The NHS, the Universities and Research

17.1 Education and training for NHS staff is carried out in a wide range of educational institutions; these include universities, polytechnics, colleges of technology, colleges of further education, NHS training schools and private We have not attempted to review these educational and training arrangements comprehensively but have concentrated on examining the links between the NHS and the universities because our evidence suggested that this relationship presented particular problems and because of the wide range of NHS workers who receive undergraduate and further education in the universities. They include all or some doctors, dentists, nurses, midwives, health visitors, psychologists, ophthalmic opticians, pharmacists, biochemists, physicists, administrators, dietitians, speech therapists and the remedial professions. This does not mean that we in any sense devalue the considerable contribution which other educational institutions make to the education and training of NHS staff. We received little or no evidence about these institutions and we discovered nothing in our work to suggest that the NHS received other than excellent service from them.

17.2 In addition to training many NHS staff, the universities make a major contribution to medical and health services research, some of which the health departments fund, either directly or by commissioning work from them. Some staff appointments in university departments are funded by the health

17.3 The close relationship between the NHS and universities has advan­tages for both sides, but it has been under strain since 1974 for several reasons. NHS reorganisation broke established working arrangements especially in England and Wales; the financial aspects of this relationship were given undue prominence by the pressure on resources in the public sector; and the introduction of the new junior hospital doctors’ contracts in the NHS had serious implications for the universities. We discuss these problems in this We also consider the criticisms of medical education put to us in evidence, and the arrangements for research in the NHS.

Consultation Arrangements

17.4 Before NHS reorganisation most teaching hospitals in England and Wales were administered by boards of governors and funded directly by the Secretary of State. The universities were represented on the boards and the medical schools had an influential voice in the management of teaching hospitals. However, the administrative separation of the teaching hospitals from those hospitals administered by the regional hospital boards was thought to be a barrier to comprehensive planning of health services in the regions. The White Paper on NHS Reorganisation in England stated:

“Administrative unification is essential if there is to be a properly balanced development of community and hospital facilities to meet the needs of teaching, of research and of services to the public. Teaching hospitals have in recent years gone a long way in providing district hospital services. Unification will help them to take this further, and in so doing, will bring great benefit to the districts concerned.”

The NHS Reorganisation Act abolished the separate boards of governors of teaching hospitals except for the 12 boards of the London specialist post­graduate teaching hospitals, and the administration of these hospitals became the responsibility of the Area Health Authorities (Teaching) (AHA(T)s).

17.5 Arrangements for the administration of the 12 specialist post-graduate teaching hospital boards were left unchanged at reorganisation pending consideration of their future. The advantages of integrating them into the regional structure of the NHS were not thought to be great because they concentrate exclusively on particular specialties and provide a national service. They are all in London and employ a high proportion of national specialist staff resources. The government has recently extended the life of the boards until 1982 and has proposed that a new authority is set up to administer them to pave the way for their full integration in the NHS structure. We are not certain that this is the right solution. Later in this chapter we recommend that a special inquiry is mounted to look at a number of the problems of health services in London and the future administrative arrangements for the post­ graduate teaching hospitals.

17.6 In Scotland and Northern Ireland the teaching hospitals have been administered in the same way as other NHS hospitals since 1948. The Committee of Vice Chancellors and Principals (CVCP) told us, however, that many of the problems of the Scottish universities with medical schools are similar to those in England.

17.7 Under arrangements introduced in 1974 each regional health author­ity (RHA) has a representative from each university with a medical school in the region. Each AHA(T) in England with a medical school has up to three such members with experience in the administration of teaching hospitals. For each RHA and AHA(T) there is also a university liaison committee consisting of representatives of the health authority and the university or universities involved in medical and dental education. Its purpose is to advise on the university’s needs for NHS facilities and the resource implications of those At district level the university is not formally represented on the district management team, although in most districts a university teacher has been nominated to work with it. In most cases university interests are also represented in the medical advisory committee structure, but there are no formal arrangements for this.

17.8     The main complaint made in evidence about these arrangements was that the university’s interests tend to be submerged in the struggle to deal with the daily problems of the NHS. This conflict is seen at its sharpest when financial matters are under discussion. If there were less pressure on resources, the difficulties would doubtless seem less serious. Moreover, in England and Wales the one-to-one relationship of medical school to board of governors has been replaced by the more complex structure of the reorganised NHS. The CVCP commented:

“The three level structure inevitably imposes a strain in relation to the distribution of resources for medical education and adds to the delay and complexity in obtaining decisions.”

17.9     It was suggested to us that the university representation on RHAs and AHA(T)s should be strengthened. In Chapter 20 we propose some development of the role of RHAs and it is likely that increased university representation will be needed. More spokesmen do not necessarily mean more influence, however, and we think that the main requirements are to strengthen links at operational level and to make sure that university representation on health authorities is at a sufficiently senior level. It may be appropriate for the Vice Chancellor or Principal, or Dean of the Medical Faculty to sit on the health authority, but that would be a matter for the university to decide.

17.10 We were told that generally the joint NHS/university liaison committees have not been working as well as they should. It is the responsibility of the health authorities to see that they work well, in particular that the medical schools and their teachers are involved in all planning which affects their interests and to which they can usefully contribute. For their part the universities could do more to help health authority members to understand the functions and contribution of the medical schools within the NHS.

17.11 At national level there should be regular discussion between the universities’ representatives and the health departments about the development of NHS policies and their implications for medical education. They will cover such subjects as the need for expansion or contraction of medical schools, the provision of specialist clinical laboratory services by universities, the impact of formulae for resource allocation, facilities for clinical research, the provision for teaching in non-teaching hospitals, the functioning of NHS/university liaison committees,   the  contribution   of  universities   to   the  education   of paramedical personnel and the implications for universities of new NHS terms and conditions of service. The University Grants Committee (UGC) told us that liaison between the health departments and the appropriate sub-committee of the UGC was satisfactory. However, it has not always been apparent to those in the field that central policies have been adequately balanced and co­ordinated between the interests concerned; and too great reliance may have been placed on personal relationships and informal contacts. These were perhaps adequate in a less stressful era but may no longer be so.

17.12 The CVCP drew our attention to a particular anomaly which has arisen in the arrangements for liaison between the universities and the health Arrangements exist in London, Scotland, Wales and Northern Ireland, but in England are lacking for the medical schools outside London. We think this gap should be filled in view of the growth of medical schools outside London and the importance which they are likely to have in the future. A more formal central structure to co-ordinate the policies of the health departments, the UGC and the universities may be required. We recommend that this should be considered by the parties concerned.

Teaching Hospitals Finance

17.13 Before 1974 the teaching hospitals in England and Wales were directly funded by the health departments. With the disappearance of the boards of governors of the undergraduate teaching hospitals responsibility for their funding passed to the AHA(T)s. This need not have presented serious problems; seven university hospital management committees in England and the teaching hospitals in Scotland had been funded through the regional hospital boards and there were no indications that this arrangement was But the change roughly coincided with two other developments, a significant reduction in  the  rate  at  which  spending  on  the  NHS  was increasing, and the introduction of formulae for the allocation of resources within the NHS. The effect has been that at a time when much of the NHS has suffered from financial restraint the teaching hospitals have felt themselves to be particularly hard pressed.

17.14 Teaching hospitals are generally more expensive to run than com­parable non-teaching hospitals. The extra cost is only partly due to their teaching activities, but it is difficult to separate the costs of teaching from those associated with the provision of specialist services and their traditional role as hospitals where higher standards of treatment and care than are normally possible are achieved. The Resource Allocation Working Party (RAWP) estimated that in England 75% of the excess costs of teaching hospitals could be attributed to their teaching functions, and the formula the Working Party proposed gave them an increase for this known as Service Increment for Teaching (SIFT). The SIFT is based on the median hospital excess cost per student: hospitals above the median lose in the redistribution of funds, those below it gain. One effect is that most of the London teaching hospitals lose. It has to be said that the basis for the allocation of funds in this
way has been much criticised.

Centres of excellence

17.15 Teaching hospital costs contain an element which is impossible to quantify, attributable to “excellence”. There is no doubt that in teaching hospitals clinical standards are high and that most medical research is concentrated in them. In these hospitals the leaders of the professions and teachers are trained, many specialist services provided, specialisms advanced, new techniques developed and new equipment evaluated. They embody a tradition of high standards, contain a high concentration of professional and scientific expertise and have an influence in attracting and fostering talent which does not exist elsewhere in the NHS. They are an invaluable asset and are rightly called “centres of excellence”. The teaching hospitals have served the nation well in advancing medical knowledge and in pioneering high standards of care. This is not to say that centres of excellence of research and development are not to be found outside the teaching hospitals. They are, but they tend to be the creation of one man or of a small group, possibly within a relatively narrow field. Standards of clinical care are often as high outside the teaching hospitals as within them, but less uniformly so.

17.16 Part of the quality of care provided by the teaching hospitals is due to their higher staffing levels, particularly of medical and nursing staff. There is a difficult decision to be made about how far the non-teaching costs of “excellence” should be protected from the redistributive effects of RAWP and efforts to promote the more even distribution of doctors. Not surprisingly those who work in the less well provided hospitals and areas are not always sympathetic to arguments for more resources based on the need to maintain very high standards.

London

17.17 Particular problems arise in the case of the London teaching hospitals. It has been a major achievement of the NHS to spread the specialist services including some supra-regional specialties more evenly across the country. This, and the creation of new medical schools in other parts of England has resulted in the birth of many new “centres of excellence”. There is no doubt that RHAs have looked, and will look, less to London for specialist expertise. However, despite the recommendations of the Royal Commission on Medical Education in 1968 that the number of medical schools in London should be reduced little progress has been made. There is still an excessive concentration of teaching and research facilities in London and more hospitals than its population needs. They include the famous and long-established teaching hospitals which between them train about one third of all the doctors of the UK as well as many nurses and other health professionals. They have been hard hit by RAWP. The University of London recently set up a working party under the chairmanship of Lord Flowers to examine the future of the London medical and dental schools. One of the options of the working party is to consider the closing of one or more medical schools in London.

17.18 We welcome this action by the University. We are conscious, however, that London has a number of specific problems which in our view require independent detailed examination. We have already referred to the need to examine the administration of the post-graduate teaching hospitals in Other matters which an inquiry should consider are whether London needs four RHAs, whether some special adjustment to the RAWP formula is required to take account of the high concentration of teaching hospitals in London, and what additional measures can be devised to deal with the special difficulties of providing primary care services and joint planning discussed in Chapters 7 and 16. We recommend that such an inquiry is set up as a matter of urgency.

Alternatives

17.19 We are in no doubt that the well-being of the teaching hospitals is as essential to the NHS as it is to the universities with medical schools. The Welsh National School of Medicine argued that:

“Some way must be found to insulate the teaching hospital from the conflict between short-term patient care and the longer-term needs of medical education”,

and suggested that teaching hospitals should be financed and run by the Department of Education and Science. Another suggestion was that they should revert to being directly financed by the health departments in England and Wales (or that their funds should be earmarked in the regional allocations). We do not believe that such a degree of insulation is desirable or in their long-term interests. At whatever level the needs of teaching hospitals are considered they will have to be balanced against other demands on available resources. However, their important national and regional functions must not be allowed to suffer. This places an important responsibility on the health authorities concerned.

Cost sharing

17.20 The close relationship between universities, especially those with medical schools, and the NHS means that there are grey areas where financial responsibility between the university and the NHS is unclear. These include the balance of time spent on clinical work by university staff and time spent on teaching by NHS staff; responsibility for buildings and equipment; and for post-graduate education. Neither side has operated a strict system of account­ing for shared costs. They have followed “the principle of uncosted mutual assistance”, to quote the UGC. This “knock-for-knock” arrangement is a gentlemen’s agreement based on goodwill and the knowledge that anything much more refined would be infinitely laborious and in many respects entirely arbitrary. The arrangement has derived strength from its flexibility:  its weakness is that responsibilities are not clearly defined, and in recent years financial restrictions and different conditions of service in the universities and the NHS have put a serious strain on their relationship.

17.21 The cost-sharing relationship between the universities and the NHS is complex as far as medical education is concerned. The undergraduate medical course normally lasts for five years. The typical arrangement is for a two year pre-clinical period of study in the basic sciences followed by three years clinical training. The pre-clinical period is entirely the responsibility of the university, but the education in the clinical years is shared with the NHS. As a result, clinical NHS staff are involved in teaching and academic university staff participate in patient care. The exact balance depends on local circum­stances and could not readily be ascertained, even if this were desirable. Hospital doctors’ contracts carry no defined teaching commitment, but consultants usually welcome the opportunity to take part in clinical teaching.

17.22 The interdependence of the NHS and the medical schools extends to the joint use of buildings and equipment. Responsibility for the capital cost of teaching hospital building schemes is apportioned between the NHS and the university concerned according to the Pater Formula of 1957, and this seems to have worked reasonably well. There has been no such agreement about paying for the running costs of buildings shared by NHS and university departments, or in the new integrated teaching hospitals and medical schools; and local negotiations about running costs have often been protracted and There seems to be a need for a formula for the shared payment of running costs which corresponds to that for capital costs.

17.23 The escalating costs and demands of post-graduate medical educa­tion have added to the strain on NHS/university relationships. The costs are unknown in total, those that can be identified are large, and the NHS meets the bulk of them. It is right that the NHS should do so, since post-graduate medical education is vocational and its main purpose the improvement of the quality of care provided to patients. Trouble stems from the fact that the UCG does not specifically fund the universities’ share of post-graduate medical If a university runs post-graduate courses it can recover their costs from fees, but these fees are normally not sufficient to meet the cost of recruiting extra staff. Thus university departments, serving the NHS in this way, meeting rising demands, have sometimes felt hard done by. The concordat which has determined the financial responsibilities of NHS and university authorities for post-graduate medical and dental education, agreed by the UGC and the health departments in 1973, has been under strain.

17.24 Clearly in times of economic stringency there will be pressure to minimise obligations and scrutinise expenditure very carefully. We believe that this should not be carried too far. General formulae can be helpful providing they are not too specific, but it is sensible to accept the existence of a “grey area” of obligation and accounting between the NHS, the UGC and the rigid definitions of responsibility might lead to neater accounting but would impair good relationships and efficiency.

Hospital Doctors’ Contracts

17.25 We remarked in Chapter 14 that we had received representations from university interests that the new NHS contract for junior medical staff with its introduction of units of medical time, defined duties and payments for overtime, had from the point of view of university recruitment, teaching and research been wholly injurious. The proposed new contract for consultants, if introduced, is likely to do far greater damage and further impair relationships between the NHS and the universities. It goes directly against the ethos of academic life and commitment. We recommend that NHS staff, if expected to teach students, should have that requirement written into their contracts. To go further than this, to prescribe individually the amount of teaching to be done, would be to replace flexibility and goodwill with rigid obligations; while to pay for it as an item of service would lead to endless wrangling.

Medical Education

17.26 The main areas of criticism of undergraduate medical education in our evidence were that the medical curriculum was inappropriate to the needs of the NHS, and that some medical schools’ selection procedures were biased in favour of certain kinds of applicant.

17.27 The aims of university education are of course wider than those of the NHS which are more concerned with the vocational aspects of medical or dental education. The tension between these interests is wholly understandable and should be constructive in its effects. While post-graduate medical education is explicitly vocational, the under graduate curriculum has also always had a vocational bias. The majority of the teachers are clinicians, not scientists; and if the curriculum did not have this bias it would not be acceptable to the majority of students, and would seem to them inappropriate to their future professional needs.

17.28 Critics of the undergraduate medical curriculum argued to us that medical education was not well adjusted to the working world, that it was too concentrated on acute general hospital medicine, and that it produced a doctor whose skills, attitudes and expectations were sometimes poorly related to the health problems and needs of the community.

17.29 The need for preparation for multi-disciplinary team working was also remarked on. The British Association of Social Workers said:

“Opportunities should be provided for all health professionals to have multi-disciplinary training . . . This is especially relevant to the medical training courses, where doctors have a crucial contribution if effective teamwork is to take place between different staff groups.”

We agree that the medical student should be far better prepared than he is at present for team working with other disciplines. There are few things more important for the NHS than that its health professionals should work well together.

17.30 Medical education should be relevant to the major health problems of the day, and amongst these are now geriatric illness, mental illness, disability and handicap and the potentially preventable diseases and injuries which result from an unhealthy life-style. .There should be more emphasis on community care and the importance of continuity of care. There has been some change in these directions in the curricula of the medical schools since the Royal Commission on Medical Education reported in 1968 but not enough. These are matters for which the General Medical Council (GMC), now reconstituted under the Medical Act 1978 with much broader powers, is responsible. We believe that we can rely on the newly constituted GMC to use its new powers wisely, and give this important matter its continuing attention.

17.31 The universities have been criticised for being slow to develop academic departments in fields which have been chosen by the health departments as deserving priority. Geriatrics, mental handicap, and rehabili­tation are examples. A wholesale invasion of educational territory by the NHS would be quite inappropriate; but it should continue to help the universities by funding academic developments in specialties where it is important to raise standards or pioneer change. We recommend that the health departments should, as a matter of national policy, fund chairs or senior lectureships, or promote joint university/NHS appointments as in Northern Ireland, in the priority specialties. There are already a number of appointments of this kind; for example, the Welsh Office supported the chair of geriatric medicine at the Welsh National School of Medicine in 1978 and the government endowed the Europe chair of rehabilitation at Southampton University in 1973.

17.32 Another aspect of medical education criticised in our evidence was the selection of medical students, although some of the criticisms would apply equally to the arrangements for selecting students in other faculties. Most medical students are selected from the science forms of the secondary schools and from the middle classes. There is some evidence of a slight increase in the already high proportion of final year medical students with fathers from social classes I and II between 1966 and 1975. Most medical students enter university straight from school. In their selection increasingly high academic school qualifications have been required; they are now at least as high as those for entry into any other university faculty; but no reliable techniques have been developed to test motivation. We recommend that universities should encourage and monitor experiments in medical student selection which take account of factors other than the traditional academic criteria. We suggest that they should retain some pre-medical courses which will allow the student who has not made his choice of career early in his teens, or who has not studied the requisite science subjects at school, or not to a sufficient degree, to switch to science and medicine. A more positive policy towards the admission of mature students to medical schools is needed, including some entrants from the other health and social services professions.

17.33 The development of post-graduate specialist education has had less influence that it should have had on the undergraduate medical curriculum in reducing some of its specialist vocational content. Similarly the existence and planned expansion of continuing education seems to have taken place apart from the development of specialist training. The duration of training in most of the medical specialties has been very similar, despite apparent differences in the complexity and sophistication of their subject matter and techniques of investigation and treatment. No doubt these are matters which the new GMC will view critically.

Research

17.34 Research is vital to improve standards of patient care. It increases knowledge and fosters a critical attitude to existing patterns of care and The government currently spends about £80m a year in the UK on medical and health services research. The money is allocated through the Medical Research Council (MRC), the health departments and health authorities. In England in 1978 the Department of Health and Social Security (DHSS) devolved responsibility for the administration and funding of health authority sponsored research to RHAs. Immediately before this more than £2m a year was made available for locally organised health services research. This new arrangement should be monitored to make sure that RHAs do not neglect research. In addition a valuable contribution is made by charitable foundations and by the pharmaceutical companies.

17.35 It is convenient to classify research into biological and biomedical, clinical and health services research, although the boundaries are somewhat A wide range of disciplines make a contribution to research. We deal in Chapter 7 with primary care research and in Chapter 13 with nursing research. Biomedical research is concerned with the biological mechanisms which operate both in normal functioning and in disease. It is not clinically oriented but may result in advances important for clinical medicine. In the UK it is funded mainly by the MRC and its record has probably not been bettered in any other country with comparable resources.

17.36 Clinical research starts with the detection and delineation of the phenomena of disease or illness. Trials of new regimes of treatment and of new drugs are some of the most common examples. It is the kind of research most obviously relevant to the treatment of individual patients. Clinical research is undertaken mainly, but by no means exclusively, in the clinical academic departments of the universities and is funded by the MRC, by the NHS and by the universities themselves. We commented above that the changing contractual arrangements for NHS staff pose a threat to the recruitment of suitable staff to clinical research. Another problem is that the post-graduate education of doctors, and some specialist training programmes in particular, are too inflexible. While some allowance is generally made for research, it is commonly insufficient to foster clinical research which should be accepted as an integral part of post-graduate education.

17.37 Health services research has only been undertaken on any scale within the last decade. It embraces many disciplines, including epidemiology, statistics, sociology, psychology and economics. It is concerned with topics such as the demand for health care, the needs of client groups, the organisation of services and their cost-effectiveness, the ordering of priorities, manpower and industrial relations and more generally with the efficient and effective use of Although the health departments, the universities, the Social Science Research Council (SSRC) and charitable trusts have promoted health services research, its development has been slow in comparison to clinical research.

17.38 There is an acute shortage of trained researchers in the relevant Health services research is a complex process in which continuity is essential. The present arrangements for funding and commissioning research do not meet this requirement. The London School of Hygiene and Tropical Medicine told us that they:

“make it very unlikely that a cadre of able and experienced workers can be built up in health services research”.

The DHSS has tried to overcome this problem to some extent by channelling a significant part of its research budget to a number of multi-disciplinary units which are guaranteed support for a few years ahead. This improves security of tenure for a few essential staff, but still does not provide researchers with the secure career structure enjoyed by academic staff in universities. It is recognised that recruitment, especially of senior or experienced staff, is hampered. An alternative approach might be for the health departments themselves to employ a cadre of scientists to undertake research in the same way as government departments like the Ministry of Agriculture, Fisheries and Food and the Ministry of Defence, but this is open to other objections. The Institute of Health Service Administrators told us:

‘To be of real value such research would have to be sponsored at a high level and undertaken by bodies of sufficient standing and independence to command general support and acceptance.”

We accept this view.

17.39    A solution to this critical problem of encouraging systematic research into health care issues would be the establishment of an Institute of Health Services Research. Such an institute should be sufficiently large to provide secure employment, and even a career structure, to at least some research workers from a wide range of disciplines, and would provide opportunities for full-time and part-time research activity by those pursuing academic and scientific careers. The institute would need substantial independent sources of funds, and this might be provided by linking it to the SSRC, and perhaps also the MRC. Such funding would enable coherent research programmes to be developed. The institute could undertake specific research projects within the customer-contractor relationship on behalf of the health departments, health authorities, community health councils and other bodies, and supplement its funds in this way. It would encourage the development of a corpus of knowledge and experience in the sphere of health services research, and could help to co-ordinate the research undertaken by universities and other agencies. It could also provide training in research methodology for health service professionals, and participate in post-graduate training programmes. We believe that such an institute could contribute greatly to the development of health services research and we recommend that an Institute of Health Services Research should be established in England and Wales and its activities and output carefully evaluated. The health departments in Scotland and Northern Ireland should consider their position as separate institutes may not be appropriate there.

17.40 Although public spending on medical and health services research is the equivalent of only about one per cent of total expenditure on the NHS, it represents a large sum and it is important that research expenditure is properly evaluated and co-ordinated. The annual research budget of the DHSS totals about £26 m, of which the largest proportion goes on commissioning research from the MRC which also informally co-ordinates much clinical research, whether funded publicly or privately. More than £8m is spent by the DHSS itself on research in the health and personal social services, in fields determined by its own administrative divisions. Following the Rothschild Report, a Chief Scientist organisation was set up at the DHSS. It has attracted criticism; the scientific community thought that the department had not yet made effective arrangements to represent its interests as a customer for research. We have been pleased therefore to note that recently the office of the Chief Scientist has been reorganised and that new arrangements have been introduced for the control of the department’s total expenditure with the aim of underpinning the Chief Scientist’s role in providing a single focus for research in the department and in advising ministers on research and development matters. A Chief Scientist was appointed also in Scotland and the developments there have been more harmonious and fruitful. A review of the arrangements between the MRC and health departments will be made later this year.

Conclusions and Recommendations

17.41 The arrangements that existed for consultation between the NHS and universities were disturbed by NHS reorganisation. The transfer of responsibility from boards of governors with direct access to the health ministers to area health authorities would have given rise to difficulty at any time until the new arrangements had settled down, but was made much more difficult by the financial pressures on the NHS. Both parties have to work at getting the new relationship going properly: on the NHS side this means making sure that universities are properly consulted on matters which affect them, and on the university side it may mean that the Vice Chancellor or Dean of the Medical School has to be personally involved. We are doubtful whether consultation arrangements at national level between educational and health interests are

17.42 It is likely that teaching hospitals would have found themselves under financial pressure even if NHS reorganisation had not occurred because of the general pressures on NHS resources since 1974. There is a conflict between the short-term needs of the NHS and the importance of providing for the future. The teaching hospitals feel themselves exposed to the pressures of keeping the NHS going, but this would have to be faced whatever the financing arrangements. We are strong supporters of centres of excellence, but we think the teaching hospitals will in the long run gain through their closer integration into the NHS. It is a difficult time for the teaching hospitals, but the example of Scotland should offer some encouragement. Another aspect of the financial pressures is the tendency for both university and NHS to start counting the cost of services provided to the other. This is a profitless occupation since the funds being argued over come from the Exchequer and the loss of flexibility, not to mention the complexities of computation, would merely make for future difficulties.

17.43 There have been criticisms of undergraduate medical education, but this is not an area into which we have gone in detail. The curriculum has been criticised on the grounds that it is not as relevant as it should be to the work of doctors in the NHS, and the selection of medical students has been criticised on the grounds that universities rely too much on academic performance and too little on other evidence of suitability. We think there is room for development in both these areas.

17.44 Biomedical and clinical research are adequately catered for by the existing agencies, particularly the MRC. Health services research needs to be developed.

17.45    We recommend that:

  1. a formal structure at national level to co-ordinate the policies of the health departments, the UGC and the universities should be considered by the parties concerned (paragraph 17.12);
  2. an independent enquiry should be set up to consider the special health service problems of London including the administration of the post­ graduate teaching hospitals, whether London needs four RHAs, whether some special adjustment to the RAWP formula is required to take account of the high concentration of teaching hospitals in London, and what additional measures can be devised to deal with the special difficulties of providing primary care services and joint planning in London (paragraph 18);
  3. NHS staff who are required to teach students should have this requirement written into their contracts (paragraph 17.25);
  4. the health departments should as a matter of national policy fund chairs or senior lectureships, or promote joint NHS/university appointments as in Northern Ireland, in the priority specialties (paragraph 17.31);
  5. universities should   encourage   and   monitor   experiments   in   different approaches to student selection which take account of factors other than the traditional academic criteria (paragraph 17.32);
  6. an Institute of Health Services Research should be established for England and Wales to encourage systematic research into health care issues and its activities and output should be carefully evaluated. The health depart­ments in Scotland and Northern Ireland should consider their position as separate institutions may not be appropriate there (paragraph 17.39).

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