§ 1.50 p.m.
§ Sir Hugh Lucas-Tooth (Hendon, South)
I am very grateful for this opportunity of raising the question of hospital registrars, and in particular the circular, "Review of Appointments to Registrar Grades." This is a subject which is full of inflammable matter, and I shall try to avoid any sort of provocation, which I hope will also be the attitude of all who speak in this debate. It is too important a subject to permit anything in the way of a "dog fight."
First, I ought to tell the House what hospital registrars are. I find in speaking to people outside, and even with Members, that there is a great deal of misapprehension about the nature of the duties of registrars. They are, of course, fully trained and qualified doctors; indeed, they should be, and they generally are, the very pick of the medical profession. They have a double function in the hospital. First of all, they are salaried members of the hospital staff doing specialist work. They are not fully qualified specialists, but they do specialist work, and they do it without what can be described as supervision.
While doing this work, they are acquiring skill with a view to becoming 1527 fully qualified specialists or consultants—I shall use the word "specialist" as covering the two, if, in fact, they can be distinguished at all. Not all registrars become specialists. A certain number fail to make the grade. But a fair proportion do make the grade, and all who become registrars do so in the expectation that in due course they will become specialists. They are no novelty. They have existed in our hospitals for a long time past.
Since the inauguration of the National Health Service, the number of registrars has very greatly increased. The reason is a very simple one. The country and the individuals concerned were told that the present number of 5,200 specialists, for the most part-time, would be increased to 7,500 full-time specialists. It was not intended that they should all be full-time, but that the total number should be the equivalent of 7,500 full-time specialists. In other words, the increase was to be something in the order of 100 per cent.
§ Sir H. Lucas-Tooth
The increase was set out in the plan, "Development of Consultant Services," published about the same time as the National Health Service Bill was introduced, and I understand that the document was re-published earlier this year. I presume, therefore, that it represents the official view of the Minister.
§ Sir H. Lucas-Tooth
Certainly that is the way that I understood the document. It is certainly understood in that way by a large proportion of the medical profession, if not by all the medical profession. If that is not the Minister's intention, I hope that he will give an explanation in the course of his speech.
Hospitals were certainly encouraged to increase the number of registrars on their staff. To say that they were "encouraged" is putting it mildly, because they were, in fact, told that they could and should make this specialist increase. The increase was, in fact, absolutely necessary because of the added amount of work that was coming to the hospitals. The individuals concerned, who saw what was happening and who were told of this intended 1528 expansion, not unnaturally thought that here was an opportunity, a very proper opportunity, to rise to the highest posts in their profession.
The result of this increase is that we now have some 2,800 registrars on hospital staffs, and of these about 1,400 are senior registrars—that is to say, they have done more than two years' work as a registrar. It is also proper to mention that at the present time a very high proportion of these senior registrars are over 30 years of age. That is exceptional, but it is the result of the delay which occurred by reason of the war. A high proportion of these registrars, who are to do this essential work in the hospitals, are men just entering the best period of their life and probably facing their heaviest family responsibilities.
From the training point of view, I must admit quite candidly that 2,800 is too many. I wish to emphasise that I am now looking at this question from the training point of view. The hospitals cannot at the present time absorb the number of new specialists who will be coming forward on an establishment of 2,800 registrars. That has meant that something had to be done. If no action is taken, we shall necessarily have one of two results—either a very serious bottleneck in promotions, or specialists without the facilities to do their work as specialists. That was the situation that the right hon. Gentleman had to face, and he has faced it by bringing out the circular to which I have referred.
If I may put the circular shortly and, I hope, fairly, it proposes that the establishment of registrars shall be reduced to 600 senior registrars and 1,100 registrars for the country as a whole: that is to say, a total of 1,700 as compared with the existing total of 2,800—a reduction of 1,100. The method to be employed is that the registrar's course, if I may use the term, his period as registrar, is in future to be for five years, with suitable pruning at the end of every year. I have no quarrel with that as a suggested policy. Secondly, it is suggested that hospitals are to limit the number of new appointments to fit the new establishment. Without discussing the question of what is the proper size of establishment, I must agree that new appointments must fit whatever establishment is decided upon.
1529 Thirdly, it is suggested—and this is where all the trouble has arisen—that the hospitals are to terminate 1,100 existing appointments at the end of the current year. These terminations are to start with effect from 1st January. I think I am right in saying, and I hope the right hon. Gentleman will correct me if I am wrong, the intention is that much the largest part of these 1,100 registrars who are to be disappointed will come from the third-year senior registrars class. It is quite clear, as the main cut is to fall on the senior registrars, that the majority of those disappointed will be in that class. I think the intention is that out of that class again the majority will be those who have, in fact, been in the hospitals for the longest period.
The most significant sentence in the circular to which I should like to draw the attention of the House is contained in paragraph 3. It reads:The information available indicates that for some years to come the number of appointments available to senior registrars to complete their training at hospitals in England and Wales is unlikely to exceed 150 annually.Thus, of the new specialist coming forward, it is intended that after making good wastage by death, retirement and the supply for posts overseas, there will only be something of the order of 30 additional specialists coming forward every year. That is the figure which was calculated by my hon. Friend the Member for Luton (Dr. Hill) when he spoke in the House the other evening. I should like to get confirmation or otherwise from the Government, but on any basis the number could not possibly exceed 50 in a year. The House will, therefore, see that if we are to reach the kind of figure which was contemplated in the Government's paper, namely 7,500 full-time specialists, it will take us on the worst footing at least 80 years, and on the best footing something well over 30 years. The immediate increase will be negligible.
The question I wish to ask the Government is, how do they propose to carry through the plan for the development of the consultant service as contained in that paper? If they are no longer aiming at a specialist service of some 7,500 specialists, what is the figure that they have in mind, and when do they intend to achieve it, because it is on the answers to those question that all matters raised by this circular depend. We are entitled 1530 to ask the Government for an answer to that.
The Minister of Health has said in answer to a question that he was not prompted by economy in the action which he has taken, and if I may say so, I am willing to accept that statement. Indeed, it is perfectly obvious that the action proposed in this circular cannot be because of economy. I should like to quote from what is reported as having been said by the hon. Member for Tottenham (Mr. Messer), who is a chairman of a regional board and incidentally of the Central Health Services Council. He was reported in the "Economist" as having said:If the hospitals service of his region are not to be reduced, the registrars will have to be replaced by the appointment of more consultants, senior hospital medical officers, junior hospital medical officers or general practitioners with the right qualifications and the time. The first two categories, who alone can really do the work, will cost far more than the registrars they will replace.This is accepted by all, and that is what the right hon. Gentleman intended. If he was not prompted by motives of economy, what is the purpose in cutting down the immediate increase to the total number of specialists which was envisaged in his paper and I imagine confirmed earlier this year? What is the reason for the sudden change in policy on the part of the Government? I can understand, as I said at the beginning, that there is need to take action in this connection, but why have the Government suddenly changed their policy from a contemplated total of 7,500 to what appears to be now merely the existing total, and, indeed, a total very similar to that which existed when the National Health Service first came into operation?
This circular has struck dismay—and I do not think I am putting it too high—in the breasts of all those concerned with the Health Service—doctors, hospitals, politicians and everyone concerned. Even the Socialist Medical Association has put in a very warm protest to the Minister asking him to withdraw the circular. Quite apart from the question of broad policy, we have here 1,100 acutely disappointed individuals. It is true that alternative work was suggested to those individuals who lose their positions as registrars. I refer to paragraph 12 and 1531 the appendix of the circular. I do not wish to develop This point.
I believe that certain of my hon. Friends have something to say about it, but I would say that to tell these men who have already had their careers once disorganised by the war and have spent quite substantial periods overseas, they are now to lose the expectation of becoming specialists, and as an alternative they can seek posts overseas or in the Forces is really the epitome of psychological ineptitude. The posts themselves are such that I would warmly recommend anyone to take them, but to make that recommendation in this connection at this time was surely the way to wreck this scheme from the very start.
Why was this situation not foreseen? There is now a sense of injustice amongst those who are concerned and there is also a sense of personal waste. They feel they have been unjustly treated because the cut—and I am not using that expression in any offensive sense—has fallen on a single class of the medical community, and that is a class which once before has had its life seriously interfered with. They have a sense of personal waste in that they have done five years in training to become specialists and a great deal of that work must necessarily be lost. Of course, there is the actual waste to the community of the effort and time required to train these men to be specialists. Some no doubt must necessarily be lost in the ordinary course of events, but I feel that the House is entitled to an explanation why the position was allowed to reach its present pitch before some action was taken, which would have avoided a great deal of this personal hardship.
If I may in conclusion generalise, I think this is a particular example of the general trouble affecting the Health Service. The inauguration of the service stimulated demand for what the service could supply. I think the right hon. Gentleman would agree with me when I say that, while the service enormously stimulated demand, very little was done and indeed little could be done to increase the corresponding supply. In financial matters, when demand enormously exceeds supply, we get currency inflation. In effect, we have here something in the nature of medical inflation: there are too 1532 many patients chasing too few doctors, dentists and hospital beds. That is what is causing the trouble in other departments of the Health Service, and it is at the root of our present difficulty.
What we must do somehow is to bring the demand for hospital beds and hospital specialist attention into line with supply, and I do not believe that what is proposed in this circular will do anything to help. Indeed, my own view is that it will aggravate the trouble rather than otherwise. I ask the Minister to look at this matter again, to withdraw the circular and to bring forward other suggestions to deal with the matter in a more fundamental and more humane manner. If he does so, I am certain that it will be for the ultimate good of the service as a whole.
§ 2.11 p.m.
§ Mr. Messer (Tottenham)
I rise to speak only because I think it is my duty to convey to the Minister the very deep and widespread feeling that has been aroused by the issue of this circular. The regional hospital boards, which were charged with the responsibility of planning the service, found it a very difficult job at the beginning because of the nature of the hospitals with which they had to deal. After planning the service in the way which they thought was the best to meet the needs of the people, by grouping several hospitals together for the purpose of forming units and then, of necessity, grading those hospitals to do the work required, they found in their grading that they were compelled to recognise what for years now has been the practice of building up medical teams on a three-tier system.
In that three-tier system, as explained by the hon. Member for Hendon, South (Sir H. Lucas-Tooth), the registrar played a very important part. The question is not only what the registrar is, but, more important, what is the work that he does. When we are considering, as we must consider, the relative figures of staffs, it is not sufficient to say that as a result of examination there must be a reduction. There must be a reduction in that section which will not affect the service to the same extent as a reduction in other sections.
The functions of the registrar in teaching hospitals differ slightly from 1533 those in non-teaching hospitals. In the teaching hospital he is not, as the name would imply, somebody who registers. I do not know how the name "registrar" came into existence, except that, originally, the high-ranking specialist had a man who wanted to be a high-ranking specialist tailing on behind registering his cases and looking after him. That, I believe, was the origin of the term. In point of fact, the registrar is a man who has passed through the other stages; he has been the house surgeon or the house physician, where he has not been in a position to determine whether or not he would specialise. Later he may discover he has an aptitude or liking for a particular branch of medicine or surgery and may decide to follow that line. In doing so he would become junior registrar, then senior registrar and finally a specialist.
When a man has decided on that course, it is not very easy for him to switch, although there are some specialist branches which are more readily adapted to switching from one to another. It is not an easy thing for a man to decide, after a period of years of training in a particular line, to branch out into general practice. There are, of course, specialist practitioners. I do not say it is impossible; I do not say that all these registrars who will lose their posts will be signing on at the employment exchanges. That is not the case at all. There is a need for every doctor in the Service, and indeed for many more who could come into it.
I am not really concerned with the registrar, even though that may sound a little selfish. If the registrar has got to be sacrificed, and that sacrifice can be justified in the interests of the service, it must be made. I am concerned rather with the service. As I have said, the registrar in a teaching hospital does not occupy exactly the same place as the registrar in a non-teaching hospital. What he does is not merely clinical work, although he does that too. He follows his speciality; he has the day-to-day responsibility for a certain part of the work; but in addition to that, a very large part of his time is taken up in teaching others; he is part of the teaching staff, and he is therefore not merely a doctor in the sense that he is looking after patients; he is also doing the educational work.
1534 It is obvious that there are too many registrars in the service at the present time, and I cannot agree with anybody who goes to the extreme of saying that the Minister is doing something fundamentally wrong in interfering in this respect. The Minister is responsible to this House and to the country, and when he finds that the situation is such as to require his attention, in this or in any other direction, it is his duty to put right what he believes to be wrong. In passing, I might say that I am not always in agreement with the way he does it. It is possible to do the right thing in a way that does not produce the best results, and I rather think that the approach to this matter might have been made rather differently, so that those of us who believe that he has a case for reducing the number of registrars could have discussed with him the method by which it should be done with the least hardship.
It will be necessary for me to point to the illustration of the regional board of which I am the chairman. Every chairman of every regional board is proud of the work they have been doing, and I am rather proud of the high standard of the work which is being done in my region. In planning I must have regard to the fact that we have got what may be described as nine major hospitals; that is to say, the type of hospital which will be affected by the implementation of this circular. The other hospitals will not be affected because the same system does not operate there. We group the hospitals together, which means that some of those hospitals are small and are devoted to a different type of work from that which requires the high standard of skill of the specialist staff.
I have gone into this carefully in those nine teaching hospitals, and I am saying here, with a due sense of responsibility, that unless there is a replacement of staff of equal skill—and that is the important thing; we cannot have unskilled people doing the highly skilled work that the registrar is doing—unless there is a comparable addition to replace those registrars, we shall have to close 400 beds for the type of work which we are now doing. One cannot have regard to that and feel that, if it happened, the service would not suffer. This country has a deserved reputation of being in the front rank in 1535 medicine. If the standard of the work we are doing is to be degraded, it will be a bad thing, not merely for the service and for the profession, but for the people.
One of the alterations to which we have been turning our attention is how to meet the need for dealing with those tuberculosis patients whom we have been unable to get into hospitals or sanatoria. As is known, the length of the waiting list for such patients is not caused merely by lack of accommodation. There are about 4,000 beds in the country which could be used if we had the nursing staff. We are driven, therefore, to considering in what way we can deal with patients in their own homes.
What we have attempted to do is this. We make the chest clinic a centre. We appoint a specialist in charge of that chest clinic and we can give a number of beds in the hospital for the purpose of the observation of cases or for the primary induction of an artificial pneumothorax so that the patients can be discharged to their homes, where refill and other treatment, which normally takes place in hospitals or sanatoria, can be effected. This means, however, that we must have the same type of specialist staff—consultants at the top, the registrar, and the junior. If we are going to lose, as we are in our region, about 80 per cent. of our registrars, we must either replace them with some other type of staff, or the service will suffer.
An hour on the Adjournment is not long enough to go fully into this question. What I have said has been only by way of illustration. I have had such expressions of deep feeling from so many quarters that I urge my right hon. Friend the Minister, before he implements this circular, to take into consultation the teaching hospitals and the regional boards, so that he hears from them first-hand their view of what the result will be.
§ 2.23 p.m.
§ Mr. Henry Brooke (Hampstead)
I am happy to have this opportunity of following the hon. Member for Tottenham (Mr. Messer), because he holds an important position as chairman of the North-West Metropolitan Regional Hospital Board, and I represent a constituency within his region. We have heard this matter discussed from the standpoint of hospital 1536 administration and also of the unfortunate prospects of the 1,100 registrars who are to disappear.
I ask the House to concentrate upon the problem from the standpoint of the locality and the patient. The Minister has issued a circular designed to solve a serious problem that exists, but so far neither from the circular nor from any of the explanations which have been given has it been possible to understand how the patient in future is to receive as good and efficient treatment as he has had in the past.
I will give an illustration which, I think, follows on what the hon. Member for Tottenham has just said. A large number of women go into hospital to have their babies. Emergency caesarian operations may have to be performed. In some maternity departments a considerable proportion of those are done by registrars. The Minister would help us if he would explain, in a case like that, who is to be available to perform these operations in future. They may occur at night or at weekends when consultants are away, and hitherto the bulk of those have fallen on the registrars.
The Minister is diminishing in size this slice of doctors who are serving the needs of patients in hospitals. He presumably is not going to make a serious diminution in the total medical and surgical staffs, because otherwise there could surely be no consequence except the closing of beds. Although I had heard rumours that in the North-West Metropolitan Region it might cause a closing of beds, I was appalled to hear confirmation from the hon. Member for Tottenham that the closing of 400 beds might become inevitable.
§ Mr. Messer
I should not like to be misunderstood. I said—unless people of comparable skill can be found to undertake the work which the registrars are doing.
§ Mr. Brooke
Yes. In my mind I was adding that proviso. It is exactly that which we are asking the Minister to explain. He is taking away this slice of doctors. He is presumably thinking that the regional hospital boards, who, I understand, have not been consulted over the drafting and preparation of this circular, are in some way to maintain the 1537 quality and quantity of the hospital service, in spite of this cut in the number of registrars. It is that point, in particular, which I invite the Minister to explain to the House and to the country.
§ 2.27 p.m.
§ The Minister of Health (Mr. Aneurin Bevan)
I am sorry to have to intervene so early but, as the House knows, we have only a limited time and other questions are to be raised, and I wanted to give myself time, if the House will permit, to give a full explanation of the existing situation regarding registrars. I say at once how glad I am that the question has been raised and how grateful I am that it has been raised in so temperate a manner. The atmosphere in which it is raised in this House, however, is not the atmosphere in which it has been discussed in what should be responsible journals, some of the medical journals included, and certainly some of the daily newspapers.
It really is about time that some publicists should begin to develop a responsible attitude towards the Health Service and not make it the occasion for inflammatory statements, not only in respect of the organisation of the hospitals, but also regarding the tuberculosis side of the matter. I listened last night—I am entitled to say this because of what my hon. Friend the Member for Tottenham (Mr. Messer) said about tuberculosis—to a broadcast on the radio in the nine o'clock news which saw fit to reproduce the observations of a doctor, which were quite disgraceful in the consequences they might have on people suffering from tuberculosis.
When dealing with hospitals and with people who are sick, and sometimes sick with grave maladies it is absolutely essential to be discreet, objective and impersonal in one's observations. I do not know what the hon. Member for Croydon, East (Sir H. Williams) is grinning at, but I should have thought it was obvious that if there was one field in which levity is not required, it is this. Therefore, doctors in particular should express their views on these matters with rather more objectivity than we have seen in recent pronouncements.
The situation is perfectly clear. Every speaker so far has admitted that there were more registrars than we could find 1538 consultant posts for. The first point, therefore it admitted. It is not I who appointed the registrars. That is the answer to my hon. Friend the Member for Tottenham. The responsibility lies, not with the Ministry of Health, but with the hospital boards and the teaching hospitals.
§ Mr. Bevan
We will see in a moment. In the first place, I would point out that there is now a rather different light on the Health Service than many gloomy Jeremiahs thought at the beginning. They thought the National Health Service was going to be such a failure, so discredited and unattractive, that we would find very great difficulty in finding doctors at all.
§ Mr. Messer
My right hon. Friend has given the impression that the regional boards are responsible for the appointment of registrars. That is not the case. The management committees are responsible.
§ Mr. Bevan
I accept the correction; it is the management committees under the regional hospital boards, but the regional hospital boards are, of course, responsible for the appointment of the management committees. I am only pointing out that in the first instance, whereas many of the charges levelled against the National Health Service and the Ministry of Health are charges of over-centralisation, here is the direct consequence of the fact that authority lies with the teaching hospitals and the management committees, and therefore it is not the Minister who is responsible for this. It has been said that this has been done under encouragement. But the language of the booklet to which the hon. Member for Hendon, South (Sir H. Lucas-Tooth) referred is very cautious. The foreword says:In short, the aim has been to state objectives and to suggest methods by which over a period of years these objectives may be reached from the starting point of the existing resources in buildings and personnel."From the existing resources." Further, it says:Two points in particular should be mentioned. The first is that the memorandum is not put forward in any sense as a series of instructions which regional boards must follow. It seeks merely to suggest tentative answers 1539 to questions which each Board must necessarily face in considering the planning of the services for their area. The second point is the obvious one that the whole of the proposals made in the memorandum cannot be made effective immediately.Later on, the circular says:Such estimates"—that is, the estimates of the number of specialists who ultimately will be desirablemust be largely speculative, for as yet there is not sufficient information on which to base even approximately accurate estimates.Later it says:The realisation of these ideas may not be achieved for several years since building on the scale required will not he possible for some time and the necessary consultants cannot he rapidly produced.It is, therefore, not correct to say that the Ministry of Health, in sending out that booklet, have led people to believe that there might be such an enlargement of the number of consultants as would be indicated by the number of registrars appointed.
§ Mr. Bevan
That must be read with the other things I have read out; not only that particular paragraph but the whole of the booklet is extremely cautious. I do not want my strictures to be too strong about it, but what happened was that a very large number of doctors returned home from the Services and were extremely anxious to take posts in the hospitals and to be trained as consultants. Under the pressure of that situation, very many more posts were provided than was reasonable. I accept that at once. But what would be more cruel than to allow them to go on on the assumption that when they did complete their training there might be consultant posts for them? Surely it is very much better to tell them as early as possible that there may not be posts for them when they have finished their training. There is nothing very wrong in saying to a trainee that he might not be a consultant. That happens normally anyhow. When one considers the extraordinary increase, I believe that what we have done has been justified.
What did the circular do? It suggested that the regional totals of posts for the two training grades, senior registrars 1540 and registrars, should be related to an annual demand of 150. For England and Wales it is suggested that the totals for the whole country should be 600 senior registrars—a total for first, second and third year trainees—and 1,100 registrars—a total for first and second year trainees. Next, and this is the answer to my hon. Friend the Member for Tottenham, it asked boards to consult together and submit proposals about training posts for each region within the regional total. Thirdly, it proposed steps for bringing existing numbers and new recruits down to the approved establishment of posts, and, fourthly, it suggested alternative arrangements at this level of medical staffing where the volume of hospital work necessitates it.
In other words, so wholly subjective and charged with interest is the atmosphere about these things that people do not appear to read and, if they read, they do not appear to understand. The assumption all the while is that if we reduce the number of registrars that will necessarily reduce the number of bodies in the hospital to help the consultants to do their work. That is where practically every pronouncement on this matter has gone wrong. The "British Medical Journal," which ought to know better, says here, quoting the Socialist Medical Association, with unusual enthusiasm:the circular shows a total failure to understand the importance of the contribution made by registrars to the hospital service. By concentrating on the training they receive, it fails to appreciate how much of the essential work on the wards and in the out-patient departments is done by registrars, many of whom in fact are doing consultants' work.One could not have in a responsible journal a more juvenile misunderstanding of the situation than that because, as the hon. Member for Hendon, South pointed out in his statement, it is obvious that if we have a very large number of registrars who are doing normal hospital work and we cut down the number of registrars drastically, we must find some people—it may be the same people—to do the work they were doing. That is exactly what we say. Indeed, this was made absolutely clear—because this circular has not come like a bolt from the blue; this circular is a result of consultations with representatives of the medical profession, and the whole matter has been made perfectly clear to them.
§ Mr. Bevan
Of course, because in the meantime, as the hon. Member knows very well, there are medical teams going round the country setting out the establishment of hospitals and when those establishments are fixed, they will be the establishments for the hospitals. It must be clear, and it is clear to the hon. Member, that unless there is a desire to see some sinister object that does not appear on the surface, the hospital work must be carried on, and must be carried on by adequate establishments. All we are trying to do here is to relate the number of trainees, the number of registrars to be trained to be consultants, to the number of consultant posts that may be available, and not to lead people to believe that a larger number of consultant posts will be available.
§ Sir H. Lucas-Tooth
The right hon. Gentleman says that this scheme has been devised after consultation with representative bodies, which I think was the term he used. That rather implies that he obtained agreement. Will he say what bodies he consulted and whether he obtained any agreement?
§ Mr. Bevan
If the hon. Member will permit me, I shall deal with that point later. Of course, agreement was not obtained, but I am bound to tell the House that the Minister of Health is the representative of the general interest, of the interests of the community as a whole. This is a specialist interest, or rather may I say, in order not to be misunderstood, a specialised, a sectional interest. It is by no means unusual that the particular interest concerned does not agree with what it is intended shall be done in the general interest. If every time a responsible Minister had to find agreement with a sectional interest before anything was done, we should have a nation of syndicalists.
§ Mr. Linstead (Putney)
With whom in the hospital service has the right hon. Gentleman in fact got agreement on this particular matter? The regional hospital 1542 boards? No. The management committees? No. The medical profession? No.
§ Mr. Bevan
I did not say that I had got any agreement, but I will tell the hon. Member at once the body with whom I expect to get agreement—the House of Commons. That is a rather important body, as important as any of them, I should have thought. The House of Commons represents the general interest, and what the House of Commons has to consider, and what I hope the House is now considering, is whether the particular claims of certain people have been properly balanced against the claims of the community as a whole.
§ Mr. Snow (Lichfield and Tamworth)
My right hon. Friend has drawn attention to inflammatory articles in certain allegedly responsible medical journals. But the South-East Metropolitan Hospital Board have, I understand, put consultants on a day-to-day basis. Would it not be more desirable, bearing in mind the dignity and importance of those appointments, to put the whole question of reducing the total number on a phased basis?
§ Mr. Bevan
The whole point is that this is to be discussed by the regional hospital boards, and we are hoping to receive their observations in the beginning of the year. Let me say at once that no one is anxious to do any injustice to the registrars concerned, but hon. Members must concern themselves also with the welfare of the people as a whole and must not only be concerned about individuals.
I said that before this circular was issued a full explanation of the position was sent on 6th July to the joint committee of consultants and specialists, together with statistical information. The draft of the circular was discussed with their representatives on two occasions. The need for action was recognised by the profession, but they did not agree on the exact form it should take, which is not unusual. The reason for the circular is that inquiry showed that the number of senior registrars and registrars in hospitals had risen to nearly twice the number needed as trainees to produce the specialists likely to be required each year. 1543 The proposed number of trainee posts has been related to an annual demand of 150. The actual number needed to replace the wastage only is not likely to be more than 100 in any of the next five years. That is the answer to the hon. Member for Hendon, South, who said that we were stabilising the number of specialist posts. We are increasing them.
§ Sir H. Lucas-Tooth
Would the right hon. Gentleman agree with the figure of 30, which was given by my hon. Friend?
§ Mr. Bevan
I am agreeing with the figure which I have given, not the figure given by anyone else. The balance will be available for new posts in the hospital services as well as, of course, for posts overseas in other services. The hon. Member for Hendon, South said in the course of his speech that he thought it was extremely unwise—I forget the actual language he used so I will put it in those words—psychologically unwise, to have suggested that there were posts in the colonial services and the Services. Why? I have never heard a more astonishing observation. Here are a number of doctors who have been trained as registrars in the hospitals. They are told that it is extremely unlikely that there will be specialist posts for them. In the circular in which we are informing them that they ought not to spend more time on that work, we say that there are a number of posts available for them. Of course there are also G.P. posts.
What is wrong in advising people that there are available posts in the colonial services? It was only recently, as the hon. Member for Hendon, South will recall, because he was a Member of the Committee upstairs, that with the consent of Parliament I made it possible to make superannuation benefits mobile between the colonial medical services and the National Health Service at home. In other words, we want to encourage doctors to staff the colonial medical services. What is wrong in saying that posts are available there? In fact, as the hon. Member knows very well, one of the obstacles to the staffing of the colonial medical services was that those who went could not carry with them their superannuation benefit. We need more doctors in the colonial medical services, not only for the sake of administration itself and the welfare of colonial peoples, 1544 but because we now need a much wider clinical field for the training of our doctors. In fact, as has been made obvious on several occasions, because of our medical success many of the endemic diseases with which our people were familiar no longer occur, and unless the medical profession can have experience in other fields they will have no knowledge about them. So far from it being a naughty thing to do, I should have thought it something which is highly desirable to do.
What is the context in which we offer this information? It is "You are not likely to get as many consultant jobs as this, but we can inform you where you can get desirable posts." We say that there are vacancies in the Services. The party opposite have always been reproaching us for not having done something about the Services long ago. Since when do they say that there is something psychologically wrong in doing this, that there is something wrong with the Services. I think that condemnation is not called for.
§ Mr. Linstead
I do not know whether the right hon. Gentleman wants an answer to that question. If he does, it is that registrars, according to the Ministry of Health's own conditions for their appointment, stated in writing, have assumed that they have a four years' course appointment before them and have made all their domestic arrangements accordingly.
§ Mr. Bevan
That does not invalidate what I am saying, that every year the progress of the registrar is reviewed.
There have been several criticisms of the circular. It is said that it does not allow for increasing the number of specialist posts. I have answered that: it does allow for that. But obviously it is not wise to enlarge the number of specialist posts until we have the hospitals in which we can find them work to do. One has to be related to the other. Let me give one or two figures to show the extent to which this problem has 1545 occurred. In total, the number of trainees is nearly 3,000; in 1938 it was not more than 750–3,000 as against 750. Even the proposed new total of 1,700 represents a figure nearly two and a half times more than it was pre-war.
§ Mr. Bevan
In fact, it is those who were considered to be training for specialist posts. That is the comparable figure. I am setting these figures against the analogous classes of persons pre-war. The new figure we suggest is two and a half times the pre-war figure. There can be no complaint there. In one hospital in London, which is a representative teaching hospital, the number of in-patients in 1949 was down by one-quarter compared with 1938. The number of out-patients was up by one-sixth, and the number of registrars was two and a half times as great. At another hospital the number of in-patients in 1949 was up by one-seventh, the number of out-patients was up by one-half, and there were three times the number of registrars compared with 1938.
Obviously there is a case for action on these lines. In some instances we hope that it will be possible to get selected general practitioners to do some of the work in the hospitals. It has been my desire, and I have expressed it on more than one occasion, that the general practitioner should be more closely associated with hospital work than he has been in the past. There has been a good deal of misunderstanding about this, and there has been a good deal of resistance. Let me say at once that the resistance quite often comes from inside the medical profession. It must not be assumed that complete harmony exists between the specialists and the general practitioners.
On the contrary, there is very often a considerable amount of friction, as members of management committees and regional boards well know. When they have tried to arrange that general practitioners should have access to hospitals, the difficulty has sometimes been with the consultants concerned. We are anxious to ensure that, where we 1546 require new bodies, some of the new bodies shall be provided by part-time work by the general practitioners in the area.
I apologise to the House for speaking at such length on this matter. I know that hon. Members wants to get on to other debates, but I was anxious to make the position clear.
§ Lieut.-Colonel Elliot (Glasgow, Kelvingrove)
Before the right hon. Gentleman sits down, I am sure he will agree that we have not been able completely to probe this matter this afternoon. I should like to say that we will take the earliest opportunity of having a more extended discussion on it.
§ Mr. Bevan
As fat as I am concerned, the more extended the discussion is, the better it will please me. I am most anxious that there should be no misunderstanding about the position. The hospital boards have been asked to consider proposals for carrying out the circular by 1st January. The suggested number for each region must be divided as between teaching and non-teaching hospitals and as between different specialities. I emphasise the words "different specialities," because it is essential, in these days when there is a tendency to proliferate specialities, that some of the more substantial specialities shall get an adequate number of registrars. Some of the new ones have too many registrars and some of the older ones have not enough.
§ Mr. Bevan
Certainly. The regional hospital boards can make any observations they wish on the matter, and I shall be delighted to receive them.
I conclude by saying that the main purpose of the circular is to enable one very simple thing to be done, and that is to try in future to have sufficient doctors to do the normal work of the hospital and then to have an identifiable number of persons as registrars who are training to be consultants. In the past these categories have been blurred. The necessary general hospital work of assistant consultants has been performed by persons who at the same time were training to be consultants. It is because of 1547 this that there has been a tendency to enlarge the category of registrars.
The number of registrars is always tentatively in excess of the number who at any time can become consultants. By relating the number of registrars to the actual possibilities of consultation posts, we clarify the whole position, at the same time keeping in mind the needs of the hospitals by appointing senior medical officers, assistant medical officers, clinicians and, in some cases, part-time general practitioners in order to carry out the general hospital work. Thus it will be very much clearer in future than it has been in the past and, so far from this being a subject which causes annoyance and dismay, I am certain that it will be in the interests of all concerned.