Health: Polypill

Debate between Lord Turnberg and Lord Willis of Knaresborough

Monday 7th July 2014 Lords Chamber

[Lord Turnberg (Lab)]

My Lords, I too am grateful to my noble friend Lord Hunt for introducing this debate. It is pretty obvious that he, like me, has been briefed by Sir Nick Wald—and I suspect that the noble Earl may have heard a little from him too—so if what I say sounds a little familiar, I hope he will forgive me. Heart attacks and strokes remain among the biggest killers, despite the improvements in mortality rates in recent years. We know many of the risk factors—smoking, alcohol, obesity, salt and lack of exercise—and we must not be distracted, as the noble Baroness, Lady Brinton, says, from dealing with these public health issues. They are not mutually exclusive, of course.

We know that we should do more to detect and treat high blood pressure and raised blood cholesterol levels, but there is one important risk factor that we can do little about. That is age. There is a straight-line relationship between age and the incidence of heart attacks and stroke. The older you are, the higher the risk. The most striking thing about this is that about half of those getting one of these killers do not have one or other of the conventional risk factors—they have normal cholesterol and normal blood pressure. They come as a surprise in people thought to be fit, and it is in these unsuspected and unsuspecting individuals where the polypill may play a role.

The rationale for the polypill relies on a number of basic principles and here I rely specifically on Sir Nick Wald’s briefing, so what I say, as I pointed out, may not be entirely novel. First, we know that using drugs to lower a raised serum LDL cholesterol reduces the rate of heart attacks, and lowering the raised blood pressure reduces the incidence of strokes, but the intriguing observation is that the same drugs reduce even normal levels of cholesterol or blood pressure to a similar proportion as in those with raised values.

Furthermore—and here is the nub of the argument—lowering even normal levels reduces the risk of heart attacks and stroke. For example, Nick Wald calculates that a fall in blood pressure of 10 millimetres of mercury reduces the risk of stroke by about 60% and reducing serum LDL by 1 millimole per litre lowers the risk of coronary artery disease by 40%. The fact is that there does not appear to be a lower limit below which reducing blood pressure or cholesterol is not effective in reducing risk.

The second principle is that you can achieve as good or better effect in reducing blood pressure from a combination of two or more hypotensive drugs given in half or lower doses than a single drug given in a normal dose, and in this way markedly reduce the incidence of side effects. You get the same impact on blood pressure with many fewer side effects from a combination of half doses.

Therefore, combining these pieces of evidence—risk increasing with age, lowering risk factors even when they are seemingly in the normal range, and combining low doses of drugs to reduce side effects—leads to a conclusion that points to a need to give polypills as a preventive measure to those at risk, namely all the population over the age of 55, say, regardless of their conventional risk profile. Indeed, if they have other more obvious risk factors they are likely to be treated for them by one means or another already. It is the unsuspecting population where a polypill is most likely to be effective. In these, it lowers cholesterol and blood pressure as well as risk.

Nick Wald has suggested that one in three individuals taking a polypill containing small doses of simvastatin, losartan, amlodipine and hydrochlorothiazide would live an extra eight years than they would have done without the pill. It could reasonably be concluded that we should be giving everyone over 55 a polypill of this type, and it would help those harbouring unsuspected coronary artery disease or strokes. If this were a preventive programme like vaccination, as my noble friend suggested, we probably would not hesitate, but of course it is not a one-off, single shot like a vaccine. It is to be taken life long, every day, as a prophylactic treatment, more like the contraceptive pill to prevent pregnancy, although of course for rather longer.

So many issues would have to be overcome, and a number of critics of the mass medication that such a programme would entail have to be answered. There is the question of regulation. Although all the constituents of the pill have been through all the regulators and are in fact well out of patent, the MHRA and MEA may well need convincing that the combinations do not need further appraisal and approval. There is the question of side-effects. Although doses are low, there are undoubted side-effects with all the constituents of the pill, even in the low doses used here. They may well become significant when trying to reach whole populations.

Some say that we are already an overmedicalised society and we do not need yet more pills for everyone. I am not sure that that is a terribly good argument, because we rely quite heavily for our longevity on many of the medicines we take. I am one of the few, it seems, who is on simvastatin without side-effects, out of a huge population who are similar to me. In any case, no one is forced to take drugs if they do not want to. Nevertheless, those are views that we cannot easily dismiss and are to be taken seriously.

We come to the question of whether the polypill should be available for prescription on the NHS or simply over the counter at pharmacists. It is probably very cheap, and the economic value of preventing those diseases is a strong argument for prescription. It would at least allow us to get a clear angle on the number and incidence of side-effects, which free availability would not. It would allow doctors the opportunity to assess their patients for other preventable risk factors at the same time, which we have to do something about. On the other hand, an approach in which people simply decide whether to buy the pill over the counter is certainly more libertarian, but would probably not make a great impact on the epidemiology of those diseases, nor on the health of the nation.

There are certainly interesting debates to be had, and I am very grateful to the noble Lord, Lord Hunt, for starting us off on this topic.

[Lord Willis of Knaresborough (LD)]

I am grateful to the noble Lord for giving way. One issue raised earlier was about the dosage and combining those dosages in relation to particular side-effects. It was only 12 months ago, I think, that NICE advised against giving particular doses of simvastatin together with a modifier. When doses are given separately, you can take the evidence and change them. When they are combined in a polypill, that goes out of the window and you are left with all the elements at the dosages that have been agreed. Is that not an argument for retaining the current position of giving separate dosages rather than combining them all?

[Lord Turnberg]

Those are very good points. The doses used in polypills are very low, in fact—20 milligrams of simvastatin, when the normal dose is 40 to 80 milligrams. The other drugs in the polypill are half doses. The point is that, if you have raised LDL cholesterol or raised blood pressure, you should certainly be on the treatments; they have been shown to be effective. It is people who do not have raised cholesterol or raised blood pressure who we are aiming to treat—or to prevent their diseases—so it is a different situation. The point about safety is important. It is clear that we need and should have proper clinical trials of those doses, but the impact of such doses, from what we know about them in this combination, is that they are likely to be safe in the vast majority of cases. What we do not know is the number who will get side-effects.

Care Bill [HL]

Debate between Lord Turnberg and Lord Willis of Knaresborough

Tuesday 4th June 2013 Lords Chamber

[Lord Turnberg]

My Lords, I will speak to Amendment 2. Before I do so, I should explain that I have heard from the noble Lord, Lord Patel, who cannot be in this place this evening because of illness in the family. I strongly support the amendments of my noble friend Lord Hunt, in particular the idea of a nurse on the boards; I also very strongly support his ideas on trying to attract good managers to stay in the service for as long as possible.

Amendment 2 is the first of several amendments that I have tabled emphasising the need for Health Education England and the local education and training boards to pay particular attention to the maintenance of standards and quality in education and training. I express my interests here as someone who has spent many years trying to raise standards of medical education in my previous jobs as dean of a medical school, the president of the Royal College of Physicians and, perhaps of equal significance, as president of the Medical Protection Society, where I was brought face to face with what happens when standards fail or are allowed to slip.

This amendment specifically concerns the membership of Health Education England and the need for it to include at least one person with expertise in research and another in education and training. I will save my remarks on research until we debate later amendments, but so far as education and training are concerned, my fear is that in the drive to meet workforce requirements and staffing numbers we will lose out on standards and quality. This amendment simply makes more explicit the need for input on the board of someone who has particular expertise about education and training, and the maintenance of standards.

I will make another point now to save making it later. I believe that there is a conflict, not easy to resolve, between the desire to provide sufficient numbers of trained staff locally—as determined, quite rightly, by local providers—and the need to maintain national standards. For example, in medicine it is vital that a cardiologist, orthopaedic surgeon, general physician or trained nurse is trained to a national standard that is recognised everywhere. It is not acceptable for a local provider to decide what training should consist of, but they want someone whom they can rely on. It is vital that there are national standards and hence there is a need for someone at the Health Education England level who has the expertise to look at how those standards can be set.

So far as national workforce planning is concerned, I have lived through innumerable efforts at medical workforce planning and found them to be fraught with difficulty, largely because it takes so long to train doctors: five or six years as undergraduates, then another five or 10 years of specialist or general training. Predicting need for different types of doctors 10 or 15 years downstream is far from straightforward. The noble Earl kindly sent around a document on a mandate from the Government to Health Education England. However, I fear that the section entitled “Excellent Education”, with its emphasis on training multipotential individuals working in teams across all health sectors—important though that is—de-emphasises the need for specialists. That prospect fills me with apprehension—that five years downstream we will have a health service lacking essential parts. I fear that the right balance between the need for general across-sector care and specialist care may be tipping too far in these particular aspirations. In any event, for the moment, I will press for the placing of relevant education expertise on the board of HEE, as suggested in this amendment.

[Lord Willis of Knaresborough]

My Lords, in the Second Reading debate on the Health and Social Care Bill, now an Act, I made the point that while we were talking about structures until the cows came home, the things that really mattered were the education and training of the staff within the NHS and the research element that gave those staff the very best tools in order to be able to care for patients and have good patient outcomes.

I compliment not only my noble friend, but the whole House, and indeed the whole Parliament, on the way in which it got behind the proposal in that Bill which is now in this one to create Health Education England as a way forward. The appointment of Sir Keith Pearson, who knows the supply side very well and has the ability to bring people together to listen to what he has to say and to be able to develop Health Education England as a real force for good, is quite outstanding. My worry is that we will start to bind the hands of Sir Keith and Health Education England, and we must not do that. What is required now is an organisation that is given sufficient flexibility and power to be able to grasp the key issues that are facing the NHS and to move forward.

I support very strongly the amendment in the names of the noble Lords, Lord Turnberg and Lord Patel, to include on the board people with relevant expertise. I am pleased that the noble Lord did not go on to say exactly who should be on that board, because I believe that that would be a step too far. But to have somebody with a real background in training, education and medical research would bring great strengths to the board.

I also support Amendment 3 in the name of the noble Lord, Lord Hunt. Indeed, I support virtually all the amendments tabled by the noble Lord and compliment him on the way in which he introduced this part of the Bill. Having a registered nurse on the board is so important. If we do nothing else in terms of the Francis report, the one thing that shines through is that you need somebody within the organisation who brings to the board those issues of quality care at every level. That is really quite exciting. I hope that my noble friend will listen to the wise words of the noble Lord, Lord Hunt, and others, and ensure that nursing is given a real place at the table, because quite frankly for generations it has not been. Nurses are no longer the handmaidens and “handmasters” of other professionals. They are in fact equals.

Health and Social Care Bill

Debate between Lord Turnberg and Lord Willis of Knaresborough

Monday 27th February 2012 Lords Chamber

[Lord Willis of Knaresborough]

My Lords, I am eager to speak at this late hour. It seems that every time we talk about research it is always around 11 o’clock at night. The Minister and his minions must be planning something which we do not quite know about, but here we are. I support Amendments 66AA and 67AA standing in the name of the noble Baroness, Lady Morgan of Drefelin. Will my noble friend the Minister clarify the issue over the head of research at NIMR? At an early stage on Report, he clarified the duties of the Secretary of State and the commissioning groups, and how they will be reported. I think that is quite clear to the House. Speaking on behalf of the medical research charities, one of which I chair, there is general agreement on and support for the Minister’s general direction of travel. However, the Commissioning Board is a different issue altogether. The Minister was silent on that when he reported back but he indicated that it would be the role of the chief executive of NIMR, Dame Sally Davies, to prepare plans and report back on research. However, my understanding is that Dame Sally Davies has two specific jobs. On the one hand, she is the chief executive of NIMR and is therefore responsible for funding research proposals that come to the Department of Health. That is a very distinct role of looking after more than £1 billion of spend in this particular direction.

Her other role is that of Chief Medical Officer. In that role, I understand that she is responsible for organising, on behalf of the Department of Health, research programmes that deal with both public health and those areas of the health programme that require specialist research input. The Minister appeared to say earlier on Report that Dame Sally Davies would, in her role as the head of NIMR, report to the board on research. However, perhaps she will not report to the board on research; perhaps she has a separate reporting line to the Secretary of State or Parliament. In that case, I should very much like the Minister to clarify that role.

In conclusion, I strongly support the arguments of the noble Baroness, Lady Morgan of Drefelin, in making her point about cherry picking duties. Earlier today, in response to Amendment 38A, moved by the noble Baroness, Lady Masham, the Minister rightly said that we should not cherry pick particular conditions in order to report on them. However, that is exactly what is happening over the duties. A specific set of duties, of which the whole House is incredibly supportive, are laid down in the Bill. However, only certain ones must be included in an annual plan and reported on. There can be no duty more important than that of research. It is the one area in which we will get the very latest treatments to patients quicker and with better health outcomes, yet it is one of the areas that is regarded as less important than others. I hope that the Minister will be able to satisfy both the medical research charities and this House on those two issues.

[Lord Turnberg]

I strongly support the amendments in the name of the noble Baroness, Lady Morgan, and the words of the noble Lord, Lord Willis. It is almost churlish to return to the matter of research when we have heard such welcome words and support from the noble Earl on research in the Bill. However, as an ex-chairman of the Public Health Laboratory Service, it would be wrong for me not to comment on Amendment 60A, which seeks to have research supported in the health service for the purpose of protecting the public in England. It is in that area that we may have a specific problem because public health will be dealt with largely by the local authorities. It is unclear how local authority support for research will be kept within the context of the needs of the country, and how that will work with the marvellous amendments that the noble Earl has tabled. Perhaps he will clarify how local authorities will be engaged in promoting research and how we will encourage them to do so.

Health and Social Care Bill

Debate between Lord Turnberg and Lord Willis of Knaresborough

Wednesday 8th February 2012 Lords Chamber

[Lord Turnberg]

My Lords, I put my name to Amendment 12 but I have shifted my allegiance to Amendment 13, along with other noble Lords. However, I want to speak to the other amendments in my name in this group. In doing so, can I say how much I, too, very much appreciate the government amendments in this group?

At the end of the day, education and training have to be provided within hospital trusts, in general practice and—a slightly separate issue—in local authorities for public health consultants. At this level, local education and training boards are to be given responsibility for overseeing the provision of all this education. Here, local employers are to play a key role in the trusts. These local employers clearly have an interest in being able to plan for their manpower needs and in having an influence on what sort of training their employees should have to do the job that they want doing. However, they are not in the best position to decide the educational content of the programmes that the trainees go through. They are not best able to design the training or education of an orthopaedic surgeon or cardiologist, for example.

Furthermore, they may have a conflict of interest when they are asked to make sure that the facilities for training are adequate to their trusts’ needs. Is there a full range of patients coming through the hospital to give trainees the necessary experience so that a specialist trained in one area can practise somewhere else? Are there enough staff to enable trainees to have the time they need for education? Will they have the time to attend courses? Will it be in the trusts’ best interests to allow the rotation of their trainees to other trusts? In all these areas employers may have different priorities. For this reason, it is vital that we have the input of those with particular expertise in and knowledge of education and training, and enough independence to ensure that the training needs of the trainee are met.

Hitherto, specialist postgraduate training has involved the medical royal colleges in designing the curricula and educational programmes for trainees, and in setting and running the postgraduate exams and assessments, while the postgraduate deans are responsible for ensuring that local conditions are right for trainees—that training posts are available and for funding those posts. With the dissolution of the strategic health authorities, the postgraduate deans and deaneries are left in the air and the local education and training boards are to be taken over by the employing authorities. The amendments in my name try to redress that balance by ensuring that the training boards have in their membership the independent voices of those—namely the universities—whose prime role is to help them with the activities. To this I would add the postgraduate deans and colleges. Furthermore, it is important that the local education and training boards, while quite reasonably including local employers, should not be led by them. Boards should have sufficient independence to keep employing authorities focused on meeting the needs of trainees. That is why I have tabled these amendments.

I know that the Minister has given some reassurance from the Government along those lines in the letter that he has written to some us. He said in his letter, which I hope he will not mind my quoting back to him:

“This framework will be maintained in the new system, with the LETBs assuming responsibility for the quality management role at local level”.

That bothers me a little. Quality management should be independent of the employers themselves. We now need to see something in the Bill that will give us the confidence that it will happen.

My name is also attached to Amendment 105. Here we are concerned specifically that private providers should not be able to shirk their responsibility for training. There is no doubt that training requires more time and money. If private sector providers are able to avoid training, they will have an unfair advantage over NHS providers. Of course, there is much valuable experience and training to be gained from private practice. For those reasons, I am happy to support this amendment, too.

[Lord Willis of Knaresborough]

My Lords, I support government Amendments 61 and 104. As regards Amendment 2, which the noble Baroness has introduced, Clause 6 adequately describes the duties of the Secretary of State in relation to education and training. My noble friend the Minister has done an incredibly important job in recognising the real anxiety that existed at Second Reading about education and training. Indeed, we are grateful to the noble Lord, Lord Walton, for withdrawing his amendment at that time as that has enabled major discussions to take place on the issue.

Government Amendments 61 and 104 bring us to the heart of who will be driving much of the education and training—that is, the national Commissioning Board and the local commissioning groups. In fact, neither of these groups seems to have any responsibility for education and training, even though, as the noble Lord, Lord Turnberg, rightly says, they will be right at the heart of commissioning the healthcare required, whether it is in an NHS setting or a private, approved setting. That appears to be an omission in the Bill.

Although I have much sympathy with Amendment 109 of the noble Lord, Lord Turnberg, and he is right to point out that there is a requirement on private sector providers or, indeed, third sector providers, to engage in training, I hope that when the Minister winds up on this group of amendments he will point out the advantages to those providers of engaging in education and training. Indeed, he has privately assured many of us that they are more than willing to do so because they cannot become qualified providers unless they are engaged in cutting-edge training and education.

In Amendment 109, the noble Lord, Lord Turnberg, raised the important issue of the involvement of universities. It worries many of us that the universities which have been very much at the heart of education and training, particularly postgraduate education and training, appear to be sidelined in the new architecture of the Bill. Frankly, that is unacceptable. It should not be for local employers to decide whether or not they want a university to be involved; it should be a requirement for universities to be involved. We must not have a situation where universities are regarded as predators in relation to education and training, as they are fundamental to it. If research is a fundamental part of the architecture of the Bill and of improving patient care, frankly, it is absurd to have universities outside that remit. Therefore, I hope that when the Minister responds he will assure us that universities are part of the solution—as the noble Lord, Lord Turnberg, rightly said—and are not seen as part of the problem.

Health Research Authority (Establishment and Constitution) Order 2011

Debate between Lord Turnberg and Lord Willis of Knaresborough

Tuesday 15th November 2011 Grand Committee

[Lord Turnberg]

My Lords, this instrument is to set up the Health Research Authority as a special health authority. The main reason given for taking this step rather than the primary legislation route is because there is some urgency in finding a home for the national research ethics committees that will soon find themselves homeless when the strategic health authorities and the National Patient Safety Agency go out of business.

I can, of course, understand why it is necessary to go down this rapid secondary legislation route because even if the Health Research Authority were to find a place in the current Health and Social Care Bill, it would still be a couple of years before it would be fully enacted and we need something sooner. However, there remains the question of why it cannot be put into the Bill as well so that there can be a smooth transition from this temporary solution to a more permanent one. No doubt, we will be exploring that when we come to debate it later in the Bill.

The anxiety remains that we will have to wait a considerable amount of time before we see another round of primary legislation to set up a permanent agency. In our debates on the Bill yesterday, we heard about the doubts being expressed about when we will see further legislation. Can the Minister enlarge on the hint he gave in the debate last week that we might see something relevant to this in 2012?

It might be helpful if I said a few words about why the establishment of a health research authority or agency is so important. It comes directly from the recommendations in the Academy of Medical Sciences’s report A New Pathway for the Regulation and Governance of Health Research which the Government commissioned last year and which, to their credit, they have endorsed enthusiastically. The report described in great detail the current regulatory burden faced by clinical researchers and proposed a number of solutions, the most important of which was setting up this agency. It pointed out how the UK research effort is being undermined by an overly complex regulatory and governance environment and how this has caused a fall in the UK’s global share of patients in clinical trials of all types, as well as a marked increase in the time needed to navigate a very complex research approval process. Regulation has grown as new regulatory bodies have been set up, often in response to some scandal or other, and often with seemingly good reason, but without any consideration of the overall impact of yet another new hurdle and without any evidence whatever that they have improved the safety of patients or the public.

The problem is confounded by the delays and duplication in the governance arrangements within individual NHS trusts. They are now thought to be the single greatest barrier to health research, especially where several trusts are involved in multicentre trials, for example. There is a definite need for a regulatory pathway that allows us to cut through all this unnecessary and complex bureaucracy while at the same time ensuring the safety and interests of patients.

Now we have a research regulatory authority as an important government response, and we have to see how it is going to achieve all that is expected of it. First, the National Research Ethics Service, with its 80 or so local ethics committees, has done a marvellous job in the past few years in streamlining the ethics approval process. It has, for example, made it much easier for those engaged in multicentre research proposals to gain approval. Preserving its function has been vital, but unfortunately moving it by itself from one body to another will do no more than preserve the status quo. It simply moves it from one home to another, yet the research regulatory agency was expected to do so much more.

My questions for the noble Earl are: will the authority have any more responsibilities? For example, will it have any of the responsibilities currently undertaken by the ethics and confidentiality committee of the National Information Governance Board? That committee advises the Secretary of State on whether permission should be given to researchers wanting to use data about patients where it is not possible to gain consent. It is a very important safeguard for patients, but it means that researchers have to have two sets of ethical permission to do the research, one from a normal ethics committee and another from this committee, and that causes all sorts of delays. Can we expect some streamlining here? I see in the Explanatory Memorandum to this order that that might be on the horizon. If so, can the Minister give any further information on that and on when it might happen?

Then there is the problem posed by the delays caused by the local R&D committees in each of the NHS trusts. They can hold up research for months, especially if more than one trust is involved in multicentre research proposals. For example, Cancer Research UK said that the average time for a multicentre research grant to be approved was over 600 days. Can the noble Earl say whether the new authority will have any role in easing that problem, perhaps by ensuring that limits are set on the times that trusts can take in considering proposals? Will it, for example, be able to vet research proposals in such a way that it can save local R&D committees from each having to repeat much of the straightforward common areas of a proposal, leaving them to check on aspects of specific local importance? That would certainly help to speed up the process.

The excellent report from the academy outlines a whole range of other regulatory bodies and functions that could and should be rolled up into the new authority. I shall not go into them, save to recommend that noble Lords who have not read the report might find it of some interest.

A research regulatory authority or agency has enormous potential for good if we can get it right. If we do, all will benefit—the researchers, certainly, but most importantly the patients, who will access new treatments sooner and more efficiently. We will gain economically too, because we will regain something that we are already losing: the investment from the pharmaceutical industry, which is watching our debates with interest.

We owe a debt of gratitude to the Government for setting up this authority and removing the uncertainty surrounding the ethics committee, but much more needs doing. I look forward with interest to the response of the noble Earl, Lord Howe.

[Lord Willis of Knaresborough]

My Lords, first, I apologise to the noble Lord, Lord Turnberg, for arriving one minute into his speech; I did not realise that the earlier business would have been dispatched so summarily this afternoon. I am grateful to him for introducing the debate and giving us an opportunity to address the issues he raised ahead of discussions during the passage of the Health and Social Care Bill, to which there are clear amendments on some of these issues. Like him, I say to the Minister without hesitation that I welcome the establishment of this special health authority. He promised it in answer to questions some time after I had arrived in the House and saw the need to move on the academy’s report as quickly as possible, and I compliment him and the Government for moving so speedily; there is no issue about that.

The need to find a home for the National Research Ethics Service was important. There was haemorrhaging of staff and good will and, in terms of any research project, it is important that you have a stable, effective and well respected ethics service. We probably have the best research ethics service in the world. We welcome the appointment of Janet Wisely, the current chairman of NRES, as the new chief officer for the Health Research Authority; she is well respected and that level of continuity will serve us well.

NHS Commissioning Board Authority (Establishment and Constitution) Order 2011

Debate between Lord Turnberg and Lord Willis of Knaresborough

Tuesday 1st November 2011 Lords Chamber

[Lord Turnberg]

My Lords, many of the points that I might have raised have been raised by my noble friends, but I still have some concerns and quite a lot of confusion as to what this body will do. Will it have budgetary responsibilities from day one and, if not, when will it start having some responsibilities for the huge amount of money at its disposal? What controls will be placed upon it? If it is going to meet in public only occasionally, who will hold it to account if things seem to be going wrong? What role will the Secretary of State play if it does not seem to be delivering what it should? It has an enormous set of responsibilities. Will it have sub-committees or will it be decided, among the five non-execs and others, how it will go about its business? I find the whole thing rather confusing at this stage. It would be nice to have some clarity and I hope that the noble Earl will be able to give it.

[Lord Willis of Knaresborough]

Perhaps I might say first to my noble friend that I support and appreciate the idea of bringing forward a special health authority to shadow the new Commissioning Board. That is right and proper but, like other noble Lords, I think the idea of doing that is a little confusing before we have had a chance to examine this proposal in Committee, and to test it against the large number of amendments which are coming in to tease out what role the Commissioning Board will ultimately perform and what its form and functions will be.

I do not want to add to the questions asked by my noble friend Lady Barker, the noble Baroness, Lady Thornton, and the noble Lord, Lord Warner, all of which I am sure the Minister will get to in his response, but I particularly want to raise one issue with my noble friend. It is the question of research; he will not be surprised that I have raised that. In another place, the Government conceded that research ought to be put into the Bill and that it will be a duty not only of the Secretary of State but of the Commissioning Board and commissioning groups to promote research. At the moment, research within the NHS is of course promoted by the Chief Medical Officer of health, who has responsibilities for the National Institute for Medical Research. To be fair, I think that Sally Davies carries that job out very well indeed. She has done a remarkable job since the Cooksey report and the setting-up of OSCHR with the identifying of resources within the NHS for research. We are starting to see the fruits of that work; indeed, during the passage of the health Bill I hope to be able to speed up the process of getting a special health authority for research and, ultimately, a new research authority.

However, will this shadow authority have a duty to commission research? In which case, will that budget be within the £80 billion to £100 billion identified by noble Lords? Will it in fact take over the duties currently held by the Chief Medical Officer, Sally Davies, or will she continue to retain them and report to the Commissioning Board? In short, where will NHS research reside and who will have authority for it in making the decisions within the new arrangements?