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We also need to look at a few other reasons for the demise of medical academics. The noble Lord, Lord Turnberg, mentioned bureaucracy. One would expect a Government that managed to deregulate the City in such a dramatic and fantastic way to be able to do something about deregulating medical research. We must remember that there is not pay parity between clinical and academic staff. Newly qualified doctors have huge debts. Medical students have a longer training and it is full time, so they cannot take part-time jobs to help pay their fees and debts when they qualify, so they are more likely to want to go into medical and clinical training and get on the ladder quickly to earn a decent salary as clinical staff than to spend time doing academic work or research.

I raise the question also of women in medicine. I am delighted that most medical schools now take in more women students than men. This is excellent news for women, who are eminently suited to a medical career. However, they, too, may be in a hurry to get their higher qualifications. They may want to earn money not only to pay off their debts, but also perhaps to pay for childcare in future; so they may reject medical research and get on with clinical work to earn a higher salary. Is the NHS doing any research to analyse the hopes and aspirations of the women doctors who are qualifying and are their circumstances being taken into consideration for properly planning the workforce in future?

Another factor is the private finance initiatives. Polyclinics and new health centres were mentioned by one noble Lord. The noble Lord, Lord Mawson, mentioned the integration of social care—how I wish that we could have integrated health and social care. Polyclinics would be an ideal place. However, no private developer will want to waste money on facilities for teaching and research. He will want a return on his money, and it will be much more difficult to make a profit if there is social care as well as teaching and research going on in an establishment.

I read something interesting about contracts with the private sector and commissions for routine surgery that are often taken out by PCTs. I read about a gastroenterologist who had his entire endoscopy list taken away from him without being consulted by his managers. The endoscopies were to be done by a private hospital, away from the main hospital. Most of his research and teaching of students was based on how endoscopies should be done and what he was discovering. When that sort of thing happens, it is crazy and counterproductive.

In conclusion, in the past 10 years the National Health Service has improved beyond recognition. Many new facilities have been built and a great deal more equipment supplied, along with more doctors and nurses—I do not have to recite the Government mantra for them. Everything has improved hugely. We know that quality is an issue, but the noble Lord, Lord Darzi, is addressing that. Surely the challenge now is to make sure that medical education and research go on being the best in the world, as they have always been. They must not fall behind because we are concentrating on profitability, efficiency and patient throughput. We must remain the best in the world for medical research and education.

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4.23 pm

Lord McColl of Dulwich: My Lords, I, too, thank the noble Lord, Lord Walton of Detchant, for initiating this important debate and for introducing it in such a lucid and informative way.

The report Best Research for Best Health stated that the objective of Her Majesty’s Government is to ensure that patients benefit from clinical research, that areas of unmet needs are addressed and that the health of the people is improved. Bearing in mind these worthy objectives, I will examine how they relate to the greatest hazard that threatens millions of people in the UK. I refer to the obesity epidemic, which is increasing all the time and represents a dangerous threat not only to the nation’s health, but also to the NHS and to the economy as a whole.

Evidence-based medicine is quite rightly the best basis for the practice of medicine, but sometimes lobby groups position themselves between science and good evidence-based practice. The food industry has concentrated on the lack of exercise as the cause of obesity, which of course suits it very well because, understandably, it does not want any reduction in its trade. The science is clear: if one wants to take a pound of weight off by exercise, one has to run a mile; whereas simply reducing the number of calories eaten or drunk is guaranteed to reduce weight. Exercise is very good for the integrity of the cardiovascular system and is effective in reducing the wrong sort of cholesterol. There is also evidence that exercise helps in reducing the amount of fat in a patient’s body, rather than a reduction in muscle. But that is when exercise is combined with a reduction in the number of calories, as the noble Lord, Lord Addington, knows well. It should be emphasised that one can put on weight just by drinking fluids. Let us take, for instance, the cocktail, Mai Tai: three such cocktails provide 1,000 calories.

In a predominantly sedentary population such as ours, it is clear that exercise is not an efficient method of weight reduction. In fact, many obese adults are precluded from exercise by problems such as arthritis, heart disease and respiratory inadequacy. The emphasis on physical activity has political supporters, however, as there are fewer commercial interests opposing the message and it fits with the promotion of events such as the 2012 Olympics. The alternative message, which proposes a move towards healthier diets and reducing the consumption of energy dense foods, such as fatty snacks, confectionary, soft drinks and so on, is much more sensitive politically. A man who was confined to an electric wheelchair and therefore could not exercise decided to reduce his weight by two stone, or 13 kilograms, which he did in a rather revolutionary way. He simply ate less and quite soon he came down to the size he wanted.

There are a number of red herrings in this subject, including brown fat, big bones and hormones, but at the end of the day we are what we eat. An overweight man consulted me about his excessive weight and he assured me that he had tried every diet in the book, but without any effect. He asked whether I could help. I noticed that his wife was quite thin—perhaps I should say she was a normal size. So I suggested that he ate the same quantity as his wife. He saw the danger

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of that and was somewhat reluctant, but he agreed to give it a try. Three months later when I inquired of his wife how successful this regime had been, she said, “It has been a disaster because I’m putting on weight”.

Danish doctors have reported that a British formula- based diet was successful in reducing the weight of their patients by more than 12 per cent, which gave very good symptom relief in obese men and women with arthritis of their knees. One hundred and ninety two of them followed a 500 calories a day or an 800 calories a day diet for eight weeks and were maintained on a stabilising diet for about six years. On average, the patients weighed 16 stones and lost two stones in 16 weeks, and 60 per cent had a significant improvement in relieving their symptoms, especially pain in their knees.

Professor Bliddal from the Parker Institute, Frederiksberg Hospital, commented that obese patients have very bad knees and if they exercise before losing weight they almost certainly wear the knees down and make things worse. In his programme people lose weight first and when they are a lighter weight, they usually regain their former activity. He ends by saying that bad knees are no excuse for failure in losing weight.

Those who insist that exercise is the solution to the problem of obesity give obese patients just the excuse they need to say that they cannot exercise to lose weight. They remain in their morbid and eventually fatal outcome. Yet there is some comfort for those obese people who find it difficult to lose weight. A strange mechanism in the brain is relevant in weight control. As one’s weight increases, a complex brain regulatory system adapts to lock in to the new, heavier weight. It becomes the new level which the appetite and activity control centres then try to maintain. This explains why some people have difficulty in reducing weight. Even so, they can still lose weight if they diet.

I have so far dealt with adult obesity. As the noble Lord, Lord Addington, mentioned, we need a different approach with children, one combining a reduction in calories with increased activity and counselling. At the same time, all children have to be encouraged to be much more active: walking or cycling to school, plenty of games and reducing the amount of TV and computer pastimes. Prevention is much better than trying to cure the obesity when it occurs. The culture has to change radically if the nation’s health is to improve.

Life today is such that we need to eat 500 calories less than was the case. The food industry has got to produce new, mainstream foods with far lower calorie densities. At the start of the last war, one-third of the British people were either underfed or ill-fed. The introduction of food rationing changed that within a few weeks. That was the greatest public health experiment ever. We cannot put the clock back but we must have voluntary change. This can be helped if Her Majesty’s Government in particular and politicians in general accept what research has already revealed: we are what we eat and there are no mysteries.

I have forgotten to declare an interest. When a person tells me that I am lucky to be thin, I am tempted to say “Actually, I am normal”. As that might be construed as a criticism of his obesity, I explain

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that I cannot claim any credit for being the size that I am. It is all due to a patient of mine 40 years ago. I was on my way to a black-tie dinner wearing the black-tie outfit belonging to my father-in-law. It was 50 years old and green round the edges. I was called out to St Bartholomew’s Hospital to see a lady who was bleeding to death from a tumour in her groin. I went up to the bedside. To my amazement she seized hold of my jacket and said, “That jacket is very old”. I said, “It is 50 years old”. She said, “It looks it.”

I did not quite know how to cope with this. There was this lady dying yet joking away. She said:

“Now, look. I know I’m dying. I know there’s no hope and it’s inoperable. But I want you to take me to the operating theatre and have a go. Take a risk and try to remove this tumour. You will have to put a new artery in”—

she knew her medicine.

“I am in the cloth trade in the East End and if I survive I will make you a new black-tie outfit”.

I was amazed to hear this. I operated all that night and because she was indestructible she survived eight years. During that time she made me a new suit.

As a tribute to her, I have to stay the same size. As I am Scot I do not want to buy a new suit. We are what we eat.

4.34 pm

Baroness Thornton: My Lords, it is a pleasure and privilege to be responding for the Government to this debate. I am grateful, as other noble Lords clearly are, to the noble Lord, Lord Walton of Detchant, for initiating it. If nothing else, it has been wide-ranging—a veritable potpourri of contributions. I hope I will be able to address all the themes and individual issues. I confess that I have a large pile of notes in front of me and it may be necessary to write to some noble Lords, for which I apologise in advance. I will do my best.

I turn first to health research. The Government fully recognise that a vibrant and well-organised health research sector is of enormous importance to our healthcare system, to our economy and to countless individuals and their families. That is why we have the radical and ambitious health research strategy that the National Institute for Health Research is delivering. That is why funding for all aspects of research has been increased to the highest-ever levels and why the place of research within the NHS has been given renewed emphasis. We hope the combination of our strategy and the growth in funding is powerful. No one can fail to be struck by the progress that the NIHR has made or by the efforts being made under Sir John Bell and the Office for Strategic Co-ordination of Health Research in invigorating translational research.

What we are beginning to achieve through that research—through what the OSCHR partners are doing together—is, as several noble Lords have mentioned, unequalled anywhere else in the world. We are doing it by building on, and in no way diminishing, our strengths in basic science. That much and a great deal more are clear from the progress report that the chairman of the OSCHR published last November.

Progress is unquestionably what the NIHR—I apologise for using initials—has achieved. The energy and determination which so many people in the Department of Health and the NHS have put into

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implementing Best Research for Best Health has enabled enormous strides to be made. The evidence is clear in the positive impact that the new funding regime is having on all parts of the research community and across the NHS. It is clear from the impact of the clinical research network on the numbers of trials taking place in the NHS and the scale of patient recruitment to them. It is clear from the effect of bringing together and supporting the people who conduct research in the NIHR Faculty.

We want a research-intensive NHS. It is good for patients and, as the noble Lord, Lord Walton, rightly said, it is good for clinical teaching at all levels and across disciplines. The quality improvements and innovation that lead to productivity gains and better patient outcomes depend on the new ideas that research generates and evaluates. We recognise the need for vitality, which was mentioned by several noble Lords, including the noble Baroness, Lady Tonge, who correctly said that we have to remain at the top. Clinical fellowships and lectureships provide research, exposure and experience for academically gifted medical and dental trainees. We are moving to the stage where there will be some 750 academic clinical fellowships and 400 clinical lectureships in the NHS, which is equivalent to more than 2 per cent of all hospital doctors in professional training.

We are uniquely placed in this country in the scope the NHS offers as a base from which to conduct clinical trials. We and our research partners in industry and the charitable sector believe that we have the right policies and right structures to capitalise on that potential. There are of course challenges internationally and at home to the full realisation of that objective, but I do not believe that the European clinical trials directive—mentioned by several noble Lords, including the noble Lord, Lord Walton of Detchant—is one of them. The total number of clinical trials in the UK has remained stable since the introduction of the directive and we continue to be at the top end of the European league table in our sponsorship of both commercially and non-commercially funded trials. If we are to remain there, and to face the international competition, we need efficient, robust and, above all, transparent ethical and governance systems. I shall return shortly to the points raised by my noble friend Lord Turnberg on those issues.

Real and considerable effort is being made in this area. We are making our research ethics committee structure simpler and stronger and integrating it more closely with other aspects of research regulation. We are simplifying and streamlining the administrative and regulatory procedures governing trials and other studies and updating our research management systems.

The noble Lord, Lord Walton, mentioned research charities and their excellent umbrella organisation. The support we give those charities is as important to them as it is to us. The clinical research network now provides automatic infrastructure support for all eligible trials, and the 2004 science and innovation investment framework committed the Government to underpin the charity-funded research undertaken in our universities. This investment is made through the Higher Education Funding Council for England through its quality-related funding stream and will rise to £194 million in 2009-10.

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The noble Lord, Lord Walton, also raised the issue of the European working time directive. There is no evidence that greater numbers of trainees are failing in their end of year assessments where 48-hour working has been introduced. No junior doctor can become a consultant until the appropriate royal college has issued a certificate of completion of training. This is an essential safeguard ensuring that medical training remains of the highest standard. Given the concerns raised by some professionals, we have listened and acted. The former Secretary of State for Health announced a review on the impact of the implementation of the European working time directive on 20 May. This review will consider concerns that the introduction of a 48-hour working week may have a detrimental effect on junior doctors’ training, particularly on the training they receive while at work. It is important that there is an independent and objective assessment of whether the introduction of the directive fully into the NHS will necessitate changes to the current system of postgraduate medical training.

I shall address the issue of social enterprise as part of these remarks and then return to the individual points raised by noble Lords. I feel that I should declare an historic interest, as it were, as the founding chair of the Social Enterprise Coalition and as someone who has been working with social enterprises and co-operatives almost all my working life. I believe that social enterprises can make a big difference to the lives of the people and local communities they serve. We agree entirely with the noble Lord, Lord Mawson, that they are able to transform the way services are delivered and to improve health outcomes. Innovative and flexible solutions to transform health and social care can be found in social enterprises and they have strong potential in other sectors, such as housing, leisure and transport. That is why encouraging social enterprise in health and social care is a key part of our patient-led reform of services.

The department is actively promoting social enterprise in health and social care through the Social Enterprise Investment Fund and by supporting the next stage review commitment for the staff’s right to request. The Social Enterprise Investment Fund has so far provided £20 million of funding to 200 social enterprises and the new fund manager is working to build on this success to support even more. The fund offers a range of financial services, including grants and loans, as well as providing business support tailored to the needs of social enterprises in various stages of development.

In addition to evaluating the impact of these investments, the department is working with the Office of the Third Sector to pilot the social return on investment. We are working with six social enterprises delivering mainstream health and social care services, to measure the social value that they are bringing to their local communities. The department’s investments include funding for several healthy living centres, such as Well UK, Community Docs for All and St Luke’s Healthy Living Centre. These centres address local health inequalities and improve access to services for the local population, making a real difference to local communities. The right-to-request commitment in the next stage review is enabling clinical staff in primary

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care trusts to use their entrepreneurial and leadership skills to develop innovative services to improve service provision for their patients and their local communities and we are very committed to that programme.

The noble Lord, Lord Mawson, raised the issue of social enterprise and expressed his frustration. He is correct that we have yet to crack the need for holistic commissioning and he knows that I am a great champion and supporter of this issue. He knows that it works and there is no doubt that we still have to crack the issue of rolling this provision out. We are committed to encouraging commissioners to grasp the opportunities offered by this sector. For example, Manchester PCT has commissioned the Big Life Group to run the Kath Locke Centre, a primary care centre in Moss Side. The centre allows local people to access services and to help deliver them. We have published two documents that we hope will help local commissioners to crack this.

I take issue with the noble Lord about polyclinics being based on a biomedical model. One of the largest community-owned health organisations is Local Care Direct. It was set up to provide out-of-hospital care to 2.5 million patients in Yorkshire and Humber. Being a Yorkshirewoman, I am particularly fond of this organisation. Local Care Direct was the first organisation to open one of the new GP-led access centres nationally in December 2008. These services complement existing GP and out-of-hours services in the area and demonstrate how a social enterprise can help transform primary care.

I pay tribute to the noble Lord, Lord Mawson, for the work he has been promoting on healthy living centres and I hope that I can help him to crack the bureaucracy. He is quite right that getting bureaucrats to be entrepreneurial and to recognise the benefits of social enterprise is a major challenge, and that is clearly what we have to crack. He is absolutely right to make that point.

The noble Lord, Lord Walton of Detchant, mentioned academic health science centres. These bring together a small number of health and academic partners. The aim is to help speed up the process of translating developments in research into benefits for patients and the local community, and to promote the adoption of their discoveries within the NHS and across the NHS and the world. Designation is awarded for a period of five years and the successful centres will be subject to review. The international panel of designation recommended that there should be a reapplication process. The Secretary of State has accepted this recommendation and he also reserves the right to suspend or remove designation if that is deemed necessary.

The noble Lord asked about the 1.5 per cent research spend. The Government have made unprecedented increases in funding for health research. Total government investment in health research will be £1.7 billion by 2010-11, an increase of more than £290,000 in the three-year period covered in the 2007 Comprehensive Spending Review. There is no evidence to suggest that a particular proportion represents a right level of support to aim for. We need to aim to make that investment work for us and to make it as effective as possible.

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The noble Lord raised the issue of MTAS. Since the old system was abolished the Department of Health has worked with the medical professions at various levels to design the best possible recruitment system for doctors in training. Nearly all the deaneries use the same IT system for their local recruitment. National recruitment has continued to improve. The establishment of Medical Education England represents a unique opportunity to work with professions and get the right number of staff in the NHS, at the right level.

My noble friend Lord Woolmer was correct to mention the next stage review and made a good point about patients’ needs and experience and how they should inform how services are organised. I will address funding issues in a moment. He also made the point about more clinicians in leadership roles. Clinical leadership is key to the future success of the NHS and the National Leadership Council has been established to support the service delivery in this.

The noble Lord, Lord Rodgers, raised the issue of stroke, as did several other noble Lords including the noble Lord, Lord Walton of Detchant. He was right to point out that we have a new national framework for stroke and we are endeavouring to give it the right kind of emphasis and prioritisation that stroke requires. I can confirm that the 10-year plan is on track, that the stroke strategy acknowledges that the networks are of great benefit and that all the stroke services in England now fall within one of the 28 networks. The work of the stroke improvement programme, including the networks, will be evaluated over the next year, after which future work plans will be considered.

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