HC Deb 14 July 1950 vol 477 cc1776-85
Mr. Bevan

I beg to move, in page 4, line 20, to leave out from "registered)," to "registered," in line 22, and to insert for the words 'under this Act' there shall be substituted the words under the Medical Acts or provisionally so.' Perhaps the Committee will permit me to explain the purpose of this Amendment and the following few Amendments standing on the Order Paper. They are not as formidable as they look, nor are they the result of second thoughts about the Bill. On the contrary, they are the result of the fact that, after the Bill emerged amended from another place, the Parliamentary draftsmen sought to take this opportunity of anticipating consolidation, and therefore to alter the nomenclature so that the work will be simplified when consolidation takes place.

Amendment agreed to.

Further Amendments made: In page 4, line 25, leave out "medical register," and insert: registers to be kept under the Medical Acts.

In line 26, leave out "a separate part of that register," and insert: separate parts of those registers.

In line 28, leave out "that," and insert "the separate."

In line 35, leave out from "Council," to "and," in line 36, and insert: a register relating only to persons provisionally registered, to be called 'The Register of Provisional Medical Registrations,' in the like form and containing the like particulars as the Medical Register, but compiled by reference to such date or dates in the year as the Council may direct.

Leave out lines 38 and 39, and insert: Register of Provisional Medical Registrations as, it applies to the Medical Register.

In line 46, at end, add: and the register in which provisional registration is to he effected shall be determined accordingly."—[Mr. Bevan.]

Mr. Hastings

I beg to move, in page 4, line 46, at the end, to add: (8) A person provisionally registered under this Act shall have all the duties and privileges of a registered medical practitioner but only while serving in an approved hospital or institution as defined in Section one. What medical students are everywhere asking is what will be their powers and duties when they are provisionally registered. The Committee ought to know what it will be possible for a provisionally registered doctor to do. I do not think we are justified in leaving this matter entirely to a question of regulations. I suggest that a provisionally registered doctor will have the powers of a fully registered doctor only when serving as an intern in the institution to which he is attached. In other words, if he goes away for a weekend as a locum he will not be able to sign death certificates and order poisonous and dangerous drugs. What I feel very strongly is that while this man is serving in hospital he should have the full powers and duties of a medical practitioner.

2.0 p.m.

Might I make two points? First, there is the question of ordering dangerous drugs. I do not think a man can do his duty in an intern hospital without that power. He may get a case coming in suddenly of a bad accident or an individual with coronary thrombosis in the most acute pain which anyone can suffer, and he ought to be able to give morphia in such cases without waiting to send to his chief for permission.

There is then the question of the signing of death certificates. I feel that that should be permitted to him, too. A case could happen concerning an individual attending the outpatient department with some kind of heart affliction. The person comes into the hospital, but before the chief can be called he dies. The provisionally registered doctor knows about the case; there is a full record, but the only person who has seen him is this provisionally registered doctor. I feel that in such cases he should have the right to sign the death certificate. I feel, too, that everybody, including the public, should know exactly what are the powers of the provisionally registered doctor, and that these should not be left to be defined by regulations.

Dr. Morgan

I agree with all that has been said, and I think it rather hard lines if a man, after his medical training and after getting his certificate, decides not to accept these terms, because he will have to get into another profession. The only difference between my hon. Friend the Member for Barking (Mr. Hastings) and myself is on his point that this must apply only to the institution to which the provisionally registered man has been attached. Under the National Health Service, some of these men may be appointed under a regional board which has several hospitals under its jurisdiction. The man may serve for a time in one institution and then the board may want to change him to another institution, in which event he comes under the ban mentioned by my hon. Friend, and cannot continue in his job.

Some laxity should be allowed, and I think the Clause should stand as it is. Of course, I should like my Amendment to be made, but I am prepared to let that go. The Amendment now under discussion will, in my opinion, do the Service harm and the man an injustice, if he has to stick to a particular hospital to which he is attached after being provisionally registered. I, therefore, hope that my hon. Friend will not succeed in his Amendment.

Mr. Pitman

There is a point to be cleared up here, and I do not know whether the Minister can consider it between now and the Report stage. It is that the public and other doctors should know clearly whether people who call themselves doctors, are in fact qualified to treat and to give orders in respect of, say, a street accident. I had the misfortune to break my leg on the football field, and people immediately jumped in to assist. It may well be that Dr. Fleming, of penicillin fame, might be the head of a medical faculty and not be qualified to do anything outside his particular hospital. There might be other doctors who would come up later. They see Dr. Fleming in charge, giving orders to the Saint John's Ambulance people and others.

There is no clarity of power and responsibility as between the various people in such an emergency. The word "Doctor" is loosely enough used as it is, and I think there is in this very great danger for legal actions to be based on a doctor following what he believes to be the orders of a fully qualified practitioner, who turns out subsequently to be one of those curious, non-professional men, who are neither fish, flesh, nor fowl, who has not done his year but has gone into university research and is not, therefore, properly qualified to give orders either to doctors or nurses.

Surgeon Lieut.-Commander Bennett

I should like to join issue on one point with the hon. Member for Warrington (Dr. Morgan). He suggests that if an intern doctor is permitted to carry out full medical functions at one hospital, on transfer to a hospital where he becomes an employee of a regional hospital board he loses that power. It is only consultants and senior hospital medical officers who are employed by the regional boards, and all the junior ranks are taken on by the hospital at which they work.

Dr. Hill

I am rather uneasy about this. If it is agreed that the practitioner on becoming provisionally registered should be regarded as a registered medical practitioner for a fairly wide range of purposes, then this year may fall into disrespect. I believe it must be regarded as an essential part of medical education, and at the risk of repetition, I say that to equate the provisionally registered with the permanently registered man, merely leaving an interval of time to pass between them, seems to suggest that the standard of registration is reached with provisional registration, and that this final year is a kind of burden or testing time imposed by the State.

We must get it into our minds that this year is part of the medical education, and we ought not to determine, without very careful consideration, those purposes and functions that are reserved to registered medical practitioners, to pass them automatically to the provisionally registered man, even though he is in a hospital. I confess I prefer the words here, because the Clause that follows possibly needs a certain amount of further consideration. Indeed, until we see the picture of this provisional year, and until we see the form that the internship takes, I doubt whether we are in a position firmly to decide that all the privileges of registration should go with provisional registration. It needs more thought and more consideration before such a decision can be reached.

Mr. Bevan

I am in fairly general agreement with what the hon. Member for Luton (Dr. Hill) has just said. Unless we are exceedingly careful, this intern year will lose its status. After all I know it is difficult to describe it except that it exists in other academic fields. It is not that the doctor is not fully educated when put on the provisional register, but it is considered that a year's satisfactory experience of this sort is necessary for his final equipment as a general practitioner. That is the kind of reasoning that lies behind the Goodenough recommendation. I explained earlier that for purposes of his intern year he is a fully qualified doctor. In the institution he can sign death certificates if it is appropriate for him to do so in the circumstances of the case, and he can give drugs. He can do all those things which are appropriate to his position as a doctor on the staff of that hospital, which indeed he is, and he is paid by the hospital. Therefore, his status in the hospital is fully protected.

Also, the status of the intern year is protected by confining his powers to his internship and saying that outside, he cannot act as a fully qualified practitioner. In other words, it means that he has not got on to the Medical Register but only on to the provisional register. The difference is that until he has served this further year he cannot get on to this further register. Here it is stated positively, as in most Acts of Parliament, not negatively. What is not stated here, he is assumed not to possess. Subsection (3) says: Persons provisionally registered shall be deemed to be registered so far as is neces-sary— (a) to enable them to be employed as mentioned in subsection (1) of section two of this Act, Where it is not stated, they are assumed not to be, because registration and qualification are qualifications and not negative rejections. Therefore, I prefer the words here.

Dr. Morgan

Would the Minister make it clear whether it is a single institution?

Mr. Bevan

An institution for purposes of the statute is not a building, and therefore an institution for this purpose could comprise several hospitals or any of those hospitals that are approved for this purpose.

Sir H. Lucas-Tooth

Is the right hon. Gentleman completely satisfied that the rights and interests of third parties vis à vis these hybrid individuals are safe? They may find that a person provisionally registered purports properly to act as a doctor in one case and is unable to do so in another case. That may be difficult as far as third parties are concerned.

Mr. Bevan

I am not a lawyer and I cannot say how far third parties are affected by this, but there is nothing to prevent any citizen from coming to the medical assistance of any other citizen. He can do that, but he cannot claim that for those purposes he is a fully qualified registered medical practitioner. Therefore, in so far as that would affect the rights of a citizen whom he attends, that risk would be carried. I should doubt, however, whether any legal burdens would follow because if someone in the absence of anybody else gave any skill at his disposal to an afflicted person, he would be an extremely unChristian person who would then proceed against that man because he had made a mistake.

Mr. Pitman

I see the Minister's point but there is nevertheless a point of third party relationship. There may be several doctors who leap to the case, one of whom appears to be the senior and he may get on the scene first. It may well be that the relationships between third parties would be befuddled by this lack of extension of the powers of the provisionally registered man to emergency cases of this kind, and it may well be worth looking into.

Mr. Bevan

I will certainly look into it, but I cannot see, for the life of me, how we could protect ourselves against it.

Mr. Hastings

If I heard the Minister aright, he agreed with me completely on the substance of my Amendment. Would he consider putting this in the Bill or, at any rate in the regulations which will be framed eventually? If the Minister agrees to do that, I should like to withdraw my Amendment.

Mr. Bevan

I understand on my reading of it that it is in the Bill now.

Mr. Hastings

Then I beg to ask leave to withdraw the Amendment.

Amendment, by leave withdrawn.

Motion made, and Question proposed, "That the Clause, as amended, stand part of the Bill."

2.15 p.m.

Dr. Hill

I have referred to Clause 2, and a little earlier the question was raised of the practitioner who, after passing his examinations, wished to go into laboratory work, into research, tropical medicine and the like. The substance of the Minister's answer—I believe I am right in attributing it to the right hon. Gentleman—was that the man might become provisionally registered and enter his field of work without becoming permanently registered, and if subsequently he decided to practise clinical medicine, it would be necessary for him to do his intern year. With that contention I agree, but, as the Clause is worded, on passing his examinations the individual will be required to apply for and obtain a post. The relevant words are: Provided that he produces evidence satisfactory to the registrar that he has been selected for such employment as is mentioned in subsection (1) of section two of this Act, It seems to me to be a difficulty that passing the examinations and obtaining the diploma, in the university sense, of itself does not entitle a man to provisional registration. Even though he is going straight into laboratory work, he has to apply for and obtain a post. This is worth reconsideration so as to make possible the idea expressed earlier. As matters stand, passing the examinations, of itself entitles the person to nothing, not even provisional registration. He has subsequently to apply for and get a job.

Dr. Morgan

There is a point arising on my Amendment. A man may apply for a post in order to get permanent registration and may not succeed, but equally he may not apply. What is to be done with a man who has all his degrees and does not apply to be put on the provisional register? Is that man to be wasted in a period when there is a shortage of medical practitioners? Would the Minister explain that?

Mr. Bevan

As I understand it, the argument is this: the person has passed his examinations and at that stage he asks himself what his future course will be. He may decide not to go in for clinical practice but for research work. Therefore he does not want to serve his intern because the intern year is for the purpose of getting him on the medical register which is not essential for the specialised work he proposes to do. Therefore he wants to be exempted from the necessity of serving the intern. At some later stage, however, he may want to become fully qualified, so he ought to be allowed to apply to be put on the provisional register at any time.

I think there is some substance in that argument. Of course there is no reason why he should apply for the provisional register. I see that the man's future rights need some protection, because—I am thinking aloud for a moment—he ought to be able to complete his training at some future period if he so wished. I will look into the matter to see whether this would be covered.

Sir H. Lucas-Tooth

In particular there is the case of the man who is qualified by examination in this country and who may wish to do his intern service overseas.

Mr. Bevan

In that case, it is not so difficult.

Sir H. Lucas-Tooth

But it would be extremely useful to the man if he were able to produce evidence of provisional registration instead of showing merely that he had passed the examination.

Mr. Bevan

Yes. It is not always easy, when looking at these very technical Bills, to see what construction they bear. As I understand it, there is nothing to prevent a man from postponing his application to be put on the provisional register almost indefinitely, so that his rights are kept alive. I will, however, see whether it bears that interpretation.

Dr. Hill

Would the Minister, in reconsidering the matter, give a thought to the suggestion that provisional registration should be obtainable on a man's satisfying his examination for his diploma? After all, it is provisional registration and nothing more. Thereafter, the man has to apply for and to get his appointment and to hold it for the specified period before full registration is granted.

Mr. Bevan

I see some difficulty here. The educational authorities must have some assurances that the posts they are making available are going to be used, because the assumption is that when a man applies to be put on the provisional register, he wishes to have a post to complete his intern year. Nevertheless, I see no great administrative problem here. The man could indicate whether he proposes to take up the post at once, so as to give the authorities the necessary information. In any event, I will see whether this position can be cleared up.

Dr. Morgan

I want to make a point about homoeopaths. There may not be sufficient posts in institutions to enable them to serve their year of provisional registration. Sometimes the waiting lists would involve a wait, not merely of one year, but perhaps of two or three years, before a man could enter a homoeopathic institution in order to qualify under the Bill.

Mr. Bevan

Now we are treading on dangerous ground and I move gingerly as though I were treading on the fields of asphodel. When we come to consider homoeopathy and more orthodox medical practices, this is where a layman refuses to express any opinion at all if he has any sense—and I have quite a bit of sense in this field in the last five years at least. I should have thought that homoeopathic medicine is not necessarily excluded by learning all medicine. Thinking aloud once again, I see no reason at all why the intern year could not be served in a general hospital, and homoeopathic practice is merely a matter for the individual doctor to decide to do as a doctor when he has qualified. Over that, we have not the slightest control.

Dr. Morgan

I was speaking of the qualified doctor who had taken all his medical examinations.

Mr. Bevan

No. We have just said that a person is not qualified for general practice until he has served an intern year. What I am now asked to do is to make sure that arrangements are going to be made for him to serve that intern year in a homoeopathic hospital. I am afraid that I cannot give such a guarantee at this moment. As has been said, there might not be enough posts.

Surgeon Lieut.-Commander Bennett

The problem which was raised by my hon. Friend the Member for Luton (Dr. Hill) might not appear so awkward if it were made clear that university and research authorities, when seeking people holding medical degrees to go on to their staffs, asked for people holding degrees or diplomas rather than for people who were on the provisional register. If it is only the possession of a degree that is necessary for research, then I think that the question of a provisional register would not arise.

Question put and agreed to.

Clause, as amended, ordered to stand part of the Bill.