Clause 2.—(CERTIFICATE OF EXPERIENCE IN APPROVED HOSPITAL.) (Hansard, 14 July 1950)

§ Sir Hugh Lucas-Tooth (Hendon, South)
I beg to move, in page 1, line 25, at the end, to insert: (2) No order shall be made under subsection (1) of this section unless a draft thereof has been laid before Parliament and has been approved by resolution of each House of Parliament. The right hon. Gentleman has just indicated the attitude of the Government to this Amendment, and we on this side of the Committee welcome what he has said. However, it is right that we should have some discussion on this, because it raises important matters of considerable interest outside this House. Clause 1 lays down the general principle that a doctor is not to start independent practice until he has had some experience. It states that in the most general terms, and it is apparent that hon. Members on both sides 1744 of the Committee are in full agreement with that general principle.
Clause 2 provides the machinery by which that principle is to be carried into practice. Here we are on much more difficult ground. The Clause is not specific. For instance, it lays downs no precise period for intern service. I do not quarrel with that. Indeed, it is an Amendment made to the Bill in another place and it is right, on the whole, that the machinery provided by this Clause should be thoroughly flexible and capable of Amendment from time to time, in order to meet changing circumstances and to cover what experience may show.
There are, however, quite serious misgivings in various quarters as to how this change will operate in practice. The most obvious misgiving in this connection is that which all hon. Members have had communicated to them by those who are now actually in process of being medical students, who have entered the profession on the basis that they were to do five and a half years under instruction before they could begin to earn money, and now have some apprehension that they may have to do six and a half years.
12.15 p.m.
Unfortunately the hon. Member for Batley and Morley (Dr. Broughton) was not here to move his Amendment to Clause 1, page 1, line 18, so we have not been able to dispose of that point, but it would be helpful if the right hon. Gentleman would indicate when he expects this new arrangement will be brought into operation. It would be unfair to those who are now just about to finish their training to find that they have a long period still to go, so that if the Minister says he does not intend to bring this in for a year or two, it would go a long way to allay misgivings on that score.
Those interested in this matter from a rather different angle are concerned with the position of the hospitals. Are there enough house appointments to provide the further training which this part of the Bill contemplates? I have calculated that it will require three new appointments per group of hospitals. I am not sure whether that figure is accurate. There is misgiving in the medical profession that the effect of this will be to alter the quality of the work to be done by the men now filling house appointments.

§ The Deputy-Chairman (Colonel Sir Charles MacAndrew)
I cannot follow the hon. Baronet. This Amendment deals only with affirmative Resolutions, surely?

§ Sir H. Lucas-Tooth
I have gone beyond the narrow terms of the Amendment, Sir Charles, but I was indicating to the Committee the kind of consideration we would have to bear in mind when the order to be made under this Amendment comes before the House.

§ Lieut.-Colonel Elliot
Further to that point of order, Sir Charles. It was with the object of having the discussion on this question arising out of Clause 1, that we waived the discussion on that Clause and got straight on to the point of the orders to be made. It was hoped by us that some wider discussion than the narrow one as to the orders might be in order in virtue of that arrangement.

§ Mr. Bevan
I have already indicated that I am prepared to accept the Amendment in substance, but as usual we would like to look at the words. I accept the purport of the Amendment, which is to make these orders subject to an affirmative Resolution. May I suggest, therefore, that we can dispense with the Amendment, which would not therefore cause trouble with the Chair, and have our discussion on the Question "That the Clause stand part of the Bill," because there is no other Amendment to this Clause.

§ Sir H. Lucas-Tooth
If that would meet the convenience of the Committee, I am perfectly willing to withdraw the Amendment and then to discuss the matter on the Question "That the Clause stand part of the Bill."

The Deputy-Chaiman
Is it the desire of the Committee that this Amendment be accepted?

§ Mr. Bevan
In substance, not in form—

§ Lieut.-Colonel Elliot
On that point, does the Minister indicate that he would wish to move on Report stage an Amendment embodying the affirmative Resolution, but in other words?

§ Mr. Bevan
Yes.

§ Lieut.-Colonel Elliot
In that case I think my hon. Friend should be pre- 1746 pared to withdraw the Amendment, and accept the suggestion that a more general discussion should take place on the wider question of the Clause standing part.

§ The Deputy-Chairman
Perhaps the hon. Member will do that, and then we can carry on.

§ Sir H. Lucas-Tooth
I want to be quite certain that the general discussion can range over the two Clauses together. We have deferred the discussion on Clause 1, and it would he unfortunate if we could not discuss both Clauses together.

§ Mr. Bevan
I am in the hands of the Committee and of you, Sir Charles. I have not the slightest objection to the discussion on Clause 2 going as wide as is necessary to ventilate the points which have been raised.

§ The Deputy-Chairman
If it be the wish of the Committee, the discussion can be as wide as necessary on the Question "That the Clause stand part of the Bill."

§ Sir H. Lucas-Tooth
I beg to ask leave to withdraw the Amendment.

§ Mr. Bevan
I beg to move, in page 2, line 21, to leave out from "applicant," to the first "the," in line 23, and to insert who has been engaged in medicine has also been engaged in surgery or in midwifery or both, or an applicant who has been engaged in surgery has also been engaged in midwifery. This Amendment is intended to remedy an omission in the existing subsection, which, as it stands, provides for the way in which a doctor who engages during his intern service, in work which is a combination of medicine and surgery, or of medicine, surgery and midwifery, is to have that period of employment divided into so much time on medicine, surgery, and, where appropriate, midwifery, respectively. It makes no provision for the doctor who engages in work which combines only medicine and midwifery or surgery and midwifery. The Amendment ensures that the same arrangement shall operate in all three cases.
I have always been in a little difficulty about this, because it cannot be said that the intern is having proper experience if most of his experience is confined to a certain speciality. Therefore, it is necessary that there should be a proper 1747 division of time over the whole of the work, in order that he might take full advantage of the intern service.
It has been put to me in several quarters that unless proper arrangements are made—and this is the reason we attach very great importance indeed to the inspection of hospitals where the intern service is given—an intern might be confined to certain beds in the hospital which are dedicated to only one speciality. It is essential, therefore, that his experience should be spread as far as possible and that arrangements be made for the spreading to be done.

§ Lieut.-Colonel Elliot
I think that the Amendment is reasonable. It is the first time that this question of the duties of the intern, which will of course be rather different from the duties of the houseman because they will be an integral part of the professional training necessary to obtain his certificate, has arisen; and I think it is a good thing that the Minister should have taken the step which he has done here.
We shall, of course, have to consider, both during the remaining proceedings on the Bill and later when the proposals of the Minister come up for affirmative Resolution, how the duties of the new intern are being worked out, because, as was pointed out on Second Reading, the intern is a new figure in our professional life, and in the hospital especially. It is certainly very necessary that he should have a wide general training and not merely specialist training which might easily happen if, for instance, he were in a ward connected with skin diseases. He might have six months' service exclusively on that, which would be of great importance if he were taking up that field of work later on, but might not be of any great advantage to him if he were trying to deliver a baby.

§ Mr. Hastings (Barking)
I think most of us would agree on the dangers of too early specialisation, and that however a doctor decides to specialise eventually, whether in administration, psychiatry, medicine or anything else, he ought to have a general knowledge of the background of medical practice and of the health needs of the people. Without this background he will not have the right perspective in the study and practice of whatever branch he decides to undertake.

§ Mr. Bevan
I think that my hon. Friend is perhaps concentrating on the wrong Amendment.

§ The Deputy-Chairman
The Amendment which I called was that to page 2, line 26.

§ Mr. Bevan
That is why I think that my hon. Friend is addressing his remarks to the next Amendment: In Clause 3, page 3, line 14, leave out paragraph (b).

§ Mr. Hastings
No, I am not.

§ Mr. Bevan
The Amendment we are discussing reads: Where physical disability renders an appointment in surgery or midwifery impossible. … I propose to accept this Amendment in principle. The next one, of course, is much wider.

§ Mr. Hastings
May I continue my argument in favour of the one we are discussing?

§ Mr. Bevan
I am accepting it.

§ Mr. Hastings
Thank you. Then I need not waste time in arguing the case.

§ Commander Noble (Chelsea)
I wish to refer for a moment to a point that would have been covered by the Amendment to Clause 1 in the name of the hon. Member for Batley and Morley (Dr. Broughton) which was not moved. I would like to draw attention to one group of people who are very worried about how the compulsory period of resident experience in hospitals will operate in practice.
1749 I ask the Minister to consider particularly those whose medical studies were interrupted by the war, and especially those who, if they had not volunteered to join the Services during their medical training, would have qualified before the Bill comes into force. Many of these people are very keen to get into practice as soon as possible. They are older now than the age at which they would have qualified but for the interruption in their training; they probably have wives and families to support, and they are worried that they may be held up now for an unexpected period in hospital. I ask the Minister to bear this in mind. I fully realise the importance of the period of residence in hospital, but I hope that the Minister will make the whole scheme as flexible as possible, so that the particular group to which I have drawn attention will suffer as little hardship as possible.

§ Dr. Barnett Stross (Stoke-on-Trent, Central)
As has already been pointed out, present-day students are a little disturbed, although perhaps unnecessarily, in that those who have already planned their lives, particularly those who are married, would find it difficult if there was to be separation or break-up of their domestic life in order to serve for a year inside a hospital. Although they are not many in number, I hope that my right hon. Friend will bear them in mind and give them an opportunity of opting out of this provision, which would, I think, meet their case.
12.30 p.m.
Apart from this, I think that students may be reassured on the effects of the Clause. After all, it offers them full employment at, I hope, a suitable rate of remuneration. Apart from the married men to whom I have referred they have not, therefore, a great deal to worry about. We have already had some reference by my hon. Friend the Member for Barking (Mr. Hastings)—and the Minister accepted his Amendment—to difficulties which might arise where men have physical disabilities. But this matter should be taken a little further than illness and physical disability. Not all medical students are quite alike, nor are they likely to find an equal amount of favour among those who might accept them. They may differ a little in stature, or in colour, and we ought to have some assurance that there is room for all of 1750 them when this provision comes into force.
Not everyone wants to be fully registered forever in his life in the full sense to which we are referring. If a man has completed his medical studies and obtained his degree, he may wish to work as a physiologist for the remainder of his life, or to go on to biochemistry. He may never want to practise. If, however, he wanted to come back into practice he could do so by obeying the rule we are making. I hope the Minister will give an assurance that in all these cases where the man is going into a sister profession, he need not register fully.
I know it is not possible to get an actual definition of "satisfactory service." If my hon. Friend the Member for Warrington (Dr. Morgan) had been present a little earlier, I think he would have discussed this point quite fully. It may well be that the individual should have a right of appeal against a decision that his service was not satisfactory. If that were possible, I think hon. Members would agree. I have bitter memories of the time when I was a medical student. Our teachers are human beings after all and show some favouritism sometimes. I was a victim of favouritism, that is to say, I was favoured at times and other people did not like me so much and I was not favoured by them. Looking back on my career as a student, I wonder whether this provision is going to be quite fair to everybody. It means that if the person who is to sign a certificate, does not like the student, may be—I put it no higher—a little biased or prejudiced against him. Can we not insert a safeguard for the man who has registered and done his full year and asks for full registration, so that there should be some method by which he could say, "I do not think this is correct, I do not think this is justice?"

§ Mr. Linstead (Putney)
The proposals for an intern year have been almost unanimously accepted as a wise addition to medical education by the informed section of the medical profession accustomed to deal with the training schools and medical education. At the same time, a large number of people in the medical profession, and some of the medical students, have failed to appreciate all that is involved in this matter. Many of them have false ideas of what the new proposals 1751 will mean and I do not think the Committee would be wasting time this morning if we examined in some detail with the Minister what his intentions are and if, as a result of that examination, we cleared away some of the misunderstanding which appears to be giving rise to objections.
I have found the objections extremely well summarised in a letter which appeared in "The Times" yesterday, with no fewer than seven points. If the Minister finds it possible to deal with the bulk of those objections in a comprehensive statement I think it will be very well worth while and will clear the air a great deal. I shall mention some of those objections in order to provide an opportunity to whoever is replying for the Government. The letter deals with the point raised earlier by my hon. Friend the Member for Hendon, South (Sir H. Lucas-Tooth) on the possibility of this extra year being a breach of faith with existing medical students. I have no doubt the Minister has some period of time in mind before this is brought into operation, which will remove any suggestion that there is here a breach of faith. Nevertheless, I hope he will be able to say something authoritative about that.
The next point which is raised is that of the power given to prescribe the period of internship is a power with no limit. The writer of the letter said: With the approval of the Privy Council the General Medical Council is empowered to extend indefinitely this period of tutelage. I am quite certain that the answer to that is that both the Privy Council and the General Medical Council can be assumed to be responsible bodies who will not use the important power given to them in any callous way. Nevertheless, if the Minister can indicate that there is a limit of a year in his mind, it would remove that objection.
The next point is one to which I know students attach considerable importance. That is the question of satisfactory service. They want to know what their position will be if, after they have completed their qualifying examination and obtained provisional registration and served their intern year, a certificate of satisfactory service is refused them. Is there to be an appeal, or are they 1752 completely at the mercy of the hospital or the qualifying body under whom this period of internship is served? Have they no redress if the certificate is refused?
Then there is the question of the standing of the men and women in the service. They will be provisionally registered; will that entitle them to sign death certificates within the institution in which they are serving their year? Will it entitle them to prescribe dangerous drugs? Those are the outward and visible signs of statutory recognition and I hope the Minister will make it clear that within the institution, they can do those things and that provisional registration gives them that status.
Linked with that is the question of remuneration. The Minister told the House during Second Reading that these young men and women are to be remunerated. Can he give some indication of the type of remuneration? Is it to be merely the pocket-money remuneration of the old house physician and house surgeon, or will it be sufficient to enable these people to live with some reasonable degree of freedom? There is also the question put in this letter and put, I think, by the British Medical Students' Association of what guarantee they have that there are enough jobs to go round. I agree with my hon. Friend the Member for Hendon, South, that there should be very little difficulty in getting three or four of these people into each of the hospital groups of the country. But some reassurance from the Minister on that point would be extremely useful and certainly there should be an indication that, until he knows the posts are there, he will not begin to impose this period of training.
There are two other points which I will mention. One is the application of the Bill to different parts of the country at different times. That can give rise to a certain amount of misunderstanding and indeed of heartburning amongst students. A man in Scotland may find that it takes him a year longer to become fully registered compared with a man in England. The Minister ought to expound a little his views on that provision of the Bill.
Finally, attention is drawn in the letter to the separation of the married student from his family during this extra year. This extra year puts on the Minister an 1753 obligation to make certain that married quarters are available for any of these students who are married and who are so to speak confined to hospital for a whole year, with the possible breaking up of their family life. I have taken a good deal of time in elaborating these points because I know they are points which are misunderstood, and that it is well worth spending time over them. Any time that the Minister spends in making his intentions clear upon them will be time well spent.

§ Dr. Stross
I am sure that the hon. Member has not in mind the idea that students should take their wives with them into the hospital and that married quarters should be attached to the hospital? Will the hon. Gentleman say whether what he has in mind is that there should be available rooms reasonably near to the hospital where the students can live out, while they are working in the hospital?

Mr. Lenstead
What I have in mind is not the important consideration here. These are misgivings which are quite widely held and it is what the Minister has in mind which is the really important thing. That is what we want to find out today.

§ Dr. Broughton (Batley and Morley)
I should like to apologise to you, Sir Charles, for not being in my place to move the Amendment to Clause 1 standing in my name when it was called. This Clause and Clause 1 are closely related, and perhaps I might refer to Clause 1 in a general way when speaking about Clause 2.

§ The Deputy-Chairman
It was arranged that there should be a wide Debate on Clauses 1 and 2 upon the Motion "That Clause 2, as amended, stand part of the Bill."

§ Dr. Broughton
I remember that when I was studying medicine I had a fellow-student about 15 years older than myself. He was in Holy Orders and desired to go abroad into the field of missionary work. He wished to be able to give his attention to the physical as well as to the spiritual needs of the people. He had saved just enough money to be able to afford a medical education, he thought that he could spare just that amount of time. I am pleased to add that he achieved his ambition, he qualified in 1754 medicine and became registered, and I have no doubt that he is at present abroad doing most useful work in attending to the physical and spiritual needs of people. But if an additional period of time, even six months let alone a year, had been imposed whilst he was in training it would have wrecked his plans.
I hope, therefore, that the Minister of Health will give most careful consideration to the cases of hardship that may arise if this Clause is left without some amendment at a later stage. I said during the Second Reading Debate on this Bill that I wholeheartedly supported the suggestion that there should be a period of intern work after qualification. I repeat that. I can see the benefits that will flow from it, but I fear that there may be injustice inflicted in a few cases unless students are granted the right of appeal against it. When I say students I mean present students. Reference has already been made to the correspondence which has appeared recently in "The Times." Those letters state the case of the present-day students quite clearly, and I hope that the Minister of Health has read them.
12.45 p.m.
I have been approached by a medical student who is a retired barrister. I can give an indication of his age by informing the Committee that he will draw his postwar credit very soon. He wishes to spend the remainder of his life as a medical missionary in India. He tells me that if he has to put in an extra year's work of intern duties after qualification all his plans will be upset. He told me that had he known before he began his medical training that it would be necessary for him to spend seven years on the course he would not have started.
I have given just a few examples of the type of cases in which injustice may be suffered if Clauses 1 and 2 remain as they are. I hope that the Minister of Health will allow some Amendments at a later stage. Had I the eloquence of the Minister of Health, I feel that I could make a moving appeal for those students who might suffer hardship under the present provisions of the Bill. I have tried to put the case for them as best I can, and I hope that the justice of my claim has been understood. I would inform the Minister that the British Medical Students Association desire that all present medical students should be 1755 exempted from the provisions of Clause 1 and Clause 2. He will fail to satisfy them unless he grants that. My own view is that it would be unnecessary to go so far, but I hope that some right of appeal will be allowed in respect of those who would suffer by the operation of the Bill as it stands at present.

§ Surgeon Lieut.-Commander Reginald Bennett (Gosport and Fareham)
I should like to add such little weight as I command to the plea of the hon. Member for Stoke-on-Trent, Central (Dr. Stross) on behalf of those who may not intend to practise clinical medicine after they have finished their training. Is the Minister likely to be able to make any categorical statement about whether or not they will have to comply with the internship provision?
The other point I should like to stress was made by my hon. Friend the Member for Putney (Mr. Linstead) about the question of satisfactory service. I should like to invert the way in which he expressed the point and ask whether the Minister, in framing these Clauses, has had in mind any specific ways in which dissatisfaction may be given? What will constitute "unsatisfactory service"? Or is it entirely a matter for the judgment of the employers of the intern in question.
My third point is whether the right hon. Gentleman can yet give us any indication of what will be the length of the term of service of an intern. Is the right hon. Gentleman likely to start the ball rolling with a full year, or will six months or even three months be more likely to represent the period of the first term?

§ Dr. Morgan (Warrington)
I apologise for being late in coming from hospital this morning. I think there must have been some misunderstanding about the time, because I was told to be here not later than 12.30 p.m. and I kept to that time; but I apologise for not being here to move my Amendments which, had they been taken, would have dealt with many of the points now under discussion.
I wish especially to deal with the question of unsatisfactory service during this year of provisional service. I would ask the Minister to consider if he can, having regard to the source from which it 1756 comes, the question of granting the right of appeal to all medical students who are alleged not to have rendered satisfactory service during the year of provisional registration. As has been said, some of us have had that experience. I had a nice time at my university—Glasgow University, said to be one of the best in the country—but when I came out to get a resident appointment post in a hospital, because the religion of the country was different from my religion and because my politics were extremely different, I could not get a look in.
I remember how enraged was one of my professors to think, after everything I had done, that that should debar me and that I must go elsewhere to get an appointment. I even thought of going to Ireland where, no doubt, in the home of tolerance, I should have been much more cordially received. I would therefore ask the Minister to consider the question of giving to a student debarred during the course of his year for allegedly not having rendered satisfactory service, the right of appeal; with a sworn statement from whoever came to the decision so that the student may have the opportunity of answering the case against him.
A man may render certain "unsatisfactory service" because of his medical theories. I remember in the course of my training as a medical student, the great Professor MacEwen, one of the finest surgeons that Scotland has produced, telling a class quite candidly that when he was being examined in England for his F.R.C.S., and he gave his method of operation for certain things such as the brain and for hernia and things of that kind, he was laughed at. When he was asked, "Whose operation is that?" he said, "Mine" and they told him he was talking nonsense. He replied, "Well, I have done 300 or 400 cases already," and he was laughed at still more. But MacEwen's operation became a recognised operation—not so much in England, but it is still being performed in a modified form in Scotland. His brain surgery stands on record for ever and ever. There was a man with skill, knowledge and inventive ideas who was, so to speak, turned down on the grounds of—in those days—unsatisfactory service. The same thing might happen now during the provisional registration period.
1757 There are not likely to be sufficient hospitals to which these men may go and what will happen then? Suppose this man cannot get into an institution because of the number of students vis-é-vis the number of vacancies? Is he to be kept waiting for his appointment, just as at present many men cannot get into a medical school for studentship? When a man is qualified, he may have great difficulty in finding a hospital recognised for the purpose of giving him his provisional registration. These points may have been covered in previous discussion, and if so I am sorry, but I do want the Minister to keep them in mind, because one of my Amendments sought to give a man the right to appeal to a special tribunal, and it would have covered that point.
A student may have gone to considerable expense to plan not only his studies but his finance without having taken into account this extra period. I know he will get £350, but he may have borrowed the money from his parents, or won a scholarship which does not take him further than three years. I know that I shall be told that certain local authorities will come to his assistance. But so far as I know—it may be changed since the time I got into Parliament and left my local authority experience behind—when giving grants of this description, local authorities have to do so with an eye on the auditor. or they may be reported as having dispensed local authority finance unjustifiably.
I hope the Minister will look at this Clause again and give an opportunity for revision and if necessary Amendment. The important point is the hardship incurred by a man who is declared unsatisfactory or to have given unsatisfactory service, when, before any fair board, he would be recognised as an efficient man, capable of doing his work.

§ Sir H. Lucas-Tooth
If I may complete the speech which I started to make on an earlier Amendment and adapt what I have said, I would point out that this is of course a machinery Clause with which we are now dealing. Discussion has ranged over the general merits of the case, but it is important that we should have some regard to the actual mechanism.
If we look at subsection (1) we see that the order to be made under that sub- 1758 section is an order which apparently is to relate only to the period during which the intern service is to be performed. In terms, I think, that is the effect of this subsection. But it is also true that the appointed day, under Clause 1 of the Bill, is to be made by, I think, an order of the Privy Council, and will presumably come before the House. I am not sure whether it will be necessary to incorporate it in the order under Clause 2 of the Bill or whether it will be a separate order. But it is important when an order is brought forward to bring this Clause into effect it should contain as much as possible of the machinery which is being brought into operation.
So far as I know, the question of the payment of a provisionally registered doctor during this period will not necessarily come before the House at all. I would ask the right hon. Gentleman whether that is his intention. It seems to me, on the whole, that it would be a good thing if the order did contain general provisions regarding such payment. I am not certain how the payment is to be arranged for. It may be through the ordinary administration of the hospital or it may have to be by some order. It would be interesting if the right hon. Gentleman would tell us, and we should all like to consider the matter before we reach a later stage in the Bill.
There is also the question of the possibility of allowances being paid during this period. I do not know whether allowances would be payable especially, or whether they would be payable by the employing hospital or health centre, or whether they would be dealt with in the order. It would be essential to provide substantial allowances in some cases. For instance, where a rather older man comes in and he has a wife and children, he would have to have something over and above what would be a proper payment to a young man who was simply doing a preliminary period of one year's service. Would that be covered by the Order? If not, how would it be dealt with? I hope that the right hon. Gentleman will answer those questions.

§ Mr. Iain MacLeod (Enfield, West)
I am delighted that the Minister has accepted the principal Amendment to this Clause, because a method of medical 1759 administration which may have been appropriate to the Acts of 1858 and 1886 has been inappropriate since 5th July, 1948, when the Minister took a much more intimate responsibility for the health of the people. I should like to emphasise the point made by my hon. Friend the Member for Hendon, South (Sir H. Lucas-Tooth) that, as matters are at the moment—and it may well be a flaw in the drafting of the Amendment we put before the Committee—it appears that Parliament is only to have control of the actual period of intern service. I think that hon. Members on both sides would like to go rather more deeply into the matter than that. When this period starts, there will be a wastage, for one year at least, of general practitioners entering the Service. It is a matter for Parliament to discuss at what point in the development of the National Health Service we can afford that wastage.
The question of universal service has been discussed. Clause 34 gives permission to introduce different dates for different parts of the country, and Northern Ireland was quoted as an example. I suggest that the differences are not all purely in time or in geography. The question of universal service is well worthy of consideration. For example, it might be expedient, for a limited period, to allow doctors who have completed their ordinary training to go into practice in under-doctored areas. It might be expedient to allow them to act as assistants to group practices or, perhaps, in the few health centres which we have and which we hope will increase in number.
The advantage of that method is that we should get more quickly the doctors we need in the places where we need them. The disadvantage, which I need not stress, is that some men might not be as highly qualified and they would, in any case, lack intern service.
It is my view, from such researches as one is able to make without official services being open to one, that there are enough posts available for these men and women. But in this matter we cannot simply equate vacancies with candidates. We may well find that, both temperamentally and medically, we have at the end a number of round holes and only square pegs to fit them, where it would be 1760 unfair for a man to have to take the only vacancy open to him. I think the Minister might consider whether exemptions cannot properly be made.
I appreciate that the Minister may not be able to answer all the questions put to him today, but I think the question of salaries is by far the most important point which we shall discuss during the Committee stage of this Bill. There is some anxiety outside. The Goodenough Committee recommended that free board and lodging and something between £75 and £100 should be paid. If we put that in terms of the value of money today, it might be £150 to £200. Even that is considerably below the amount of money paid to some one holding a house appointment. Nothing would do more to remove the uneasiness than a clear statement about salaries.
There are a number of medical men in this House. There are half a dozen in the Chamber at the moment. It is one thing for organisations who gave evidence before the Goodenough Committee from their established positions, to say that it is desirable for this extra year to be added to a student's training. It is another thing when a man has planned his life, perhaps planned his marriage on graduation and his National Service, so far as he is capable of planning that to fit in with his training, if he finds that there is to be another year of training. Perhaps he may be getting to the end not only of what he thought was his medical training, but also of his own and perhaps his parents' savings as well.
I strongly endorse the suggestion that those at present engaged in medical training should not have this extra year put on to them. I agree that the students' committee before the Goodenough Committee recommended this, but any association or trade union invariably recommends, on Benthamite lines, what they think is for the greatest good of the greatest number. However, there are people undergoing medical training, to whom this is a new conception, who may well be penalised by the imposition of an extra year or indeed more.

§ Mr. Hastings
As one who has spent the greater part of his life in the training of house surgeons, I should like to say a few words especially about satisfactory service and the right of appeal. There 1761 will be very few cases in which a surgeon or physician in charge will feel justified in saying that a man's service was unsatisfactory, and if the right of appeal were agreed to, there would be even fewer. One must remember that if the right of appeal is granted, the chief would be put into the witness box, presumably, and asked all sorts of questions about his house surgeon and, possibly, even submitted to an action for libel.
Looking back through my medical history, I can remember only one case in which the service of a house surgeon was really unsatisfactory. The surgeon was an individual in a children's hospital, and perhaps the most charitable thing to say would be that she failed to prevent the deaths of four children in a fortnight, and then she was asked to resign. That is the only case in my experience where I could have said that the service was unsatisfactory. In an event such as that, I think that the right step to take would be to let the house surgeon have another try at another hospital. Even if a surgeon has fallen down once, that is not sufficient to prevent his becoming a registered medical practitioner. I hope that this point will be left as vague as possible and that it will be for the medical or surgical chief to say whether the service is satisfactory. I do not think that there will be many unsatisfactory cases.

§ Mr. Bevan
We have had an extremely useful and necessary discussion. A lot of anxiety has been expressed on a number of points and it is just as well—in fact, not only just as well but highly desirable—that that anxiety should be allayed as far as possible. However. I would point out that, as the hon. Member for Hendon, South (Sir H. Lucas-Tooth) said, this is a machinery Bill. Very largely, it is an enabling Bill. The Minister of Health is not accepting any additional academic responsibilities. He is accepting none at all, because it has been not only the theory but the practice of our constitution that the Government does not intervene either in the organisation or the content of the curricula of our educational establishments. They are under the great educational corporations and the universities.
Therefore, I would at the very outset try to get rid of the idea if there be any misapprehension about it—that the 1762 Minister of Health is here accepting responsibility for the content and management of medical education, because he is not. This is being still entrusted, some part to the Privy Council and some part to the medical corporations, all of them acting jointly, and especially where we come to inspection in the later parts of the Bill. I thought it necessary to make that quite clear at the very outset, because I see that the Minister of Health, as usual, has been selected for certain remarks which have now become almost habitual—I do not mean from the salubrious seaside resort from which the hon. Member for Luton (Dr. Hill) has come—but by some who have written to the newspapers.
Let me say at once that it is necessary for us to have a sense of proportion and keep an even balance between the legitimate affairs of the medical students and the requirements of the public. We are, in this House of Commons today, the trustees of the general public, and we must always have regard to the fact that it is not our duty to let loose upon the community what might be regarded as under-educated doctors, nor to protect individual doctors from what might appear to be hardship. It is always the case that the corporate body has a voice in the House of Commons, but the only way in which the general public can have a voice is by our zeal on their behalf, and we must always keep that before us.
On the other hand, it is perfectly true, that the implementing of the Goodenough proposals does mean that the State intervenes and alters the plans which the private citizen makes for himself when he intends to go in for medical training. Therefore, what we must do is to try to mitigate the hardship as much as possible and see to it that the arrangements made bear as little harshly upon the citizen as is consistent with the public interest.
In the first place, this is not going to be sprung upon the student immediately. It is going to take between a year and two years to make these arrangements, because, of course—and this answers one of the questions put to me—it will be quite improper for the State to say that a doctor cannot be fully registered and enter into general practice unless he has an intern year in an approved establishment which has failed to find a place for him. Both must go together. It must be made quite clear that it would be 1763 intolerable if we said to him "You have not qualified, but we do not propose to give you the opportunity of doing so." It must be quite clear that we cannot fix the period when it starts to operate until we have reviewed the establishments and made the posts available. I hope this will also assimilate part of the trouble that was raised by the hon. and gallant Member for Chelsea (Commander Noble) about ex-Service men. I should have thought that, by the effluxion of another year or two, most ex-Service men would have passed from the schools, and that there would not be very much hardship there.
In the next place, not only have we to provide the posts in hospitals, but it is quite clear that, at the same time, we must also be able to see to it that the hardship is mitigated as much as possible on the financial side. It is. therefore, proposed, to create posts carrying £350 a year for the first six months and £400 a year for the second six months, with a deduction of £100 for board and lodging. I think the Committee will agree that these are fairly generous sums to be paid, and, indeed, many general practitioners will say that it is more money than they earn in their first year of general practice before the war, at any rate. I think, therefore, that we complain that, so far as we can. we have gone some distance to meet the hardship that would fall upon the student. I hope that, after that, I shall not be pressed to make exceptions.

§ Sir H. Lucas-Tooth
Before the right hon. Gentleman leaves the financial part, will he say whether there will be any arrangements for allowances in the case of those who are married?

§ Mr. Bevan
I am afraid not; at least, it is not our present intention. After all, some of the students will be married already, and its does not necessarily follow that we are imposing a hardship. We are giving £350 and £400 a year, and, at any rate, I dare say that, as this is a machinery Bill, these conditions, therefore, are not conditions which I impose. At the moment, I am merely telling the House what the general intention is. We shall have a look at the point, however, and see whether anything further can be done in that regard.

§ Dr. Hill (Luton)
Will this be technically applied at the beginning of a provisional post, for entry into the National Health Service Scheme? It is the superannuation implication which I have in mind.

§ Mr. Bevan
That is a very special point, but I should have thought it would be understood that these sums must be carried on the Ministry of Health Vote and not on the University Vote or the Education Vote. Therefore, those doctors who are provisionally registered, will be employees of the hospital, and I should have thought that it follows almost inevitably from that that the term of service in the National Health Service would date from the beginning of the internship. But I hope the hon. Gentleman will not keep me strictly to that. I should have thought that it would be a logical inference, and it may be that the logical inferences of the Minister of Health may be regarded, by some pepole, as an indication of what might happen.
The internship period is also necessary because, for the purposes of his post as a fully qualified doctor, he has not yet gone into general practice, but, of course, for all the purposes connected with his work in the hospital and in connection with any work which might be given to him arising out of his internship, he is a doctor, and hon. Members will see in different parts of the Bill how that is provided for. Of course, some people have asked if it is fair to a person who has made his plans, based upon the assumption that his training is going to come to an end, that we have added another year, but we have got to start sometime, somewhere. If we are to carry out the recommendations of the Goodenough Committee, we must begin at some point or another.
The suggestion is that we should begin with the student coming in, and that means that our scheme will not come into full operation for seven or eight years. Surely, that is going far too far, because he is a person who will have made his initial plans, and who knows that he is going to study to be a doctor, in the light of what he considers to be the number of years which he will have in which to qualify. We are adding a year to that. But I should not have thought that he would want to go back as far as that. I hope I shall not be pressed to give concessions on grounds of hardship. Why 1765 should this House send out into the world of general practice one who is less well-trained than we think he ought to be? That, surely, is to the detriment of the patient, and is not good for the doctor. When the date falls, it should fall upon all the medical students, as, otherwise, one medical student will go through his life with a black mark. It will be said, "Oh, you did not have the year's intern, but your colleague had it." Therefore, I should not think it would be wise to invite the medical student, because of some temporary embarrassment to handicap himself by not having the benefit of the one year, and I hope we shall not be pressed in that respect.
There is a good deal of anxiety about this business of satisfactory service. Of course, it is almost a subjective term, and because it is subjective, it is the very one that causes most fear. All of us can understand it, because it is so difficult to define. Nevertheless, it is already in use. I have asked for information about this, and I am informed that it is similar to the signing of certificates now required to show a satisfactory attendance at courses of instruction before a student can sit for his final examinations.
These certificates cover conduct as well as attendance. They represent the opinions of all the people under whom the student has worked. Similarly, certificates of satisfaction will reflect a number of opinions, and there should be no possibility of victimisation by a single individual on personal grounds. The certificate itself is given by the licensing body, that is, by the medical corporation immediately concerned. Therefore, there can be no possibility—indeed, it would be frightening if there were—of a superintendent of a hospital, who might have developed a "grouch" against an intern, reporting upon him unsatisfactorily, because he would, surely, have the collective opinions of all those with whom the provisional doctor had worked in the whole of the year.
I hope, therefore, that we shall not be pressed to give a right of appeal. With whom could an appeal lodge? We cannot have an appeal against a board of examiners—I do not think the animal exists in the whole academic body. The examination takes place, and, I should have thought, takes place as objectively as possible, and sometimes, as we all 1766 know, as impersonally as possible, so that the name of the examinee does not appear. I should not have thought, therefore, it was possible to think of a body to whom an appeal could be made which would not detract from the authority of the examining body itself.

§ Sir H. Lucas-Tooth
Will there be an examination in this case?

§ Mr. Bevan
No, it is a report. As we all know, under the normal school system, the certificate is not validated until a year's satisfactory service is given in the schools, and the inspector reports upon the teacher. If that happens with regard to a school teacher, how very much more important it is in the case of a person to whom we are entrusting the welfare and the lives of the whole population. Therefore, I hope that we shall not be pressed on this matter of appeal.
I hope I have said enough to reassure the student that he is not putting himself in the hands of some individual who might have a spite against him. We must remember that when a person reaches this stage, he is provisionally registered. The intention is not to put up another hoop through which he has to jump; the intention is to give him a year's experience in association with specialists and with a diverse kind of hospital work, so that when he goes out into the world as a general practitioner he will be a better craftsman. It is not intended to put another obstacle in his way; it is intended to be, as it were, the consummation of his general medical training. Further, if an appeal can be made against the report on the student, would there not be a disposition to say, "Oh, well, he can appeal."? There may be a tendency to increase the number of adverse reports if it be present in the mind of the person sending in a report that, after all, an appeal can be made. I should have thought that, having regard to all these matters, the Committee might perhaps permit us to go on with the Committee stage.

§ Mr. I. J. Pitman (Bath)
Would the right hon. Gentleman answer one question for me on this? Is it possible for the intern who gets an unsatisfactory report, to seek another post at which he can have a second year?

§ Mr. Bevan
Certainly; there is no reason at all why if he has "blobbed it," he should not have another opportunity. Anything can happen to a young man or woman at that time. They may have got themselves into a very unsatisfactory set of domestic circumstances or bad companionship. Any kind of thing can happen. Anything can happen to all of us; it sometimes happens in Committees that we get at odds with the world. Therefore, if a person has had a bad time, he ought to be given another chance in another hospital so that he can serve another year.
There is one thing about which I have been rather worried since we made the Amendment, and that is its coming into operation at different times at different places. For the life of me, I cannot see how it is to operate, and also I do not see how it is going to operate with reference to reciprocity with Eire. I think the present intention is to bring this into operation everywhere at once. I just do not see how it is possible for us not to have all kinds of discriminatory, charges, when a doctor goes straight into general practice in one part of the country and another doctor, in another part of the country, is kept back a year. Having regard to all the administrative perplexities, we come down on the side of applying it universally. The power to vary the period is merely for the purpose of emergency.

§ Lieut.-Colonel Elliot
I think that the Minister has performed a very useful function today in giving us a forecast of what he has in view. I trust he will be able to answer the point pressed by one of my hon. Friends, and which, I gather, he did not answer, namely that the affirmative procedure would not be so narrowly drawn as merely to cover the time, but that the regulations which were being submitted to the House for affirmative Resolution would take into consideration some of the points which he has been laying before us this afternoon.

§ Mr. Bevan
I am very glad I was asked that question. The answer is, as the right hon. and gallant Gentleman knows, that if we put too much of what might be regarded as rules into the orders, they cannot be varied without another order. Therefore, to some extent, it would 1768 handicap the administration, which would need to be as flexible as possible. For example. if we put the terms of remuneration in the order, we could not alter them without coming to Parliament. Therefore, any negotiations that took place could always be subject to legislative approval. I doubt very much whether we want to put too much of that detail in the order, but what we will have to put in the order will be the intern period, and things connected with that.

§ Mr. Linstead
There is a point on this which the Minister may not be able to answer now, but I should be grateful if he will look into it. In Clause 2 (1) there is a reference to regulations of the Council approved by order of the Privy Council. That brings Parliament into the picture, but in Clause 2 (2) in line 7 there are regulations of the Council without any conditions of approval by order of the Privy Council. Similarly, in line 17 there are regulations of the Council again not to be approved by the Privy Council. Therefore, it looks at first sight, at any rate, that in the case of those two regulations Parliament is left out of the picture. Is that right and, if so, is there any reason for it?

§ Mr. Bevan
Yes. Parliament is left out of the picture quite frequently when rules are made. When regulations are made—they are not rules usually—they can be prayed against. Where they are rules, Parliament is not brought into the picture, except by raising the matter with the Minister either on Supply, or in another way, because, as hon. Members will appreciate, it would be very difficult if Parliament tried to concern itself with such minutiae as that.

§ Mr. Linstead
But these are all concerned with periods of time and nothing more.

§ Mr. Bevan
Is it the intern time that the hon. Member has in mind?

§ Mr. Linstead
Intern time must be approved by order of the Privy Council, but the other two periods, which are only periods of time and nothing else, are left entirely to the discretion of the Council.

§ Surgeon Lieut.-Commander Bennett
May I ask if the Minister would have in mind in this connection the question of 1769 the exemption of the "deviationists" who go into biochemistry and other things?

§ Mr. Bevan
We could not possibly do that. If a man said he had qualified and wanted to be exempted from the intern year, because he did not want to practise clinically, he would be a very queer kind of medical animal. We should not know what to do with him afterwards.

§ Surgeon Lieut.-Commander Bennett
The universities are full of them.

§ Mr. Bevan
That may be so but, as far as I know, nothing at present stops their practising clinically if they want to do so. There is no law—

§ Dr. Morgan
There is no law against anybody practising, qualified or unqualified.

§ Mr. Bevan
Yes we know. What we mean is that they are on the Medical Register, and therefore can practise clinically. Would those persons say they would not want to be put on the Medical Register? I think it would be found that we could not frame an Act which would put them in suspense, as it were. They are so difficult to define. They would be like Mahomet's coffin. They must come down on one side or the other, otherwise we might have some who do and some who do not intend to go into clinical work, or some who do not but who might.

§ Lieut.-Colonel Elliot
I will, if I may depart from consideration of Mahomet's coffin. You may not know, Major Milner, that I did catch your predecessor's eye, and what was going on just now was a series of sub-committee meetings of the Committee. The particular point I was raising with the Minister was whether the regulations should only cover the time or go a little wider. I agree with him that one does not wish to be too meticulous, because the old maxim that to include one thing is to exclude another holds terribly true in these things. If the Bill permitted discussion of these regulations to range wider, it would be to the advantage of all of us.
Obviously, before such regulations were drawn, they would be the subject of close consultations with my hon. Friend the Member for Luton (Dr. Hill), in some of his other incarnations, or 1770 possibly with his successor. But I think it would be desirable that here in public we should have the opportunity of reviewing the matter. The Minister knows, as well as I do, that when an affirmative Resolution covering something is submitted, it may be a narrow Parliamentary opportunity. The things we have to review are not narrow. I am sure it would be to the advantage of the Minister, and certainly to the advantage of the House and the country, that discussion should further enlighten all those concerned, as discussion this afternoon is further enlightening all of us who are taking part in it.
I do not wish that these things should be written into regulations, but that the regulations should be so drawn that they do not limit Parliamentary discussion so closely that it would be impossible to raise these matters on the Floor of the House. I should be glad if the Minister could keep that in mind. Obviously, this will not arise immediately, because, as he says, it will be a year or two before such regulations have to be laid before the House. If words like "and connected therewith" could be introduced to enable these difficult points to be raised, it would be to the advantage of all of us concerned.
I am sure the Committee is working at its very best today. It has a piece of ironwork on the anvil before it, and is actually hammering it out here. Several points have been raised on which I think we, on this side of the House, are agreed with the arguments the Minister advanced. There is, for instance, the point about appeal. I do not see how an appeal from an examiner can lie. I think the Minister went far to meet that point when he said it would "encloak," so to speak, the views of a number of persons, and would be similar to the certificate of satisfactory service which an inspector gives in the case of a school. I think an appeal to an outside body, which could not possibly have the same opportunities of examining or considering the work of the person as those who have originally been in the position of giving the certificate, would put the unfortunate man almost in the position of doing another term of service under the supervision of an examining body. It might lead to confusion worse confounded.
1771 It is for the reason that these will be discussed closely between representatives of the student body, the professional bodies, and the Department that freer discussion on these points, when these regulations come up for affirmative Resolution, will be of very great advantage to all concerned. Again, I think the Minister was probably right when he said that the scheme will have to come into operation everywhere at the same time. A provincial qualification or relaxation would be a most difficult thing to operate. I believe that in the University of Bologna a student who did not entirely satisfy his examiner was given a certificate marked. "Bon pour l'Orient" or "All right for the East." And "Exempted from intern service because no post available" would be an awkward endorsement to have on a certificate for any of us.
The Minister is probably right on the point made, on this side, that those not desiring to go on with this, or those desiring to go in for something like special service of one kind or another, should be exempt. The simple line on that is not to have one's name entered on the Medical Register. I do not think that it is possible to say that a man who may afterwards change his plans and not desire to go on with his particular special qualification should be entered as a fully-qualified man, when in fact his qualification was less than that of one who had studied alongside him. I think that if on a subsequent occasion he wished to enter into general practice, it would not be possible for him to do that houseman training. I think that it would be very necessary indeed, if he was going to enter into general practice, that he should have some kind of refresher course, because a long period in research severs one very much from the rough-and-tumble of the actual practice of medicine.
I remember Lord Boyd Orr telling me of his mental distress when, having spent his early years after qualification in high research, he found when he entered the Army that on account of his singular qualifications he was immediately put in charge of wards containing a number of acutely ill people, and told he must be properly able to look after them. This caused him mental anguish and distress, and a great deal of hard work while he was polishing up his rather rusty medical knowledge.

§ Dr. Morgan
The right hon. and gallant Gentleman is talking of men who are going into research. Let us take the man who wants to go into tropical medicine. Why should that man, in view of the limited number of hospitals here, have to go into hospital and serve his term of probationary service when he wants to get into tropical institutions here. If he can get into them, let him do so, but if he cannot, then let him go straight to the tropics.

§ Lieut.-Colonel Elliot
Surely, anyone going out to places far removed from the medical schools to take up tropical medicine, ought to have an acquaintance with general medicine, because he will have this work thrust upon him at short notice by people who trust very deeply to a medical qualification, and who may feel justly aggrieved if they find that he has escaped some particular course of training, which another man beside him may have taken.

§ Dr. Morgan
I think that the right hon. and gallant Gentleman is doing an injustice to the medical schools if he thinks that a man after five years of study—despite the year he has not spent in a resident medical capacity in a hospital—has no knowledge of medicine at all. That man up to the present will have done excellent service and will have excellent knowledge.

§ Lieut.-Colonel Elliot
It is straining it to say "no knowledge of medicine at all." It is a recommendation of the Committee that this extra refinement of medical education should be universally applied, and, if it were, I cannot conceive any person to whom it would be more rightly applied than to the man going abroad, who is severing himself from immediate contact with the great apparatus of healing available at short notice in this country. That is a difference of opinion. I only say that, on this, I myself would share the view which the Minister has put forward.
The suggestion as to remuneration has been worked out fairly closely by hon. Members on this side, and the remuneration in terms of cash now would be about £150. The sum suggested is about £200 with a reduction of £150 for board and lodging. I hope that the Minister will keep his mind open as to the possibility of a supplementary allowance of one kind 1773 or another. There are a number of people of considerable seniority who are now graduating and who have wives and families. A man with a wife, and possibly with a family, who is not able to get accommodation in married quarters, would find the sum of £200 small enough, to maintain his household in separate quarters. The Minister intimated that he would keep that in mind, and I trust that he will. All these are matters which will he threshed out in the year or two that lie immediately ahead of us. I think that this is as far as we can usefully carry the discussion on this particular point this forenoon.
Another opportunity will certainly arise, and for that we are grateful to the Minister for accepting our Amendment that when the affirmative resolutions come up to be debated and the actual enabling Bill has enabled the machinery to be set in motion, and the actual proposals affecting the individual lives of the graduates are before us for consideration, we shall have an opportunity to review these matters. I am sure that a useful purpose has been served by the discussion this morning. and that many of the doubts and fears put up to us by the Students' Association and others have been dispelled today.