GENERAL MEDICAL PRACTICE (ENTRY) (Hansard, 7 July 1950)

§ Dr. Broughton (Batley and Morley)
I have sought this opportunity of speaking on the Adjournment because I wish to bring to the attention of the House, and to the Minister of Health in particular, some of the difficulties that are being encountered at the present time by doctors desiring to enter general medical practice. Perhaps I might remind Members that in the past—that is, before 5th July, 1948, when the National Health Service Act came into operation—it was customary for doctors wishing to settle in general medical practice to purchase a practice or a share in one. That method of entry frequently had the effect of plunging a young man into debt for 20 years. I have known men who have worked for a quarter of a century before they have been free from the claims of those who lent them money.
I think it is generally agreed that it was right to abolish the selling of the good will of medical practices, and that we should now expect it to be easier for young men and women to enter this very important field of medical work. I should like at this juncture to point out that my investigations have shown that there is comparatively little difficulty in doctors obtaining appointments as assistants, but that the majority, particularly the ambitious ones, desire greater security after a period of assistantship. That, they know, can be obtained by becoming a principal or a partner in a practice. Vacancies for medical practices are advertised by executive councils, but there are surprisingly few of these advertisements. In this week's issue of the "British Medical Journal," published today, I see that there are three such advertisements.
A practice advertised with a list of a reasonable size can attract more than 50 applicants, only one whom can be successful. Thus, men in their thirties, married men, some of them with young families, men who have served during the war and who are well qualified and have had considerable experience, including experience in general practice, find themselves 918 unsuccessful applicants. After a number of failures some of these men begin to wonder whether they possess some fault and they feel a sense of inferiority. Others, and they are in the majority, lay the blame on the executive councils and claim that 90 per cent. of the appointments are "fixed." I do not share that view myself, but I can readily understand a man being driven to believe it.
The difficulties of entering general medical practice by means of executive council appointments are so great that most try to enter as partners with established practitioners. This method has now become far from easy because, all too often, it is found by applicants that they are up against what can only be called "a racket." I have already reminded hon. Members that a principal cannot sell the good will of his practice, but there is nothing to prevent him insisting that the partner shall occupy a certain dwelling, and no limit is fixed to the price he can charge for that dwelling-house.
Perhaps I might illustrate the point by giving a concrete example. A medical man of my acquaintance answered an advertisement for a partnership. He received no reply from the doctor, not even an acknowledgement of his letter, but he received a communication from a house agent in which it was stated that the partnership was conditional upon the purchase, as a place of residence, of a small bungalow, at the price £6,500. Further, during the first three years of the partnership, additional expenses would have to be incurred to the amount £2,500, making the total £9,000.
How many young men or young women wishing to start in general medical practice can afford to put down £9,000? Is it right that they should be burdened with a debt of that size? I should add that certainly not all doctors are trying to rob new entrants into general medical practice in this manner, but I believe that far too many of them are doing this. We are short of doctors in this county, and that applies particularly to general medical practitioners.
For the reasons which I have given it is still far more difficult than it should be for men and women to gain a foothold in practice. The solution to the problem is not an easy one, but I have presented what I believe to be facts and 919 I should welcome a reply from the Parliamentary Secretary. I am sure that he is not unacquainted with the problem. I imagine that his Ministry have received complaints, and I shall listen with interest to his remarks.

§ Dr. Barnett Stross (Stoke-on-Trent, Central)
The Debate initiated by my hon. Friend the Member for Batley and Morley (Dr. Broughton) presents to the House a problem which is none the less disturbing because the evidence of it, as he admits, may be confined to very few examples. He is right when he says that the type of distressing example which he has illustrated does not, fortunately, occur in many instances, but even if only one case occurs a year that is sufficient reason for him to bring the matter before the House, and some effort should be made to make it impossible.
When we considered the National Health Service Bill we discussed similar matters on Clause 35. Subsection (3) of that Clause gave some indication that, in as much as the Minister was paying, as it were, approximately £66 million for the good will of all the general medical practices in the country, we naturally did not expect that they would be sold again in the way suggested by the illustration given by my hon. Friend. If, in a backhanded way, a medical practice is to be sold twice, instead of once, it is surely illegal. Section 35 (3) of the Act says: Where any medical practitioner.… knowingly sells or lets premises previously used by that practitioner for the purposes of his practice to another medical practitioner, or in any other way disposes or procures the disposition of the premises, whether by a single transaction or a series of transactions, with a view to enabling another practitioner to use the premises for the purposes of his practice…. I should have thought that those words, which debar the sale of premises used for practice at a price above the fair market price—that is to say, they should not be sold at a price higher than they would normally receive in the open market if they were not used for general practice—would have applied also to the doctor's dwelling house.
Those of us who have worked in general practice know that it is not only the surgery but also where one lives that 920 counts. When I first went into medical practice the greatest asset I had was that the home where I lived—it had a surgery attached to it—had been a medical dwelling for 60 years already and everybody knew it. If a man is told that he must live in a certain place because of the convenience to patients and it is, therefore, an asset for his practice, surely it is exactly as if it were also a surgery or his professional rooms, even though his surgery or professional rooms are in the next street. There should be no distinction, and anything that the Minister of Health can do for us in removing this backdoor way of making the taxpayer pay twice for medical practices would be welcome.
I entirely agree that because there are not enough medical men to meet the needs of the nation at large it is easy for a man to obtain an assistantship, but it is also quite true that, on the whole, it is difficult for a man to obtain a partnership. To see, in the "British Medical Journal," only three advertisements by local executive councils for vacancies is a great change compared with a few years ago, when up to 100 practices or partnerships were being advertised for sale each week. I have been glad to have an opportunity of saying these few words because even though the instances may be few, they are serious and important.

§ The Parliamentary Secretary to the Ministry of Health (Mr. Blenkinsop)
I am glad that my hon. Friend the Member for Batley and Morley (Dr. Broughton) has raised this subject, because there is no doubt that although only a few cases may be affected by the practices he mentioned it is our real desire that the opportunities for young men to come into medical practice should be made more available and not less.
As my hon. Friend rightly pointed out, there have been many changes to the benefit of the young intending practitioner, for example, the abolition of the purchase of practices. I should also mention the valuable effect that the reducing of the maximum number of patients on a doctor's list has had of encouraging the taking on of extra assistants or bringing new partners into the practice.
921 There is also the factor that the Medical Practices Committee have been defining and classifying the different parts of the country as under, or over-doctored areas. That has had the result of encouraging intending doctors to concentrate their attention upon parts of the country where, as we all know, more medical attention is needed. Further, executive councils have encouraged young practitioners to go into those areas, particularly by approaching the doctors in the districts, and doing all they can to persuade them to take on assistants, or to enter into partnerships, with the intention of increasing the provision of medical services in those districts. We all know that when the Act was passed this was one of the matters upon which much stress was laid. We were confident of the fact that if the amount of medical skill available in the country could be more effectively shared it would be of enormous advantage to the people. As I say, there has been no doubt that the action of the Medical Practices Committee in defining open and closed areas has been an encouragement in easing the entry of doctors into practice.
A specific encouragement has been given to assistantships, in connection with which my hon. Friend has said that there is no special problem at the moment. This is a valuable method of entry into general practice, and I will quote the remarks of the Medical Practices Committee in their first Report, where they say: Partnerships are multiplying and new practices are being started. Difficulty in obtaining suitable premises from which to conduct a practice alone prevents this process from being greatly accelerated. Many assistants have become partners of or successors to their principals and the Committee considers that preliminary apprenticeship as an assistant is still the best method of entry into general practice. That is certainly our view. We have, therefore, done everything we can to encourage assistantships by grants and by encouragement from the executive councils. We are seeing quite definitely some increase in the number of assistantships over the country as a whole.
So far as the encouragement of entry into practice as a partner or as a sole practitioner is concerned, there is a much 922 greater opportunity for entry by merit today than by what might be called the chance contact of succeeding to a practice, as in the past. I know that there have been criticisms of particular appointments, but, on the whole, the procedure adopted by the executive councils has brought comparatively little complaint and, I think, has been widely regarded as a desirable method of appointing new practitioners.
There has, for example, been the encouragement of the building up of new practices by payment of a basic salary£300—which is being done to a very large extent up and down the country. Then there is the further consideration of claims that can be made upon the Special Inducement Fund by doctors who are setting up in particularly difficult areas where we want to encourage new practices to be set up.
We appreciate, however, that there are still very real difficulties, and the difficulties which both my hon. Friends, the Members for Batley and Morley and Stoke-on-Trent, Central (Dr. Stross), have raised are real ones. The problem of accommodation is very difficult for the young doctor. There is sometimes the problem of a doctor who may be appointed by the executive council but who cannot accept the appointment because another doctor has already secured the use of the surgery of the outgoing doctor's premises. There is also the problem of high charges which may be made for house accommodation, which sometimes includes the surgery and sometimes does not.
If the house includes surgery accommodation then, quite clearly, it should come within the scope of Section 35 (3) of the Act, as my hon. Friend the Member for Stoke-on-Trent, Central, remarked. Clearly, if any excessive price is being charged for a house which includes the surgery, it is an attempt to evade the provisions of the Act and is a matter which should he reported to the Medical Practices Committee.
Where the house is separate from the surgery the position is rather more difficult to define. The matter is largely one of professional conduct, in which we would hope to get the co-operation of the profession itself in insisting that this kind of conduct should be condemned. We would wish to secure the co-operation 923 of the British Medical Association in trying to secure the ending of this practice by the voluntary action of the practitioners themselves. It may be rather difficult to interpret the Act in such a way as to bring the ordinary living accommodation of a doctor within its confines if it is quite distinct and separate from the surgery which he needs for his practice. I am, however, prepared to examine this matter further.
The question which I raised earlier, of the difficulty of doctors in taking up practices to which they are appointed because of lack of accommodation, is already being discussed with the B.M.A. and I hope we may be able to find some way round this difficulty.
924 I appreciate the attitude which my hon. Friends have adopted. We are most anxious to try to help in every way possible and to encourage in every way we can the setting up of additional practices, either by way of partnership, or by way of sole principals, in the many areas which have already been adjudged as open areas, where we badly need extra medical help and where existing lists are far too high. I am sure that the mere raising of the subject in the House this afternoon will have contributed towards that end.