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.