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Dr. Andrew Murrison (Westbury): 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. Harris: 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.

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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.

4.15 pm

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

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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. Hutton: 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.

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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. Harris: 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. Hutton: 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

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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.

Question put, That this House disagrees with the Lords in the said amendment:—

The House divided: Ayes 321, Noes 193.


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