therefore, I very much hope that clinical research in our country does not remain merely confined to the NHS trusts, universities and so on, but becomes more entrepreneurial and reaches out to other countries.

Photo of Baroness Finlay of Llandaff Baroness Finlay of Llandaff Crossbench 4:36 pm, 1st December 2005

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, 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,

"Treasury would be likely to expect DH to bear the additional costs. This would make it harder than at present to recruit clinical academics".

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.

Photo of Baroness Warwick of Undercliffe Baroness Warwick of Undercliffe Labour 4:44 pm, 1st December 2005

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 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 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.

Photo of Lord Rea Lord Rea Labour 4:51 pm, 1st December 2005

My Lords, my noble friend Lord Turnberg has been so successful in recruiting speakers to this short debate that we have very limited time. As he recruited me only yesterday, my contribution will be more a series of snapshots than a deep analysis.

I agree with my noble friend that the Government have taken important steps, which he outlined, to reduce the shortfall. As well as that, they have promised an additional £100 million per annum by 2008 for NHS R&D. It would be interesting if the Minister were able to tell us how that funding will be allocated in relation to the problems outlined in the debate. However, most clinical academics will reserve judgment on those rather grand-sounding initiatives until results begin to come through. There is a long way to go.

It is surely unacceptable that clinical academic staffing levels nationally have been allowed to dwindle at the same time as student numbers have greatly increased. It is of course much easier and more politically visible to increase student numbers than create and fill new clinical academic posts. However, without that parallel increase, the end product will inevitably be of lower quality. As other noble Lords have said, it is the quality and quantity of research that is suffering most, as the clinical academic service demands on clinical academic staff are more pressing and urgent, especially when time and staff numbers are short. My information from the coal face comes from my son, who is a senior lecturer in oncology at Birmingham University and is involved in multi-centre chemotherapy drug tests. His unit is up to full strength, but other parts of the medical school are less lucky. Posts have not been filled as they have become vacant, with the results that I described.

Many clinical students have to travel some distance to peripheral hospitals to find sufficient numbers of patients with whom to gain all-round clinical experience. That practice is not new and has much to commend it; I felt that I gained a lot by those attachments to non-teaching hospitals. Teaching hospitals have a higher proportion of less common conditions, and students there have less hands-on experience. Although the National Health Service staff at peripheral hospitals who teach clinical students are good doctors and teachers, they mostly do not have protected time for teaching or research. In particular, they are often much too busy to attend academic seminars and other events at the university aimed at keeping teaching clinicians at the forefront of clinical knowledge. Those out-of-town clinicians are in fact keeping our medical schools going, especially now that student numbers have risen so much. They deserve better recognition, better academic status and facilities and, above all, dedicated paid teaching sessions. Although peripheral GP practices are perhaps treated better, many of the same factors apply there, too.

Another area pertinent to the debate is the joint funding of clinical trials and other research by the pharmaceutical industry and universities. The industry has to find not just 100 per cent of the universities' overheads, but now 110 per cent. In their present financial straits, universities naturally see this as a way of augmenting their income. After all, the company may make a large profit through application of the research. That actually means that less research is coming to the UK, despite its excellent reputation and research skills. Countries in Europe, especially the new members of the EU, are much cheaper and are rapidly increasing their skills. The Government should make it easier for the international pharmaceutical industry to continue to carry out research here.

It is vital that the Government's good intentions be translated speedily into action; otherwise, the danger is that this country's fine record in clinical research and teaching will be relegated to Division 2, instead of vying for the top place of Division 1.

Photo of Baroness Murphy Baroness Murphy Crossbench 4:56 pm, 1st December 2005

I, too, thank the noble Lord, Lord Turnberg, for the debate. I shall speak for a short time on the impact of the decline of clinical academic medicine on the NHS. It is a topic about which I have been hopping mad for at least a decade, so I am delighted to have the opportunity to be hopping mad in public.

For 15 years, I held a clinical chair in one of the so-called Cinderella specialities, geriatric psychiatry. Indeed, I hold a visiting chair at Barts and The London, Queen Mary's School of Medicine and Dentistry, to which I contribute an hour every year. Until very recently, I sat on the councils of Queen Mary, University of London, and of City University, which has a thriving and successful academic nursing department and other academic departments relating to professions allied to medicine. Now, as chairman of the strategic health authority, I have been an active go-between between the NHS and our higher education institutions and chair the joint strategic partnership board, and I am all too aware of the tensions between a medical school's priorities of research and teaching and the NHS drive for improved service delivery.

I have witnessed with increasing dismay this past 10 years the impact of education and science policy on the development of local health services. The collateral damage from the RAE—the "Exocet" that has winged its way into the health service—and the focus on molecules and bioscience away from the applied science of delivering care has had the following serious and negative impact. We have heard about the reduction in the number of academics, but I shall just talk about the departments. Academic radiology is now down from 12 departments in 1997 to three departments now. It is almost dead. Academic anaesthesia is going the same way. Some 50 per cent of academic care of the elderly medicine departments have gone, the rest are failing rapidly and the quality of surviving departments is mixed. Academic psychiatry survives by being utterly disconnected from the needs of patients with mental health problems in most places, although there are a few notable and laudable exceptions. As we have heard, a quarter of academic psychiatry posts have disappeared since 2001.

Health services research is barely surviving, and few quality departments are available for training, even though the Department of Health, for example, in its recent review of cancer research priorities, put such research as its absolute top priority for delivering cancer research to the population. Public health and social medicine are in decline, and primary care academic departments of general practice are in a parlous state in many areas. In east London, we are the baby production capital of western Europe and are very proud to be. We deliver 25,000 babies every year, and yet we have no chair in obstetrics and no prospect of recruiting one. Only a handful of serious academic departments of obstetrics is left.

I have no doubt that my foundation chair—the first in geriatric psychiatry in this country and, I think, in the world—which was funded by the NHS in 1983, would not now be created. King's College would no longer accept the money—the risk would be too great. The research funding that I was able to attract came largely after my appointment. These days, people have to be RAE stars already to be appointed to academic departments.

If I talk to my NHS management colleagues about my concern, they tend to shrug and say, "So what? These professors were very costly anyway. They did not all do the work that we wanted them to do in the NHS. They concentrated on the wilder shores of research medicine". It is true, too, that globally, on this World Aids Day, there is a serious disjunction between the need to solve the world's biggest health problems and what academic medicine wants to research. That was raised not long ago in a series of articles in the British Medical Journal. After all, the NHS is largely populated by fascinating patients with rather boring, everyday diseases. The RAE has encouraged research at the biosciences cutting edge, not perhaps the incremental painstaking studies that improve stroke outcomes or better help people with long-term conditions to avoid hospital admissions. Many NHS managers do not have much sympathy with the problem of the reductions.

The outcome of the loss of academic role models and of some of the brainiest doctors in academic medicine is that younger doctors and their professional colleagues see such dying academic specialties as second-rate. It is a self-fulfilling prophecy. The quality of the NHS services declines when a local academic department closes. That has had a real impact nationwide on the quality of maternity and psychiatric services. The care of older people in some areas is going backwards, in spite of the splendid work being done on the national service framework, which one would expect to be led by some of our brightest clinicians. In fact, we have a dearth of stars. My point is that the moment that an academic department closes locally the NHS suffers profoundly.

Why was it that back in 1973 those at Hope Hospital in Salford were rather keen to have a bright young gastroenterologist, Dr Turnberg, set up a new academic department of medicine? They were keen because they knew that it would have a serious impact on the culture and quality of medicine delivered to Hope Hospital and to the people of Salford—and so it proved. We no longer have those opportunities, and the Department of Health should say why it no longer provides support to universities to get that right. Therefore, I should like to know what the Department of Health and the Department for Education and Skills are doing jointly to stop their policies working against each other to the detriment of the National Health Service.

Photo of Lord Winston Lord Winston Labour 5:03 pm, 1st December 2005

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.

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 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.

Photo of Lord Smith of Clifton Lord Smith of Clifton Spokesperson in the Lords, Northern Ireland Affairs 5:12 pm, 1st December 2005

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 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 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.

Photo of Earl Howe Earl Howe Spokespersons In the Lords, Health 5:17 pm, 1st December 2005

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 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 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.

Photo of Lord Warner Lord Warner Minister of State, Department of Health, Minister of State (Department of Health) (NHS Delivery) 5:25 pm, 1st December 2005

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 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 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 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.

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.

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.

House adjourned at twenty-two minutes before six o'clock.