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Lord Renton: My Lords, I hope that the noble Baroness will realise that parliamentary draftsmen are there to serve and not to direct. I hope that she will bear in mind what I said about the need for consolidation.

Baroness Hayman: My Lords, I shall certainly do that. I shall go on my assertiveness training course for dealing with parliamentary draftsmen as soon as the Bill has passed through your Lordships' House!

Serious issues were raised in relation to the memorandum. Revised explanatory notes will be published to cover those new provisions on the introduction of the Bill in another place. A further revised version will be published after that, on enactment of the Bill. However, I recognise that that goes only so far and does not deal with the major consolidation issue.

I deal now with the major substantive issue which has been raised on the effect of bringing together the prescribing budgets in primary care. Perhaps I may offer some reassurance to the noble Lord, Lord Walton. We believe that allowing maximum flexibility for local clinicians to identify and take the steps which will produce the best results for patients from all the resources available in the unified budget, free of artificial and distorting boundaries between different types of expenditure, is an important driver towards the high quality prescribing which I am sure we all wish to see.

The main issue is in relation to outputs rather than inputs from prescribing. We can all recognise that spending large amounts of money on prescribing is not necessarily a guarantee of high quality in that prescribing. As I made clear, the unified budget will not place a cash limit on any area of GP activity as such, whether it is prescribing or referrals. The cash limits will apply at the health authority or PCT level and not to individual practices and GPs.

The point has been made about NICE. If it functions as we hope it will do so that clinically-effective treatments are more widely available sooner, we must recognise the need to provide a system which also delivers on rigorous and cost-effective prescribing in other areas.

The experience to which I referred earlier, in terms of peer group review and working in a broader and larger system with the advice that is available from pharmacy advisers, is that it is possible to improve the quality of

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prescribing. There are a range of ways in which that can be done without necessarily sending the bill sky high. I recognise that that is an important area if we are to see clinically effective treatments reaching all patients who need them as soon as possible.

It will perhaps be reassuring if I make clear that the extra resources we have made available to the NHS for the next three years take full account of the growth in recent years of prescribing costs, which have been about 8 per cent. annually, and of our expectations for the future. I reiterate that there is no reason for us to think that the unified budget will lead to patients being denied the medicine that they need. As I said in my opening remarks, all the evidence points in the other direction. I hope that the House will accept that these very technical and lengthy amendments provide a sound basis for what will be a better way in which to ensure that we achieve the best value for money across the board in relation to the way in which funds are spent by primary care trusts rather than in artificially-divided funding streams. I commend them to the House.

On Question, amendment agreed to.

Earl Howe moved Amendment No. 14:

Page 4, line 33, at end insert--
("(9) The Secretary of State shall provide guidance to Primary Care Trusts regarding appropriate levels of expenditure on research and development, training and tertiary services."").

The noble Earl said: My Lords, on Second Reading and again in Committee, we heard contributions from a number of noble Lords, not least the noble Lords, Lord Winston and Lord Walton of Detchant, which highlighted the importance of clinical academic medicine and training within the context of a thriving health service. The purpose of the amendment is to enable me to address those issues in what is intended to be a constructive spirit.

The Richards Report of 1997 recognised that the supply of academic clinicians is drying up. The UK is producing a lower proportion of academic papers than it used to. If we look at teaching hospitals, part of the problem is the developing fault line between the two sides of their activity: the clinical care side and the academic and training side. Those two sides are in danger of becoming dislocated due, in large part, to the increasing pressure caused by the need to treat more and more patients.

That is a serious trend. It goes almost without saying that any erosion of the teaching base will have a highly detrimental effect on both the quality of training and the numbers being trained. In the longer term, it will lead to this country losing its place as one of the foremost centres of excellence in clinical research.

The noble Lord, Lord Winston, whom I am sorry not to see in his place, reminded us on Second Reading of how intimately bound up with each other are those ingredients of excellence--the availability of academic clinicians, the concentration of specialist expertise and case studies of patients and the clinical research base. It is vital to retain the links between the universities and

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other centres carrying out basic research and the various arms of the health service, but particularly the teaching hospitals.

As we witness ever-greater demands on the NHS budget, my great fear is that those vital elements of excellence in the delivery of healthcare will diminish both in quality and quantity. Of course, the streams of money which flow into academic training and research are not exclusively an NHS spend. The DfEE element is designed to cover a large part of the teaching and research activity, although the split of responsibility between the DfEE and the DoH is fairly complex. In the unified budgetary structure of a primary care trust, especially at level 4, we may find less and less of a commitment and, therefore, less money flowing towards those activities in NHS trusts. The purchasing horizons of a PCT will inevitably be much shorter than those of the Department of Health or even of a health authority. It is not clear what mechanisms will be in place to protect the broader, long-term objectives of the health service.

Those are the issues that lie behind the amendment. They are tremendously important, but they are not easy to deal with. I hope the Minister can provide some reassurance. I beg to move.

6.30 p.m.

Lord Walton of Detchant: My Lords, I rise to support warmly the amendment so splendidly proposed by the noble Earl, Lord Howe. As he said, the issue of the future of clinical academic medicine and the related problems of teaching and research are crucial to the future of the National Health Service. It was reassuring when the Minister spoke earlier about the crucial importance of academic clinical input into primary care trusts. I am delighted that she was able to acknowledge that.

One important matter of relevance to the problem is that today's development in medical clinical research brings about tomorrow's practical development in patient care. In the area of primary care, academic departments and general practice play an increasingly important role, not least in training medical students, but also in the vocational training of future general practitioners and in a much wider range of activities than ever was the case in the past.

To the credit of the last government, they recommended that 1.5 per cent. of the NHS budget should be devoted to research and development. I had the privilege of chairing an inquiry of your Lordships' Select Committee on Science and Technology into research in the NHS in the light of the last government's reforms. The Culyer inquiry on R&D in the NHS reported at about the same time as our Select Committee. Those reports identified the need to have research and development funded, first, at a central level through the Research and Development Directorate; secondly, by regional directors of research and development; and, thirdly, at a sub-regional level, with the intention that funds for research could be channelled to those general practitioners, to those nurses and other healthcare professionals who wished to undertake research of importance to the future of the NHS.

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Such matters are of great importance. I am delighted that they have been highlighted in this amendment. I hope that the Minister will be able to give us assurances that the present Government propose to continue support for research and development at all three levels. It is a very important issue.

I am also glad that the amendment includes tertiary services. An unexpected effect of the internal market introduced by the last government was that tertiary referrals to centres of excellence, upon which so much major research depended, fell away sharply. That is a matter of relevance to Amendment No. 20 which stands in the name of the noble Baroness, Lady Masham. The issue of cross-boundary flow and the ability to have patients referred to centres of excellence, not only because of the quality of the treatment that they will receive in such centres, but also in the furtherance of the clinical research which is so important to the future of the NHS, is a vital characteristic that I trust the Government will continue to support.

Baroness McFarlane of Llandaff: My Lords, I seek to support the amendment. I am glad that the noble Lord, Lord Walton, mentioned the need for expenditure on research and development in disciplines such as nursing, physiotherapy and others. We need the ability to research and develop evidence-based practice.

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