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The Deputy Speaker (Lord Ampthill): My Lords, Amendment No. 189 has been lost in the mysteries of what transpired earlier in the day.

[Amendment No. 189 not moved.]

6.15 p.m.

Earl Howe moved Amendment No. 190:


The noble Earl said: My Lords, in moving Amendment No. 190, I shall speak also to Amendments Nos. 192 to 194 inclusive. I would have added my name to the amendment in the name of the noble Lord, Lord Turnberg, had there been room to do so. I very much support the case that he so eloquently put in Committee to safeguard teaching and research in our medical schools and universities.

The hospitals on whom those medical schools and universities depend cannot, and must not, be allowed to sidestep or wind down their role or their research ethos. I am sure that I am not the only Member of the House who noted with concern the report by the Academy of Medical Sciences, published recently in the BMJ, which identified several factors impairing experimental medicine and clinical trials and research generally.

The factors that came out of that report were, in some cases, familiar: the lack of research funding for clinical trials; inadequate facilities to undertake

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patient-orientated clinical research; and limited numbers of clinical academics. Those are familiar issues. They are, none the less, worrying but they are at least familiar. However, one contributory factor adduced in that report was the pressure on NHS beds and facilities in teaching hospitals. That is pushing out clinical research so that the NHS has less capacity to evaluate the new tools that are emerging from academia and industry. I consider that to be very worrying.

However, I revert to my own amendments. My feeling is that this clause, and the way that it is worded, needs to strike the right balance. Surely it cannot be the job of the regulator to stipulate that particular programmes of research should be pursued in a foundation trust. Maintaining research activity and promoting a research ethos is one thing, and I very much support that, but prescriptively insisting on specific programmes is surely another. Still less, it seems to me, is it acceptable for the regulator to prescribe in that way without reference to the available resources and manpower within the trust. If a programme of research is simply unaffordable and there is good reason for a hospital to feel that it cannot continue with it, the regulator needs to take that into account in the way that he acts.

I am troubled, too, by the words in Clause 14 which enable the regulator to stipulate restrictions in the activities in which a foundation trust may engage. In Committee, the Minister gave some examples of such restrictions. I did not find his explanation at all convincing. The restriction on private patient income is dealt with in Clause 15. Here, we are apparently dealing with non-healthcare income-generating activities.

Given that Clause 14(2) provides that the principal purpose of the trust must be the provision of healthcare, goods and services, I do not understand why the Government feel that the regulator needs to concern himself with clipping the wings of foundation trusts in ways which prevent them supplementing their income. Engaging in commercial R&D projects, providing non-clinical amenities and leasing space to hairdressers—some of the things mentioned by the Minister on the previous occasion—seem to me perfectly legitimate activities for a foundation hospital within the context of its overall healthcare functions. Why, and in what circumstances, should the regulator intervene to prevent those activities? I beg to move.

Lord Turnberg: My Lords, I rise to speak to Amendment No. 191. I am grateful to have the support of the noble Earl, Lord Howe. To have accumulated the support of so many noble Lords on this amendment pleases me enormously.

Amendment No. 191 emphasises rather better what I tried to do in a previous amendment in Committee. It draws attention to our major teaching hospitals—those with medical and dental schools have a specific role to teach and undertake research. Because of that, they have considerable numbers of university and other academic staff working in them, carrying out

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research, teaching and looking after patients. It is vital for these hospitals to have systems in place to ensure that these activities can continue.

They have some difficulties, even now, and many of those were described very well in the report referred to by the noble Earl from the Academy of Medical Sciences, which is improving or enhancing clinical research. However, I fear that foundation hospitals, with their new-found freedoms, will—if they survive—tend to neglect this responsibility in the face of more economically attractive activities. I will not go on because I talked about this subject at some length in Committee, but I hope that my noble friend will give us some comfort on this.

Lord Clement-Jones: My Lords, I strongly support the amendment of the noble Lord, Lord Turnberg. I confess to being somewhat baffled by the Government's approach. I read very carefully what the Minister wrote to the noble Lord, Lord Turnberg. To pray in aid Clauses 14(5), (5) and (6) in the face of a very explicit amendment such as this seems extraordinary.

The Minister said in Committee that,


    "we think there is already adequate provision in the Bill to ensure that the regulator protects the needs of research in giving a particular authorisation".—[Official Report, 13/10/03. col. 738.]

However, the legislation is hedged about with the word "may".

I think it is worth quoting from a letter which the Minister has had from the Association of UK University Hospitals. It is extremely eloquent and asks many noble Lords to go into the lists again on this issue. I am very glad that the noble Lord, Lord Turnberg, put down the amendment again. The letter says:


    "High quality teaching in research and hospitals are vitally important, not only to patients and to improving standards of care but also to the science base of this country and to the economy now and for the future. University hospital trusts are keen to ensure that they can continue to foster medical research in teaching. But they humbly urge you"—

this is directed at the Minister; I would not have been quite so humble in the circumstances—


    "to ensure that a way forward is found which will protect the future health of the nation".

All at the meeting, representing almost all the UK medical schools in university hospitals, the deans and the chief executives, were unanimous in their wish to express support for this amendment. That is highly significant; they do not feel that the Bill adequately represents their interests. I agree with them and I very much hope that the Minister will reconsider his response to the noble Lord, Lord Turnberg.

Baroness Finlay of Llandaff: My Lords, I will speak briefly to this amendment, to which I have added my name. I am most grateful to the noble Lord, Lord Turnberg, for having tabled this crucial amendment.

The noble Earl, Lord Howe, has already mentioned the report from the Academy of Medical Sciences. The one item he did not mention in his list of reasons was that companies have expressed concern that in the past decade, the United Kingdom has declined as an

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attractive location for clinical trials. One of the issues cited is a less welcoming culture. This important amendment would reverse this culture, allowing the hospitals to carry out the vital research which they recognise enhances their patient care.

The lack of capacity for research will stop the translation of discoveries in basic science into clinical practice. The NHS, however, is highly dependent on critical evaluation of new diagnostic and therapeutic interventions, as the Government acknowledged when they set up the National Institute for Clinical Excellence. But the National Institute for Clinical Excellence is dependent on the results of really high quality research which is evaluated on the population it is designed to serve.

I wish to quote a warning from the primary care sector. I refer to all the changes that have occurred in primary care. I have been sent a raft of correspondence. The Professor of Primary Health Care at Bristol University writes that,


    "hardly a week goes by without some correspondence with a practice which usually revolves around them saying they cannot teach on a particular course in that academic year. Anything you can do to help us, I am sure would be extremely gratefully received by the Society for Academic Primary Care".

There is a teaching and research crisis already and it is getting bigger. All the deans and all the chief executives from the university hospitals, many of whom are in the first wave of applications for foundation trust status, realise that this matter has to be recognised by the regulator as constituting a terribly important role if they are to advance into the future and take forward in the NHS the care that we deliver to our patients.

Lord Walton of Detchant: My Lords, in supporting this group of amendments very warmly, and in echoing what has been said by several other noble Lords, I remind the Minister that, as he well knows, from the inception of the National Health Service in 1948 the pursuit of clinical research has been one of its clearly expressed objectives. Indeed, the existence of a publicly funded health service has been greatly envied by people in other countries who recognise that such a service provides outstanding opportunities for the pursuit of clinical research. It is important to repeat what my noble friend has just said; namely, that basic research in disease mechanisms and clinical research, including the pursuit of clinical trials, nurture future developments in patient care. That cannot be expressed strongly enough. It is therefore extremely important that these amendments are accepted.

From time to time within recent years, particularly during a period of financial constraints on the health service, there has been expressed in certain quarters a feeling by members of the public and others that research is a rather exotic activity that ought not to be funded—if it is being funded—at the expense of funding for patient care. One understands that view but I believe that the point I have just made about the nurturing of clinical care through research outweighs that particular argument.

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Amendment No. 190 is important because if the phrase,


    "subject to any restrictions in the authorisation"

is left in the Bill, it would give the directors and the boards of governors of foundation trusts the opportunity to divert funds away from research activity to other objectives that they regard as being of higher priority.

I turn finally to the wording of Amendment No. 191. I have been in correspondence with the Minister about the wording. I am uncomfortable with it but I understand the reasons he gave for it. Unlike the old days when a teaching hospital was closely associated with a medical school or a dental school, nowadays teaching is often widely dispersed throughout regions. For example, in the region that I know best, the northern and Yorkshire region, there is the University Hospital of North Durham and the James Cook University Hospital in Middlesbrough. These trusts—if they become so—do not include medical and dental schools but are closely associated with them.

Nevertheless I appreciate what the Minister told me in his very courteous correspondence—that this wording has been used in previous NHS Bills. Hence I suppose we must accept it. The only very minor modification I would suggest to Amendment No. 191 is that it should apply particularly to trusts which include a medical and/or dental school because there are quite a number of universities that have both a medical school and a dental school. These amendments are very important and I hope that the Minister will give them a fair wind.

6.30 p.m.

Lord Warner: My Lords, I shall, if I may, deal first with Amendments Nos. 190, 192 and 193 before turning to Amendment No. 191. Amendment No. 190 removes the regulator's power to restrict NHS foundation trusts' non-healthcare activities. The principal purpose of a National Health Service foundation trust, if I may remind the House, is to provide NHS services to NHS patients. However, the Bill provides for National Health Service foundation trusts to carry out other activities with the objective of generating surplus income to support the NHS principal purpose. These provisions parallel the income generation powers already available to NHS trusts. So they are carrying on a tradition.

I gave examples earlier of income generation activities but I shall repeat them. Such activities might include running occupational health services on behalf of non-NHS employers; engaging in commercial R&D projects; providing non-clinical amenities for patients, staff and visitors such as internet facilities; leasing space to service providers such as newsagents or hairdressers; and providing private health services. In normal circumstances, the regulator would not intervene in these activities. However, it is right that he should have the power to place restrictions on income generation activities where there is a danger that they could interfere or conflict with or detract from the principal purpose of providing NHS services. That is

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why we have the provisions as they are in the Bill and why we think that Amendment No. 190 is inappropriate.

I turn to Amendment No. 192. The regulator must act reasonably, and as such must take into account the resources available to a National Health Service foundation trust when authorising its services. The regulator can only require the foundation trust to do what it can reasonably be expected to do. We therefore think that this amendment is also unnecessary.

Amendment No. 193 requires the regulator to take account of the views of the NHS foundation trust and its members when authorising services. We think that this amendment also is unnecessary. The regulator is a public body that must act reasonably. That would include taking the views of the trust into account when deciding its authorised services. The regulator may also wish to seek the views of NHS commissioners and/or the strategic health authority when doing so, to ensure that it has all the information necessary about the local health economy to allow it to make an informed judgment. So, again, we think that this amendment is superfluous.

I have to confess that I have a great deal of sympathy with the thinking behind Amendment No. 191 which was tabled by my noble friend and other noble Lords. In my day job—that is, when I can spare a bit of time from appearing in your Lordships' House—I have responsibility for research and development. We recognise that the NHS has great scope for translating basic scientific discoveries more quickly into benefits for patients. It is worth mentioning that the cancer translational network has shown some of the promise in this area.

I acknowledge noble Lords' point about the quality of the recent report by the Academy of Medical Sciences. It is a very well argued report which the Government will take very seriously indeed. Another report, on biosciences and innovation, is soon to be published by a group chaired by Sir David Cooksey. The Government want to look at these two reports together and then state publicly how we can take some of these issues forward. I do not diminish in any way the seriousness of some of the points that noble Lords have made. We have to make both progress and improvements in this area.

However, I do not think that the way forward is to accept Amendment No. 191. Although I understand the sentiments behind it, I gently say to my noble friend that accepting his amendment will not bring about the necessary changes. As I said earlier, and at the risk of repeating myself, the regulator, under Clause 14(4), (5) and (6), must authorise an NHS foundation trust and may require it to provide education and training and carry out health-related research. The regulator therefore is empowered to require the provision of education, training and research.

There is provision there for the regulator to ensure that the needs are properly attended to. In setting terms for the authorisation, the independent regulator will need to act in line with his general duty in

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Clause 3, which is still too often overlooked. Noble Lords will no doubt remember that under the clause, as I have said before, the regulator is required to exercise his functions in a manner consistent with the Secretary of State's duties under the National Health Service Act 1977. That includes the duty in relation to university clinical teaching and research.

With the greatest respect to my noble friend and other noble Lords who spoke in support of the amendment, I say that we accept very much the need for action and improvement in the area, but that the amendment is not the way forward. We need something a good deal more practical on the ground, and we hope to turn our attention to the issues very shortly when we receive Sir David Cooksey's report.


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