§ Order for Second Reading read.
§ 7.26 p.m.
§ The Minister of Health (Mr. Aneurin Bevan)
I beg to move, "That the Bill be now read a Second time."
The House is now being asked to turn its back on its recent performance as a theatre and become a workshop once more; and I hope that the excitement which has just occurred will not prevent us from giving proper attention to what is a prosaic, but very important, subject.
The Bill comes to us from another place, where a number of Amendments have been accepted, and I daresay that hon. Members of the House of Commons 2182 will wish to have a careful look at it, with a view to seeing whether any further constructive Amendments can be made. I am hoping it will not be necessary to have a protracted Debate on the Bill on Second Reading, because, I gather that there is general agreement with the main purposes of the Measure. The Bill does not purport to undertake a complete revision of the medical Acts. That would indeed be a major Measure calling for prolonged and very detailed study, necessitating a very heavy demand on Parliamentary time and possibly evoking a great deal of controversy. All that the Bill sets out to do is to make provision for a number of matters clearly of urgent public importance and for a few less important matters where some early change in the existing arrangements is obviously desirable. From discussions with representatives of the medical profession, and others, and from the welcome given to the Bill in another place, we believe it will command general support.
There are four main purposes of the Bill. The first is to improve the standard of medical education. The Bill gives effect to two of the main recommendations requiring legislation contained in the report of the Inter-departmental Committee on Medical Schools, called the Goodenough Committee, which was issued in 1944. It provides, in Clauses 1 to 6, that, from a day to be appointed, every medical student, after he has passed his final examination, but before he is admitted to the Medical Register, and thus allowed to take up independent medical practice, is to be 2183 required to serve satisfactorily for a prescribed period in one or more approved hospitals or institutions.
The intention is that the period of intern service should normally be one year. In fact, the Bill as introduced in another place, specified that that should be the minimum period, but, by an Amendment agreed in Committee there, the period is now left to be fixed by the General Medical Council subject to the approval of the Privy Council, without any specified minimum. Leaving the matter open in this way will, for example, facilitate any modifications which may have to be made in the event of an emergency and there is also just the possibility that at the outset there might be difficulty in enforcing a full year's service.
As the Goodenough Committee states:There has been enthusiastic support among our witnesses, including representatives of the medical students, for the proposal that, in future, entry into independent medical practice should be preceded by a compulsory period of approved and responsible clinical practice under supervision.They point out that the special value of this experience before registration lies in developing in the holder a sense of responsibility. Following the passing of his final examination, he needs—before launching out into independent medical practice—to have actual experience of medical practice under guidance and supervision in circumstances which afford adequate time for thought, for further study and for the personal investigation of the social and environmental conditions of the patients with whom he comes into contact. When he launches out into the world he will do so as a more fully trained and equipped medical man.
There are various ways in which this pre-registration period, which may be called for convenience the "intern period," could be organised. There is, however, general agreement that the intern period should be spent wholly in an approved hospital or institution, and the Bill itself provides that this must be so. It is left to the General Medical Council to decide how long the student is to spend in medicine and surgery respectively during his intern period. For the most part it is anticipated that he will hold what are in effect junior house appointments, that is, posts as house 2184 surgeon and house physician. At present these are held by doctors after registration. An Amendment made in another place makes it clear that the institutions in which the intern period may be spent include, subject to certain safeguards, approved health centres.
Before a doctor begins his intern service he will be put on a provisional register. This will enable him to discharge the duties of a registered medical practitioner so far as is needed for him to complete his intern service, and will also make him subject, if necessary, to the appropriate disciplinary machinery.
It will obviously be some time before a day can be appointed for giving effect to the requirement of intern service. It is, for example, necessary to ensure that there are sufficient house appointments or other suitable posts for all doctors who pass their final examinations, before the requirement can be imposed; and since the intern will have to live in or conveniently near his hospital or institution, accommodation problems have to be faced. Obviously, too, some period of notice to existing students would have to be given before such a requirement could be imposed. All this will inevitably take time, and that is why the Government are so glad that they have been able to make a start now with the introduction of the Bill. It is possible that some parts of the British Isles may be ready for the introduction of the compulsory intern period before others; and the Bill makes it possible for the requirement to be introduced piecemeal for this reason in different parts of the British Isles—if that should ultimately be considered desirable.
One point of interest may be mentioned. The General Medical Council still exercises some jurisdiction in relation to the Republic of Ireland, under an agreement entered into between the United Kingdom and the Irish Free State, as it then was, in 1927. For example, doctors who pass their final examinations in the Republic are admitted on application to the General Medical Council's Register. Furthermore, the universities and Royal Colleges in the Republic appoint members to the General Medical Council. It has, therefore, been necessary to enter into consultations with the Government of the Republic to ensure that the present arrangements outlined in the Bill are acceptable to them and that they 2185 for their part would similarly be willing to amend their own law as necessary. Complete agreement between the two countries has been reached on this matter, I am glad to say, and the provisions of the Bill accord, we believe, with that agreement.
It should also be mentioned that we are not the first country to provide for the introduction of compulsory intern service. New South Wales, the Union of South Africa and many States of America already have a requirement of this kind. With some countries the General Medical Council have reciprocal arrangements; and provision is made; for newly qualified doctors from these countries who apply here for registration under these arrangements to have to show that they too have served an intern period or otherwise acquired equally extensive experience.
This provision, too, it may well be necessary to apply at different times to different countries. New South Wales and the Union of South Africa are already prepared for the introduction of such a requirement; other countries with whom we have reciprocal relations are not yet ready and some time for consultation and, if necessary, adjustments will have to be given.
There is a further provision in the Bill for the visitation of medical schools. The Bill empowers the General Medical Council to appoint visitors to visit places where medical students are taught. This, again, is in accordance with the views of the Goodenough Committee as expressed in chapter 16 of their Report. Hitherto the General Medical Council have only been able to appoint visitors and inspectors of examinations, whose duty it has been to report as to the sufficiency or insufficiency of these examinations. In fact, however, the standard of professional practice obviously depends more on the teaching given in the medical schools than on any control that the Council can exercise by visiting and inspecting these examinations.
I think that that will be clear to hon. Members who have given their time to the matter, because the general standard in the schools will have a profound effect on whether or not the intern period will be advantageous. Accordingly, the powers of the Council are being widened to enable them to visit the actual places where medical students are taught and to report on the training actually given. As the Goodenough Committee said: 2186The regular inspection of medical schools should contribute to the maintenance of good standards and should prove helpful to the schools.There is power to give directions to the General Medical Council in connection with the arrangements made for visitations. This power is to be exercised by the Privy Council. The House will realise that, in this matter, we have been very careful all the time to ensure that any influence over the academic side of medicine should be exercised by authorities like the Privy Council and the General Medical Council and not directly by the Government. Here, as in the National Health Service Act itself, I have been particularly scrupulous to see that there is no governmental intervention of any sort with academic medicine. We believe that the General Medical Council and the university authorities should have no difficulty in making arrangements so that there should be some agreement as to these inspections. This particular provision in the Bill requires no long advance administrative arrangements, and will come into operation immediately.
The second purpose of the Bill is to alter the constitution of the General Medical Council. There are now 39 members of the Council, and, under the provisions of the Bill, this number is increased to 47. At the moment, the number of Crown members is five, and under the new constitution it will be eight. The number of members elected by the medical profession is seven, and the new number will be 11. The members appointed by the universities, medical corporations and Royal Colleges is 27, and will become 28. I am glad to say that the Royal College of Gynaecologists and Obstetricians is added to the number of Royal Colleges now represented on the Council.
One reason why the strength of the General Medical Council has been increased is because everybody concerned in this matter believes that it is desirable to give the profession's own representatives a fuller say in the work of the Council as a whole, and to increase the total number of elected members also gives a wider choice of such members to sit on the proposed Medical Disciplinary Committee.
The Bill as introduced in the House of Lords provided for an increase from 2187 seven to nine, but the House of Lords agreed to an Amendment which brought the number up to 11—and also provided specifically for a Welshman to be included among the 11. I myself consider that this was a work of supererogation, because I am quite certain that a Welshman would have found his way there anyway, since so many are distinguished members of the profession. There has also been a desire that there should be an increase in the number of secular members of the authority, and that is the reason why there has been an increase from one to three.
The third point of the Bill, and a very important one indeed, is the improvement in the disciplinary machinery and procedure of the General Medical Council. Obviously, a Council of 47 is not suitable to act as a whole as a disciplinary authority. It is proposed, therefore, in Clause 14, to entrust decisions on professional discipline to a new medical disciplinary committee of the Council, which will have 19 members, including the President of the Council, at least six elected members and at least two laymen.
By an Amendment made in the House of Lords, the Bill provides that cases should normally be dealt with, not by the full Committee of 19—which is itself rather large—but by between five and nine of the members, including at least one layman. The President of the Council will, however, still be entitled to arrange for the full committee to deal with a particular case, if he thinks circumstances warrant this.
Provision is made for evidence to be taken on oath and for witnesses to be subpoenaed. There is no similar power at present, and, as a result it has, for example, often not been possible to secure the attendance of necessary witnesses. This change in the law is exceedingly important from the point of view of the doctors. A doctor whose name is erased from the Register is given a right of appeal to the Judicial Committee of the Privy Council, either on law or on fact or against sentence, and this I am sure hon. Members will realise, is an exceedingly important improvement on the existing situation.
The Government considered whether the appeal should lie to the High Court, 2188 to the Court of Session, or to the High Court of Northern Ireland, according to the nature of the case, but we came to the conclusion, after looking at this very carefully indeed, that there would be likely to be three different appeal standards, and, also, that it would be very difficult to find a wholly satisfactory definition of a Scottish or an Irish case, and it was agreed that it should be exercised by the Judicial Committee of the Privy Council.
There is also provision for rules to be made, both for the procedure of the disciplinary committee—rules made by the committee and subject to the Privy Council's approval—and as to the functions which the legal assessors to the Council will exercise. All these changes will come into operation on a day to be appointed. It is necessary to have a provision for an appointed day because the various rules that need to be made will require careful consideration and discussion with all interests involved.
The fourth provision is to increase the fees payable for registration in the Medical Register. At present, the maximum fee which the General Medical Council can charge is £5. This was originally fixed in 1858. The functions of the General Medical Council, carried on without imposing any charge on public funds, have obviously much increased since then, and the income from registration fees, the main source of the Council's income and other sources, has become quite insufficient to enable the Council to pay its way.
Accordingly, the Bill now provides for a fee to be fixed of a maximum of 11 guineas for full registration, including five guineas for provisional registration when that is operative. There is power for the Privy Council to vary the maxima by Order. This provision for increased fees will take effect on the passing of the Act.
There are also a number of matters of some importance, but not of sufficient importance to warrant their mention during a Second Reading Debate. For instance, hon. Members will note that there is a provision in the Bill which makes it impossible for Members of Parliament who are members of the General Medical Council to receive fees. This is to make it quite clear that we are not 2189 creating any offices of profit under the Crown, and, therefore, we shall not in this instance find it necessary to bring forward saving legislation.
§ Mr. Bevan
For the obvious reason that it would not be right for hon. Members to receive fees for any attendances at the Council's meetings. They can draw subsistence allowances and other expenses, but they cannot take any fees, no matter how small. Otherwise, legislation would be necessary to exempt the person concerned from the most fierce penalties which he might have incurred. The provision in the Bill makes sure that that shall not happen.
I have endeavoured to be as short as possible, because I know that we are now considering this Bill against the background of an exciting day, and that hon. Members who wish to speak will be anxious to give the Bill a smooth and speedy passage. With those remarks I commend the Bill to the House.
§ 7.49 p.m.
§ Lieut.-Colonel Elliot (Glasgow, Kelvingrove)
I am grateful to you, Mr. Deputy-Speaker, for that little slip which you made in calling me "Dr." when summoning me to address the House, because it shows that there is a certain association of ideas in your mind which perhaps enables me to speak with considerable sympathy on the purposes of this Bill, though I am afraid that I have long since passed out of any immediate knowledge of the objects which it seeks to secure.
We are indebted to the right hon. Gentleman the Minister of Health for having brought forward this Bill and for his clear and succinct explanation of its provisions. I think the Bill is one to which the House will certainly give a ready assent, and, although a certain amount of consideration may have to be given to it in Committee, I do not think it should be prolonged. Like the Minister I have sometimes had experience of Bills which received the unanimous assent of the House on Second Reading, and met with general good will, but which somehow proceeded to attract a great deal more 2190 attention and discussion than matters which raised points of controversy and which could be summarily disposed of. But I do not think that will be the case here.
As the Minister has said the purposes of the Bill are fourfold. They are improvements in machinery in relation to the General Medical Council and a very important alteration in medical education. The latter, of course, is more important than all the others put together because the alterations in medical education will affect every graduate, whereas the disciplinary powers of the General Medical Council will affect only a very small proportion of those on the Register.
Dealing with them first, I think we would say that the second, third and fourth purposes which the Minister mentioned—the machinery purposes—are unexceptionable. It is interesting to note that the alteration of the General Medical Council will give elected representatives a larger representation. I hope, by the way, that consideration of this Bill will help to dispel—I cannot say that it will entirely dispel—the popular superstition that the General Medical Council is in some way or other the same thing as the British Medical Association, and that tremendous disciplinary powers are handed over to what is, after all, a trade union.
That is a matter which other trade unions bring forward as something which shows the great power of the bourgeois union as against the craft or industry unions of which they are members. Of course, the General Medical Council is in no way a trade union as, indeed, can be seen from the large number of persons appointed to it from outside, which any trade union would look upon with the gravest suspicion, and would probably insist upon dispensing with altogether. It is one of the composite bodies.
The great profession of medicine is one in which Governments have always taken a certain interest and over which they have always demanded the exercise of a certain authority, although it may be said that even the fact of being inscribed on the Medical Register gives one remarkably few privileges or powers. Anyone is free to exercise medicine without being inscribed on the Register at ill, and it is in no way possible to refuse permission to anyone to practise medicine 2191 in this country. But the General Medical Council, first of all, is to have a certain alteration in its representation. We can examine that when we come to it on the Committee stage.
With regard to the third purpose, the disciplinary machinery of the General Medical Council, I am sure that we all welcome the increase in its powers which the Minister has mentioned—the power to subpoena and to take evidence on oath—because miscarriages of justice have taken place in the past owing to the lack of those powers. As regards the right of appeal, I think we are all glad that this right has been given. I am not certain that we shall not have to examine more closely, when we come to the Committee stage, whether, in fact, the solution here determined of an appeal direct to the Judicial Committee of the Privy Council is the appropriate court of appeal to have chosen.
I do not think there are many precedents for an appeal lying directly to this august body, and whether it is the proper one to decide on questions of law, fact, and sentence I think we shall need to explore further at a later stage of the Bill. The Minister said that the Government had examined the question of using the High Court, and that the difference in standards might arise. I do not think that is a very grave danger, but his other reason—that there might be some difficulty in deciding what was actually an appropriate case to remit to the appropriate authority—had more substance in it. We shall be very glad to look at the arguments on that point.
As for the final purpose, I fear it is one without which no piece if legislation nowadays, and very few undertakings, are complete—that whatever a thing cost before, it should cost more after we have handled it. It is true that there are very few charges which have gone unincreased since 1858, and no doubt it is necessary that this one, too, should fall into line. It is a remarkable tribute to our forefathers that they were able to set up a body with such adequate provision for its expenses as to carry it on without any change since 1858 to the present day.
As for the stipulation of removing the membership of the General Medical 2192 Council from that of an office of profit, I am sure that is a good thing, although I think it would be better if at an early date the Government could find it possible to bring in legislation tidying up this matter of offices of profit, which is extremely complicated just now. Nothing is more irritating than to find that some trivial and almost nominal acceptance of a fee, or of the possibility of a fee, has made it technically illegal for an hon. Member to sit in this House, I think we had to pass legislation for the purpose of saving two hon. Members of this House from such a consequence, and I believe that one of them is sitting in the Chamber now.
If, then, we can deal with those matters—as I am sure we can—without any great delay, it leaves open for consideration at a little greater length the main purpose of the Bill, which is the improvement of medical education. Here the very important step has been taken of recommending that an additional period of a year should take its place in the medical curriculum. The danger is that the curriculum may be unduly prolonged, that the final period may be projected further and further away until it comes to a period in a man's life where he can no longer take full advantage of it. In some ways, the curriculum is already overloaded. The masses of information which the medical student has to acquire, and which were appropriate in other days, are not, I think anyone would agree, appropriate today. A pruning knife ought to be applied to this tree, otherwise it may cease to bear fruit altogether and merely develop into a proliferation of foliage and branches.
In the second professional examination, a minute acquaintance with every aspect of anatomy is called for, which I think is carried far beyond what any student will remember, even for a short period, after he has once successfully satisfied the examiners. Anyone having to deal with those intricate matters would certainly read them up very closely beforehand, and no one would trust to the casual recollections of his student days. Medical education should constantly be re-modelled to suit the necessities of the time. As a medical student, I do not think I ever saw a live man without any clothes on. I saw a great number of 2193 dead men or skinned men, but the number of dead or skinned men which a medical student sees is, in practice, very small compared with the number of people he sees who are alive, and whose skin covers their flesh and bones. The whole great question of surface anatomy was long ago greatly needed. The danger is of these things piling on top of each other instead of substitutions taking place. I am sure it would be to the advantage of the students and the patients who subsequently come under their care, if this could be done.
I yield to no one in my admiration of the training which the great hospitals give young graduates in their houseman-ship. Practically all the medical men here have put in a year as housemen after they qualified. The point is, however, that responsibility is never felt on one's shoulders to the same extent when all the apparatus and resources of a great hospital are around one, as when one is starting to grapple with the multifarious emergencies of private practice with one's own hands and knowledge. When I went to my first locum, I heard the bell ring with considerable trepidation.
§ Lieut.-Colonel Elliot
I trust that I concealed my apprehensions from them. In fact, I thought I did so fairly successfully, because the skill of the doctor is shown, not merely by his professional qualifications, but by the confidence he can impart to those under his care. It is an essential part of all successful medicine that the doctor radiates an aura of confidence, although how far I was able to do that, heaven only knows. The great hospital has the power to buoy up a man to an extent he never realises until he leaves and tries to tackle the problems on his own.
It is said that a new set of posts will need to be created to give greater responsibility to the housemen. These posts will be difficult to get, and an appropriate responsibility will be a difficult thing to devolve upon them. We all remember the "Hospital Sonnets" of W. E. Henley and his description of ward sisters, the new style and the old. "The Chief himself is half afraid of her." If the great Lister himself said that he was half afraid 2194 of them, how much more will it be said of graduates newly entering the hospital wards.
The power and authority of women, both inside and outside this House, we all know, but the power and authority of a woman who has had long professional experience is something terrific, and the support she gives to a man who thinks he may be going to make some mistake is impossible to exaggerate. I am sure that this extra year will need to be looked at with very great care, to make sure that a sense of responsibility is really developed and that it is not merely used as a further occasion for learning.
The Minister says that he is about to bring this Measure into operation on an appointed day, and that it may not be possible to bring it in simultaneously all over the country. In passing, may I say that I am not clear from the Bill, or from the Minister's explanations, what is the relation to the Republic of Ireland on this point. Is it possible for a graduate of the Republic of Ireland to come and practise in this country without any reciprocal requirements, that is to say, is it now necessary for a graduate of the Republic of Ireland to do a year in a hospital?
§ Lieut.-Colonel Elliot
I am glad to hear that, but I do not see it in the Bill, although perhaps the Minister can point it out to me during a later stage. If it is not so prescribed, then I think it will need to be prescribed.
§ Lieut.-Colonel Elliot
I quite understand that we cannot write anything into their law, but we can lay it down as a requirement for admission to the Register that those coming from outside shall not be subjected to less rigorous terms than doctors in this country. I think we can lay that down without any appearance 2195 of discrimination. It is simply part of the new system we are bringing in here.
The provisions for the operation of this new requirement will be difficult and will need to be carefully scrutinised. I trust that from time to time it will be possible for the Minister to inform us how they are progressing in regard to bringing these things into force. Apart from that, I am sure that all my hon. Friends welcome the Bill and will do their best to give it an easy passage.
Its purpose is to maintain and improve the standards of medical education in this country, purposes which all of us have very deeply at heart. The high standard of medical education, which transcends national boundaries, is very carefully guarded and is one of the glories of our country. We have maintained as high a medical education and professional conduct as anyone in the world. Admission to the Medical Register of this country is something highly prized in every country in the world.
I had the privilege during the Whitsun Recess of visiting one of the newest professional schools in the Empire, the new medical school that is coming into existence in Nigeria, the University College of Nigeria at Ibadan. An attempt is being made to bring into existence in the heart of Africa a professional school which will take men from entry to complete graduation, giving them an education which will enable them, forthwith, to enter the Medical Register of this country. That is a high ideal and something greatly prized by the students entering upon their courses. It is a school of the London University. The professional examinations are of the highest standard, and are supervised by external examiners coming from this country. It is to be in all respects fully equal to the education that can be gained in medical schools in this country. And so, we are legislating for them as well as for our own people.
Many people far and wide, will be intimately affected by what we do tonight. It is a great trust that we have to administer, and I am sure that we shall all set ourselves to the task of administering it wisely and well. For that reason, we are very glad the Bill has been brought forward, and we shall give it our close and sympathetic consideration during all its stages.
§ 8.10 p.m.
§ Dr. Morgan (Warrington)
I must oppose this Bill. I cannot be a hypocrite; I cannot get up in the House of Commons-with certain honest intentions, and then deliver a speech—nor can I listen to the speeches of other hon. Members—which I know to be not related to the true facts of the situation from the point of view of the reform of the General Medical Council, a question with which I have lived and which I have studied for nearly 40 years.
What are the chief functions of the General Medical Council, apart from the trivialities of deciding such things as whether there should be payment for a job, or considering antediluvian ideas of reform? There are three functions attached to the General Medical Council. First is that of the supervision of the British Pharmacopoeia—supervision of the dosages and preparation of drugs that are used in the course of treatment by physicians. We need not spend much time on that, because that is the one function of the General Medical Council which has been very well done—excellently done. No tribute can be too high for the men who have the supervision of treatment from that point of view.
The second function is medical education, and that is bad—very bad. There should be in this country a one-portal system of entering into the profession on one fixed standard, so that everybody—every medical man—who comes into the profession should pass a qualifying examination, and enter the profession through one door only, so that he can be recognised throughout Great Britain and the world as being of a certain standard.
Now we have different standards of examination. There are not only those of the great university schools. Again, one cannot pay too high a tribute to them. There are also the undemocratic bodies not of great concern to the public but only to themselves. Take the London Society of Apothecaries. Does the right hon. and gallant Gentleman the Member for Kelvingrove (Lieut.-Colonel Elliot) tell me that the L.S.A., as an independent society of apothecaries—as they were called in the old days, and as they are still called—should be entitled to have an examination of the lowest type—or, as I should not say the lowest type, of a minor type—to enter universities, by which a man may 2197 be qualified? Should there not be one fixed portal for medicine through which they should have to pass—one examination, one portal; and then, if a man wants to specialise, letting him do so by postgraduate courses? Surely that should be the way.
§ Surgeon Lieut.-Commander Bennett (Gosport and Fareham)
Does the hon. Member suggest that the Society of Apothecaries does not carry out its functions properly, or that the examinations are valueless?
§ Dr. Morgan
I say that the standard of medical education and of the knowledge asked for, is too low for qualification. In any case, that does not affect my first principle, that instead of having a variety of examinations there should be one governing professional qualifying examination, with an examiner—not examiners from the schools—to see that every man has a fair deal. It should be a non-judicial examination, although when I say "non-judicial" I do not mean non-medical. I mean that the entrants into the profession should be properly taught.
Many of these organisations, like the colleges, take no responsibility for training. They are purely examining bodies. I think that when we come to require a medical curriculum we should take note of the bodies which make no provision for medical education themselves, but are purely examining bodies, sometimes claiming revenue from those whom they deliberately flout.
§ Mr. Bevan
We are not, in this Bill, dealing with the medical curriculum at all. That is entirely outside the scope of the Bill. I am not saying that my hon. Friend is not perfectly entitled to make his point. With great respect, I think he is quite in order, but it is hardly a charge to be laid against me that I have not included, in a modest Bill, provisions for changes in the curriculum. Indeed. I am not quite certain that I have the statutory right so to do.
§ Dr. Morgan
I know the Minister may think I seem rash and hasty. Perhaps we could discuss these things outside afterwards. However, I think, with great respect, I am in order. I hope I will be 2198 left alone, because I feel very strongly about this. I know that the ordinary run of the profession are concerned about keeping up the dignity of the profession, but I feel very strongly on this point. One of the functions of the General Medical Council is the supervision of medical education, and it has the right to represent advice to the medical schools about what subjects should be included in the curriculum.
The Trades Union Congress is very keen on medical education. The T.U.C. wants the subject of industrial diseases, which is of great importance to the working class, taught in the medical schools. It maintains that if there is one subject in which tuition should be given throughout the whole of the medical curriculum, it is the subject of the relationship between occupation and health. The T.U.C., which, in an organised way, represents 5,500,000 workers, some in very difficult jobs, and jobs where grave risks are run of injury to health or limb—the T.U.C. says it would be of advantage to the workers of the country that it should be represented, and it has asked the General Medical Council to include this subject of the relationship between occupation and health in the ordinary curriculum.
What have the medical schools done? They simply did nothing. Indeed, in only three or four of them is there an organised course of lectures—Glasgow, Manchester, Durham and Newcastle-upon-Tyne—where the subject is excellently taught through qualified professors. In none of the others, however, is there any organised course of lectures. One specialist in London, Dr. Donald Hunter, is doing excellent work in the London Hospital, where he has taught the subject The other schools did not bother about it at all.
The General Medical Council should take its courage in its hands and have a democratic body which would not have a mere constitution of only a comparatively few elected members, with the rest nominated, or brought in by the universities. These are nominated members coming from different sources. One actually comes from the Ministry of Health. He is a medical officer of health now in the Ministry of Health. Why should an officer in the Ministry be put on the General Medical Council? Why 2199 should not other Departments be entitled to representation like this?
If the Ministry of Health can have one representative, why should not the Ministry of Labour and the Ministry of National Insurance be represented? They are concerned with medical matters from the point of view of industry and health in industry. Why should they not have one member each? I know Mr. Deputy-Speaker is looking at me, thinking I am not quite in order.
§ Dr. Morgan
That being so, I ask, from the point of view of the working class—and I appeal for support especially to Labour Members of this House—that some attention should be paid to this matter in the consideration of this Bill. It looks an innocent little Bill, but at the back of it there are great powers against the democratic administration of medicine in this country. Take the question of registration. At present, the medical course lasts six years. When a working man's son gets a scholarship his parents have to make great sacrifices for six years to get him through his school. It is now proposed to add another year. Why?
§ Dr. Morgan
He gets paid for the last year when he is working in a hospital, but how does he know he will get into a hospital? There are not sufficient institutions in the country to keep all the doctors that will come out. I am being interrupted in an attempt to put me off my guard. This is a quite deliberate act by certain people in the House who want to stop me talking on a subject which is of vital importance to the public.
§ Mr. Hastings
As a matter of personal explanation, I merely interrupted to correct what I thought was an inaccuracy by my hon. Friend.
§ Dr. Morgan
If I were guilty of as many inaccuracies as some consultants in some hospitals, including many with which I have been associated, although not the one with which I am associated now, I would keep quiet and say nothing 2200 about this. There is provisional registration on a qualified examination by any of these examining bodies after six years, and this Bill adds another year. A doctor who has been provisionally qualified and registered will have to wait for a year in an approved institution. Who will approve that institution? What evidence will be submitted for approval, and from where? There will be different standards and different types of institutions.
Suppose a man does not want to go into general or even consulting practice. Suppose he wants to be a specialist, or to go in for medical literature to become, perhaps, editor of the "British Medical Journal." Is he still to be forced to attend for another year before registration? Suppose he wants to go into medical research under the State, or in a university. Must he waste another year on a subject in which he is not interested? Suppose he decides to go in for tropical medicine and to become a specialist. What institution will he go to? There are three—it might even be four—two of which are in Liverpool and London. Does it not seem a little absurd, with, at present, no variation in the Bill, that those men who do not desire to do clinical work, either as consultants or general practitioners, should have to study a subject in which they are not interested for this extra year. Suppose a man wants to specialise in leprosy, and become a leprologist; suppose he does not want to stay in England but wants to go to India, or Nigeria, or South Africa, to follow his desires. Is that man to be asked to spend a year in a hospital handling cases in which he is not interested?
This is the weakness of the Bill we have before us today. During the passage of the National Health Act I heard even Members of the Government sometimes making statements in order to meet the Opposition—such as that hospitals like Guys were costing only £160,000 a year, though the latest accounts show that it will cost £1½ million. Before making statements of that kind we must get down to the real figures, and go into the real background to the Bill. I say that on the question of medical education there should be one system and standard; everything should be brought within this province, and we should decide so to amend the Bill.
2201 I should like the Bill to be taken back and re-considered. I suspected its origins in another place, and I now suspect them still more. This extended registration will hurt the working boy whose parents will have to keep him for another year. With regard to the British Pharmacopœia, on which we want the G.M.C. to have a stranglehold, and with regard to medical education, I say that this Bill is a rotten Bill; it is a Conservative Bill. The composition of the General Medical Council should include no nominee, or very few in comparison with the elected members. It should be a purely professional body with certain statutory duties to perform.
I am ashamed to say—and I hope the Government will pardon me for saying it—that this Government, with its particular political opinion, recognising the T.U.C. as the big organised body for industrial workers, has not yet approached the T.U.C. for its views on a matter of such importance to the workers, and particularly the industrial workers, on the question of medical education and conditions. Even now, the conditions in certain workshops are disgraceful. Let any hon. Member go into any firebox on our railways and see the conditions of heat, steam, temperature and pressure under which men have to work—men who, because the railways were deliberately kept out of the Factory Acts, have no facilities for keeping themselves in good health by cleaning themselves after their work.
It is things like that in the field of health to which this House should be devoting itself, and not passing trivial Bills which do not get to the bottom of the problem, which do not mean business, but which merely play for respectability in a superior-class way in a matter which affects the health of every working-man in the country.
§ 8.27 p.m.
§ Dr. Hill (Luton)
I shall perhaps be forgiven if I do not follow the hon. Member for Warrington (Dr. Morgan) in all his arguments and assertions, but I should like to comment briefly on his three main points. He argued, in the first place, that there should be a common portal of entry to the medical profession, ignoring the fact that the rôle of the 2202 General Medical Council is to secure a minimum standard, as applied by all licensing bodies, which are left to apply a standard in excess of the minimum standard if they so choose. High as is my regard for the university to which he and my right hon. and gallant Friend the Member for Kelvingrove (Lieut.-Colonel Elliot) belong, I, for one, as a graduate of a university on the plains of East Anglia, do not wish to see a levelling-up or a levelling-down of the qualification awarded by his university to reach the level of the one awarded by my own or any other university.
§ Dr. Hill
With his second point, on the rôle of industrial medicine in the medical curriculum, I have a great deal of sympathy, but on that he should address himself to that part of the Bill which strengthens the power of the General Medical Council in visting medical schools, and in so enabling the General Medical Council to exercise a stronger influence over those schools.
I believe his third point to be based on a misapprehension. If he is right, I share a good deal of his view. But I hope it is not right to assume that, as a result of this new and important arrangement, which I warmly welcome, under which there is first qualification and then registration, this is merely a year added to the curriculum. If he is right in assuming that, then I believe that the full purposes of this Bill will not be served in relation to medical education. I regard this as a most important change and as a most important feature of the Bill, and I welcome this arrangement under which at a certain stage towards the end of the student's career examinations are out of the way and the man or woman is enabled to assume a post of some responsibility under supervision; is enabled to have a full year, or part of a year, without the prospect of examinations looming ahead, and with such responsibility as can safely be given. I sincerely hope that is not planned as an additional year to the medical curriculum.
I hope that this Bill will lead to a reexamination of medical education. I hope that it will lead to the elimination of some of the unnecessary parts of medical education and to the integration, 2203 if I may use a laboured word, of medical education. I hope, too, that these new posts—and I am glad that the Minister used a relatively new word for this country "internship"—will be designed for the purpose; not house appointments, as we know them today, multiplied for the purpose of this year, but new posts created in relation to the function they have to fulfil in medical education. Indeed, it has been suggested in some quarters that a good way of spending this last year would be for provisionally registered medical practitioners attached to a hospital to be allotted patients on their coming to hospital for treatment and to follow those persons throughout the whole of their treatment back to their homes, with a measure of responsibility for that treatment.
The essence of the point that I want to make is that we shall get the full fruits of this important new development only if that year is related to a revised medical curriculum and special posts and the right kind of responsibility are created for the purpose. I am glad—and I am sure that the Minister will agree—that certain changes were made in another place to leave elbow-room to enable these requirements to be introduced in stages in relation to the number of posts which are created. It would be fantastic if in fact there were not sufficient posts or if there were a waiting period so as unduly to prolong registration. I regard this part of the Bill as of unusual importance and as affording an opportunity to the General Medical Council, which I believe they will take, to re-mould medical education and to secure the creation of the right kind of posts for this phase of responsibility.
The only other aspect of the Bill on which I should like to comment is that dealing with the disciplinary provisions. I am glad that discipline is to be a matter not for the Council as a whole but for a committee specially established for the purpose, because I think that will lead the Council to think more and more about medical education and save them having so much of their time taken up by disciplinary work. In Committee on this Bill there will be an opportunity to look at certain parts of the disciplinary machinery. I do not like the arrangement under which one committee of the Council—the penal cases committee—can 2204 decide whether there exists sufficient evidence to justify the investigation of a case. I do not like to think that any person involved in the original sorting out and assessment of cases may in fact be a member of the medical disciplinary committee.
§ Dr. Morgan
Why not let us say that a charge needs investigation and let there be a Clause in the Bill by which the whole thing is then referred to the Privy Council, who should appoint two judges with an independent chairman as assessors?
§ Dr. Hill
The difference between the hon. Gentleman and myself is that he detests this Bill and I like it very much. He prefers lawyers, and lawyers only, to deal with the disciplinary difficulties of doctors. I prefer these problems to be dealt with by doctors, with a lay element as is provided in the Bill.
There are other points which will be raised in Committee. I notice there is a minimum number of elected representatives to be on the committee of 19, which is the disciplinary committee. But there is no provision for any such minimum of elected representatives among the nine which will normally form the committee for hearing any case.
The last point I want to mention involves returning to the point that the hon. Member for Warrington made earlier, for it may lead to some confusion if it is left unanswered. He asked, what is to be the use of this year between provisional and full registration to a man who is going to be a medical journalist, or an expert on tropical diseases, or a surgeon or a physician. The answer is that that year is not merely something grafted on to part of the medical curriculum. It is a part of it. There is the further practical point that the expert on tropical diseases might get weary of tropical diseases. The medical journalist might get weary of his journalism and decide to enter into practice in one or other of its clinical forms. It would be wrong to have two standards for the care of patients, and he knows full well that many men who go into the field of research, change their minds and subsequently find themselves engaged in the medical care of patients.
I join with my right hon. and gallant Friend in welcoming this Bill, in welcoming the opportunity it presents for 2205 re-casting medical education, and in saying that, with such changes as may be thought wise to make in Committee, this is more than a modest contribution to medical education. It is a Bill of a modest size, but it seems to me that it makes a substantial qualitative contribution to medical education, which in the end will bear fruit in a raised standard of medical services, preventive and curative, for the people of this country.
§ 8.38 p.m.
§ Mrs. Jean Mann (Coatbridge and Airdrie)
I hesitate to intervene in a Debate of this kind, where I am surrounded by so many members of the medical profession. I would merely offer as an excuse for my intervention that I have provided quite a number of doctors from my own family, and have studied them very closely from their first year until they eventually took their Fellowship of the Royal College of Surgeons.
I want to speak on that part of the Bill that deals with the one year. I think it could be amended to give us something better. I deplore the fact that it is another year, because there are very few medical students who manage to get through their courses in orderly progression from year to year. Often the most brilliant student can be unlucky in the final, and, willy-nilly, have to wait for a further six months. The public fail to realise, I believe, that the faculty itself lays down a very high standard for entrants to study medicine. I have found, time and again, with at least three of my children that the ordinary school-leaving certificate, the highest, was not accepted by the faculty. The children had to sit again another examination either for physics or for mathematics or for something that the school certificate has excluded.
The right hon. and gallant Member for Kelvingrove (Lieut.-Colonel Elliot) said that the curriculum was overloaded and so, I believe, did the hon. Gentleman who has just sat down. I would like to ask any of the doctors here which part they would throw overboard, beginning at the first year. Would they cut down on physics, chemistry, biology, zoology or anatomy? The right hon. and gallant Member for Kelvingrove indicated that he would, yet it is recorded in the biography of Lord Lister that he took seven years, I think it was, for anatomy. And James 2206 Bridie the playwright, one of whose plays is "The Anatomist," also confesses to the years that it took to get his second professional anatomy and physiology. Surely neither of those could be dropped, or materia medica, or any of the clinical subjects that follow in the later years.
The curriculum may be overloaded, but the number of "ploughs" in the finals indicates that there is a curriculum overloaded that could very well be stretched out. There is the public aspect of this matter. The overloading from the public point of view at the moment is 4,000 patients per doctor. That is the overloading I would like to see something done in the Bill to help out with that situation. The proposals in the Bill will hinder rather than help. The Bill lays down—
§ Mrs. Mann
I am not sure that that is so, because at Question Time the Secretary of State for Scotland was asked by my hon. Friend the Member for Trades-ton (Mr. Rankin) whether he thought he could reduce this 4,000 to 3,800. [HON. MEMBERS: "As a maximum."] Well, as a maximum, but the Secretary of State for Scotland could not promise any particular date for reducing it. Even 3,800 as a maximum is far too many.
I want now to look at the six months that is proposed to be added for each medical graduate. Six months would be insufficient for a graduate who is to specialise. I do not know, from my own experience, any doctors who have not taken far more than these six months. It is not so necessary for those entering general practice. I speak from experience, from a very close experience, of watching the studies, indeed with my heart in my mouth watching the result of the examinations and then the development afterwards. Here is what I found. Those of my family who go in for specialisation, require more than six months in a hospital. They require perhaps 10 years. Others who are going in for general practice find that the six months is useless. They are clerks.
2207 Just take the set-up of a hospital. A young houseman or housewoman has to choose a ward. They probably reckon that general practice is as great a specialisation as anything, and I agree. The student has to serve six months in the ear, nose and throat ward. The doctor may have to serve his six months in orthopaedics, clinical medicines or clinical surgery just as a clerk, whereas the doctors outside are short of trainee assistants and are waiting for young men and women.
Why not amend the Bill and let the registration be not merely in a hospital but under a general practitioner? I know nothing better than that a young person should serve under the eager supervision of a man who has been serving the public as a general practitioner year in year out. I think the method is that the young doctor goes round to the patients one day and the old doctor goes round the next day. What a grand education that is for a young trainee.
Why not extend these provisions so that graduates in medicine who are going in for general practice may register provisionally with a doctor of experience in general practice? Otherwise, I think that the six months or a year as a houseman is just a waste of time and is not helping the general practitioners who are overloaded at the moment. I hope that the Clause will be re-examined and that the Bill will be amended during the Committee stage.
§ 8.47 p.m.
§ Mr. Fort (Clitheroe)
One of the reasons why it has been possible to give this Bill such an easy passage this evening is that we have been guided in so many of our thoughts by the improvements made in another place to the original Bill. The reason why someone who is not of the profession, like myself, wishes to speak, particularly on the clauses about medical training, is that those of us who have had training in technical fields similar to those in medicine often make comparisons between the training we had and that which our friends who are doctors have had.
It seems to me that one of the noticeable features of a doctor's training and his practice subsequently is that it is the most curious mixture of science and art. There is almost an art, based upon the judgment 2208 of a particular set of circumstances, in diagnosing the condition of each patient, and there is certainly science in so far as doctors are trained, like those of us who take chemistry, physics and biology, in measurement and in comparison and then can use those methods in diagnosis and treatment. Medicine never looks likely to become an exact science in the way that physics and chemistry are, and this parallel course of science and experience must therefore continue.
The purpose of the first six Clauses of the Bill will be to give a better opportunity to those who are training to be doctors to gain the experience which they must have if they are to face their patients with confidence, and, also, as most of us in the Chamber at the moment are patients, if we are to face the new doctors with confidence.
With regard to the question of medical students spending up to an extra year on gaining clinical experience in hospitals or health centres, there are certain practical features about which perhaps the Under Secretary of State for Scotland will give us further details? First, will it be possible for the hon. Lady to tell us what are the chances of there being enough space in the hospitals of England for all the house appointments envisaged first by the Goodenough Report and now by this Bill? Will it be possible to administer the extra year's planning so that the interns will be able to have 20 or 30 beds in conformity with the Goodenough recommendations?
Then there is the question raised in that Report of free board and lodging for the interns. In implementing the Measure, will provision be made for that, and if so, what sums of money are likely to be involved? Furthermore, will the hon. Lady be able to say anything about the rates of remuneration apart from saying, as was said in another place, that the rate for the job would be paid? These are important matters because we need to know whether we are talking about an improvement in medical education which will take place within the next two years or so, or whether we are looking forward to something which will only bear fruit within the next decade.
We are all grateful that, at long last, this Bill clears up the ambiguity about doctors trained in Ireland because we 2209 know that conditions would have been even worse than they are at present if we had not had the advantage of drawing on doctors from Ireland. It is because we on this side of the House think that the Bill is of great importance in medical education that all of us commend it on its way to Second Reading and will look forward to speeding it through its later stages.
§ 8.53 p.m.
§ Dr. Broughton (Batley and Morley)
This is a short Bill. My right hon. Friend the Minister of Health has described it as a modest Bill but, nevertheless, it is important. It is of considerable interest to members of the medical profession because of the effect it is intended to have on the doctors of the future. When I say that my opinion of it differs from that of my hon. Friend the Member for Warrington (Dr. Morgan) it will not be the first time that doctors have disagreed. I cannot share the views he holds on the need for uniformity, but I am sure that he and I are united in a sincere desire to improve medical services still further so that patients may receive the best treatment possible.
I welcome the Bill because it aims at raising the standards of medical efficiency and conduct. That part of it which relates to the General Medical Council and to its medical disciplinary committee I see as designed to maintain a high standard of ethics, and to be fair and just both to the profession and to the public.
The part of the Bill on which I wish to speak mainly is that which affects medical education by requiring proof of experience before the granting of full registration. The benefits to be derived from a period of post-graduate work under supervision in hospital are no recent discovery. We have known of them for a long time. Many of us did this in the past; more are doing it today. But there have been a number of doctors who have been denied that valuable experience by lack of funds.
Now that all intern post-graduate appointments carry with them remuneration, the financial obstacle has been removed from the path leading to greater proficiency, and I am sure that a period of service for every doctor will raise the standard of subsequent professional work. 2210 The Goodenough Committee, which examined the question, were firmly of the opinion that the period ought not to be less than 12 months. It might appear, therefore, that we seek to add yet another year to the course of medical training, as several hon. Members have already mentioned. That is only correct, however, in so far as it affects a minority of students, because the majority of newly qualified men and women have, in their desire to gain useful experience, already undertaken post-graduate studies in hospitals and the majority of medical students have the firm intention of doing so.
I was very pleased to hear my right hon. Friend the Minister of Health state that no injustice would be inflicted upon those students who are undergoing their course of training, who, for one reason or another, do not desire to have the year of post-graduate work in hospital and who began their medical duties on the understanding that they could qualify in six years.
The Bill may serve as a reminder that a course of training in medicine is a very long one, and that may lead, in turn, to a close examination of the medical curriculum. I was interested in the remarks of the right hon. and gallant Member for Kelvingrove (Lieut.-Colonel Elliot) and the hon. Member for Luton (Dr. Hill), because they showed that they have applied their minds to this problem. The views which they expressed briefly are views which I share. Indeed, I wish that the Government had gone further in the Bill, because I think that the system of medical education (requires review, revision and reform.
Medicine, like other sciences, does not remain stationary, and every time that a discovery is made the medical student is given additional knowledge to absorb. It takes at least six years to qualify in medicine. The Bill seeks to make compulsory a further period of training, probably a year. The whole course is one of intensive training, and is becoming more so. The medical curriculum must be examined and pruned.
When the Minister of Health, the General Medical Council and the examining bodies bring their minds to bear upon this problem I hope they will realise that a sound knowledge of medicine does not of itself make a good doctor. The 2211 expression "The family doctor" does not only mean the family's doctor, but also the family's friend and adviser on all manner of matters.
I regret very much that the universities have found it necessary to insist upon new entrants passing the first M.B. examination before admission, because it means that boys and girls have to begin the study of science in their early 'teens and to concentrate upon it alone for many years throughout the long and arduous course of medical training. I hope that the medical curriculum will soon be revised in such a manner as to allow the schoolboy to learn more about the arts, and possibly classics, before going to a university to embark upon years of intensive scientific study. I suggest this because I think that would provide the doctor with wider knowledge and make him still more capable of carrying the heavy burden of responsibility which is his when he enters practice.
This Bill is brought before Parliament for the purpose of improving medical training and increasing efficiency. I think it will do that. I see in its ultimate effect a better service for the patient, and for that reason I welcome it.
§ 9.1 p.m.
§ Surgeon Lieut.-Commander Reginald Bennett (Gosport and Fareham)
May I join with my right hon. and gallant Friend the Member for Kelvingrove (Lieut.-Colonel Elliot) and hon. Members opposite who have expressed their concern at the length of the curriculum and at the probable lengthening of it by this extra year of intern work? I cannot help feeling, however, with some confidence that a good deal of lopping is possible and that it can take place.
I can look back, not quite so far as some, upon the years I have spent in various ancillary occupations before ever I reached the clinical work of medicine, and I feel that many months of those years could have been better spent in getting ahead with medicine without prejudice to education or to one's maturity or judgment. I feel that the time spent in getting such an extremely minute knowledge of anatomy that a mass of mnemonics are required in order to carry it in one's head, is quite unnecessary, although it may be convenient to those 2212 who are to become surgeons in specialised fields.
I never found my studies of botany did me very much good in medicine. The sex life of the male fern did me no good whatever and when it came to the subject of zoology, although in my embryonic stage I resembled a dog-fish and therefore the anatomy of a dog-fish was good to learn, I cannot believe that it applied to the anatomy of the cockroach, which I had to learn in minute detail. There are many fields in which sweeping changes can be made to compensate for some of the lengthening that will be required. I had to pass an examination in divinity before I could pass my medical examination, but that did not help my clinical skill one jot or tittle.
§ Surgeon Lieut.-Commander Bennett
I hope we may have some assurance on this matter. Another thing which struck me is that I suppose that when we have these extra hospital posts there will be some kind of reduced status and responsibility' for interns below those of the normal house physician or house surgeon of today. Presumably these posts have considerable responsibility, or they would not be worth having, but they will not have the full responsibility of the fully qualified person; and the house-physicians and house-surgeons will be upgraded and some of their work downgraded to some of the intern postgraduate students. Can we expect that the intern will have responsibility extending to the signing of death certificates and other things which are open only to fully fledged medical practitioners?
§ Dr. Morgan
Once on the Register, he is entitled to sign death certificates, or birth certificates.
§ Dr. Morgan
I think the hon. and gallant Member is mistaken. He may be provisionally registered, but he is really legally registered and entitled to sign death certificates and birth certificates.
§ Surgeon Lieut.-Commander Bennett
I did not get that from a perusal of the Bill, but I am glad to find that desirable state of affairs.
There is another minor point which has occurred to me, although it is not perhaps a minor point to those concerned. The General Medical Council will be taking on the inspection of medical schools. I am sure that is a very good thing, but it has certain drawbacks in the case of some schools which are already highly organised within a university, because they can be inspected by their own university or the University Grants Committee. Are they to be liable to three forms of inspection? Furthermore, when the General Medical Council comes to inspect them, the Council, consisting as it does of members from other and possibly not even British medical schools, are the standards of those other schools to be brought to London or how are the standards to attain any homogeneity?
Another matter which has occurred to me is a rather grave affair about which I feel we shall perhaps hear more at a later stage. I refer to the question of the disciplinary powers and in particular the selection of the crime of adultery as the one type of civil case in which the General Medical Council disciplinary committee should not have power to call further evidence before pronouncing judgment on an erring doctor. I understand that criminal charges can be regarded as proved, the conviction being taken and action taken accordingly by the disciplinary committee of the General Medical Council. But adultery is a civil offence. Why when that is found proved in the divorce court, should that alone be selected as the one civil offence on which no further evidence can be offered to the General Medical Council before a decision is reached? That gives me some misgiving and I should like to hear more about it.
I would also refer to a further point affecting the graduating student. I cannot help feeling that in these days, when one's medical career and earnings are largely controlled by the State, it is a little hard on the student of all people to have to pay not only a registration fee but an increased one. He or she and his or her parents are probably the last people able to afford such moneys in these times. It 2214 is not an entrance fee to a free-for-all as it may have been in the past. This is a profession in which the earnings are to be limited, and at a time of the student's career when parents are groaning under the financial oppression, I would ask if it might not be possible for the severity of that fee to be eased.
I wish my welcome to this Bill to be added to all the others, and I feel sure that in it we have reached a milestone in medical practice.
§ 9.8 p.m.
§ Mr. Somerville Hastings (Barking)
Although in some respects this Bill does not go as far as I should have liked, I welcome it because it makes the education of British doctors, already the most practical in the world, even more practical. I have seen medical work in many countries in Europe on both sides of the Iron Curtain, and I am convinced that we have in this country the best general practitioners, the most widely knowledgeable doctors in Europe. The reason for that is because our education is already perhaps more practical than that of any other country. We depend less on lectures and demonstration and more upon practical examination and care of patients.
As I see it, the trouble today is that there is too sharp a division between the time when as a medical student the young doctor has very few responsibilities, and never has to make decisions, and the time when he suddenly becomes qualified and then finds that the life and death of his patients depend upon his diagnosis and sometimes even upon his treatment. I think that hon. Members of this House who are also members of the medical profession will agree that the most anxious and exacting time of their lives was not when they were waiting to make their maiden speeches, but when they first went into practice alone. I remember very well when, many years ago, without having taken an appointment at my hospital, having to wait some four months, I went into general practice as assistant to a doctor in North London, with, of course, much trepidation. But my anxiety was tremendously increased when, a few weeks after I had started, my principal suddenly announced that he proposed to take a week's holiday. I said, "What shall I do? May I call in the doctor opposite if I get into difficulties?" 2215 This was a good many years ago, before the National Health Service Act, when practice was purely competitive. He said, "No." I think he went so far as to say, "My dear idiot, that is the one thing you must not do." And so I was left alone.
I feel that the Bill is a very good thing in that it makes the division between irresponsibility and responsibility gradual. I do not believe in too early specialisation. My hon. Friend the Member for Warrington (Dr. Morgan) suggested that a man might be wanting to specialise in leprosy and the care of lepers; he asked why he should take appointments in medicine in surgery. Clearly, the answer is that his patients who are lepers may suffer from medical and surgical conditions in addition to leprosy and they may require his advice accordingly.
While I accept completely the general principles of the Bill, I feel that between now and the Report stage careful thought will have to be given as to how they can be carried out. I cannot see that there is enough suitable appointments for interns to go round. There are some hospitals where the young doctor will learn, mainly, what not to do. There are other hospitals, teaching hospitals, where the physician or surgeon has drawn to him cases of a special type, and these he treats, usually by operations. Such cases may be relatively rare and though of great importance may be such that a young doctor who goes into practice may not be likely to meet many of them. Therefore, although such appointments will be very valuable for the training of specialists, I do not think they will be of much value for the general practitioner.
There are difficulties in deciding whether a young doctor's work is satisfactory and there are difficulties in the case of a physically handicapped person. What about the man who has lost the whole, or part, of his hand? He certainly cannot be an efficient house surgeon, or indeed in my opinion take an appointment as an obstretrician. Yet the Bill says that he has to serve part of his time in one of these capacities. I should like to know what is to happen to such a person. We are told, and very rightly, that service in a health centre would do just as well as service in a hospital, and I am glad of that. But at present the health centres do not exist. Moreover, 2216 while I agree that to help an efficient doctor in a health centre would be most valuable training for a general practitioner, I feel that service in a special department in a health centre should only count as training for a specialist.
There are two other points I wish to discuss. I am disappointed about the constitution of the General Medical Council. It has been recognised generally that it is safe to leave the conduct of most professions mainly in the hands of members of those professions. I do not think that the public have any cause to regret that policy. We passed in this House only a couple of years ago the Nurses Act which reorganised the General Nursing Council which deals with the education of nurses as well as the conditions of service in that profession. There we provided for 34 members, of which 17 are being elected by the nurses. Here we have the General Medical Council which the Minister has told us is to consist of 47 members, of whom only 11 are to be elected by the profession. Are doctors less responsible than nurses?
Lastly, there is the disciplinary procedure. I agree that the Bill provides for a great improvement. The right of appeal is a great advantage to doctors. But I am not quite satisfied. I should like there to be some less penalty than that of being struck off the Register. According to this Bill, if the disciplinary committee decide that a doctor must be struck off the Register for some dishonourable or undesirable conduct, the doctor cannot apply for replacement for 11 months. By that time any doctor's practice will have gone to pieces. This will mean that the doctor will have to start again and probably, with his record, he may have considerable difficulty in rehabilitating himself in the profession. Careful consideration should be given to discover whether some lesser penalty should be introduced. In spite of these weaknesses, which, I hope, will be put right on the Committee stage, I strongly commend the Bill to the House.
§ 9.19 p.m.
§ Dr. Barnett Stross (Stoke-on-Trent, Central)
I find myself in agreement with the majority of those who have welcomed this Bill although it is indeed a small, modest and unassuming Measure which does not pretend to go very far. There is nothing particularly handicapping 2217 in life about modesty. Lots of folk have shown that they can do very well even though they are somewhat small or petite, as I am sure the hon. Lady the Joint Under-Secretary of State for Scotland will agree.
The Bill has caused some anxiety to the hon. Member for Warrington (Dr. Morgan). I wondered whether he was right in denigrating and blaming it because there is not contained in it the power to compel each and every medical school to set up a chair in industrial medicine. I would have thought that every university and every medical school in the country would readily and gladly set up a chair in industrial medicine, and indeed in social medicine, too, if they had the money available, and what we have to do is to discover some way of finding the financial assistance for universities, and then we might impose the means upon them. That is a suggestion which I offer to my hon. Friend as a friend and colleague, and I hope he will consider it in that way.
It has been said that this Bill consists of two parts, educational and penal, and I quite agree that, broadly, it does fall into these two divisions. We have heard quite a lot of the qualities that will make a man into a good general practitioner, and much has been said about his capacity for accepting responsibility. Of course, I agree that this is a touchstone, but there is such a thing as having a sense of vocation, which is just as important. I remember that, when I was associated with a surgeon in my medical school days, his attitude was that three things, and only three, were needed if one was to be a good surgeon, or indeed a good medical man. One must have a sense of vocation, the heart of a lion and the hand of a lady, and I think that is obviously correct.
Without a sense of vocation, no one will accept fully the sense of responsibility in work of this type, where life and death are at stake. No one, without a sense of vocation, will put in the number of hours which only Members of Parliament and members of the medical profession are prepared to put in. Without the heart of a lion, one may shrink at times from responsibility without the umbrella and the cover of the senior man. But that is a point which has been already adequately covered by my hon. Friend 2218 who has just spoken. Without the hand of a lady, one cannot be sensitive enough to understand that the pain and suffering of the patient belongs also to oneself. Without the hand of a lady, one would not be worthy of the name of doctor.
There are certain other questions which we shall want to ask during the Committee stage, but this is not the time to discuss them at any length, and I think they can safely be left to the next stage of the Bill. There are, however, certain aspects that disturb some of us. In spite of the suggestion that there is to be a year's extra work before full qualification, the word "satisfactory" is used, and we shall want to know what is meant by "satisfactory." We would also like to know whether, if certain men and women during their training are injured or crippled, or if they fall ill, possibly with infantile paralysis, they are to be denied any opportunity of further work or of service with approved institutions. We shall want to know how long they may have to wait, and, if by any chance there are no immediate opportunities for entry, we shall want to know how long it will be before they may register. But all these are matters which we can leave to the Committee stage.
On the penal side of the Bill, I welcome the matters that are there dealt with and which fall apparently into two simple improvements. One is that there is now a court of appeal. The work of the G.M.C. in its penal aspect more closely resembles a court-martial than a court of law, and I am glad to see it suggested that, if the court-martial type is to remain, it will be improved. At any rate, the court will be smaller, and will handle cases better, in addition to which there will be greater representation by elected representatives of the profession.
The right of appeal is another and even more important change which we find here, and we are all very glad about it. Here again, on the penal aspect, there are certain changes which we hope to bring about by Amendments during the Committee stage. We must separate the judicial from the executive functions of the Council, so far as the procedure of the disciplinary committee is concerned. Let us be certain, too, that no one who has been concerned with a preliminary investigation shall sit later upon the disciplinary committee itself. It would not 2219 be reasonable for anyone who has sifted the cases to say, "I recommend this one as suitable to put before a disciplinary committee." No one who has been in that position should then sit on the disciplinary committee to give judgment on the case. There is a difference between discrimination and—I was going to say execution—judgment.
Lastly, I hope we shall be able in future to see that no action is taken against a medical man unless a formal and written complaint is sent in and can be supported by whoever has made it. I remember the first time that I ever went to Venice and looked into the lion's mouth. Some medical men have to look into the lion's mouth, the mouth that sometimes has anonymous documents dropped into it, in the same way as they used to be dropped into the mouth of the lion at Venice when people wished to inform anonymously against someone. I think that anyone who informs against a medical man or woman should be asked to support his complaint by a written document and should be called upon, if necessary, to appear to substantiate it.
§ Dr. Stross
At any rate, I think that would be some improvement on the situation which has existed up to now.
§ Dr. Morgan
I am thinking of the Hennessey case in which the charge was made by the complainant in writing, and the G.M.C. struck him off. Yet when Dr. and Mrs. Hennessey were, very wisely, advised to take an action against the complainant, they won, and the judge begged the G.M.C. not to be so silly.
§ Dr. Stross
That is what I have been discussing. It has been unsatisfactory, and we want to see an improvement in the future.
May I say again that, so far as it goes, this Bill is very welcome to all of us. Even if it does not go far enough, we shall do our best on the Committee stage, and it may not be the end even then.
§ 9.29 p.m.
§ Mr. Linstead (Putney)
At the end of this very interesting Debate there really remains very little to be said. Nevertheless, there are one or two speeches 2220 upon which I desire to comment very briefly. I think that someone during the Debate might have seized the opportunity to pay a tribute to the General Medical Council for the work they have done in the educational and disciplinary fields over a very long period of years, and in conditions of some difficulty. I have attended sessions of the General Medical Council sitting in its disciplinary capacity, and I have been amazed at the way in which an extremely clumsy machine managed to function with what certainly appeared to an onlooker to be efficiency and justice. It was not the quality of the Council which was at fault, but the difficulty of the appeal which tended, perhaps, to give it a bad name.
I think that in Committee we shall have to examine a little more carefully the full implications of this extra year or extra six months. There seems to be a certain amount of misunderstanding among members of the medical profession and Members of this House. The hon. Lady the Member for Coatbridge and Airdrie (Mrs. Mann) seemed to consider it would be no more than a repetition of the house posts, and to contemplate that one of those duly qualified men in the future might go straight away to a speciality for his six months. That, I take it, is quite remote from the intention in having this period. One assumes that a completely new type of post is to be created in hospitals, which will enable the young, duly qualified man to move rapidly round among different departments and to get a bird's eye view of the profession; and that it will be a period not of specialists but of general training.
I sympathise with the hon. Member who discussed the question of overloading and undue specialisation. It is something from which every profession is suffering. I feel that there is no simple answer. We cannot cut out of the curriculum of a scientific profession—and medicine, after all, is a scientific profession—any substantial amount of its basic science. As science advances so the medical practitioner, as do the specialists, must keep pace with it, and if there is to be found any answer it can be partly, I think, in the direction of the qualified practitioner relying upon specialists in other branches in professions allied to medicine for a great deal of the technical work which at present he 2221 does himself. The radiographer and the physiotherapist, for example, must have responsibility upon their shoulders. Moreover, in the teaching of the sciences more attention must be paid to making them a part of a liberal education. We dare not substitute the arts for science, because science is a necessity in the training of medical students. So, the answer is to be found in the method of training, and I believe that a scientific education can be a liberal education just as much as an education in the arts.
There is a very large number of minor points which we shall be able to deal with in Committee. I am not quite certain that we have got this situation with regard to the Irish curriculum quite clear. As I understand it, it is this: if Ireland imposes the same period as we do, then the two countries will march in step. What we are not quite clear about is the situation which arises if we impose it and the Republic of Ireland does not impose it at the same time, and I expect the Under-Secretary will be able to tell us that there is an arrangement between the two Governments for the two things to be done at the same time. If so, the difficulty disappears.
Some consideration will have to be given to the conditions in which health centres are to be approved for this period of a year's training. There are about a dozen health centres in existence at the present time, and I should think that only one of them at present is fit for the training of general practitioners. Therefore, the Minister of Health will have to turn his attention to the standards very carefully. That we shall have to look at in Committee. I think also we shall want to look at the disciplinary machine a little bit more closely. Like my hon. Friend the Member for Luton (Dr. Hill), I am a little concerned about the position of the penal cases committee. I think that no member of the General Medical Council can at the same time be a member of the penal cases or disciplinary committees. I think that is clear. We must also be careful that the penal cases committee does not assume to itself part of the function of the disciplinary committee. By being the first sieve, it should sift out a number of cases which really ought to go on to the disciplinary committee to be determined.
2222 I also hope that the Minister will have another look at the point we raised, about a finding of fact in a case involving adultery in a matrimonial cause being binding on the Council, but no other finding of fact of the High Court in a civil case, and no other finding of the High Court in a civil case which may involve adultery in some other type of action than a matrimonial cause. It seems to me very curious that that one particular and very limited example should have been chosen for binding the General Medical Council in acceptance of facts and the hearing of further evidence. I am sure that wants looking at again.
§ Dr. Stross
Does the hon. Gentleman not agree that there is a difference in these cases, and that in effect the Council would constitute itself into an appeal court in certain types of divorce case if it were not to accept the facts as proved?
§ Mr. Linstead
I realise the argument, but I do not think we have time to go into it now. I am only saying that if a finding of the High Court in one particular type of case is to be accepted as binding, then one wants to look very carefully to find why a similar state of affairs is not to apply in other cases.
There are only three other matters to which I want to refer, and to all of them quite briefly. Personally, I welcome the introduction, for the first time in this type of legislation, of the Judicial Committee of the Privy Council. Hitherto the High Court has been the court of appeal from the professional tribunals. Owing to constitutional changes in the Dominions, the status of the Judicial Committee of the Privy Council is obviously changing, and it may be a very happy innovation here to give to the Judicial Committee of the Privy Council a new type of jurisdiction. Most of the professions value their association with the Privy Council, and if we can gradually substitute the Judicial Committee for the High Court as the court of appeal for professional tribunals we may find that we have introduced a very useful innovation into our legal system.
My hon. and gallant Friend the Member for Gosport and Fareham (Surgeon Lieut.-Commander Bennett) drew attention to a difficulty that may arise in connection with overlapping inspections by the University Grants Committee, the General Medical Council and the parent 2223 university itself. For some years now I have served as an inspector for the Pharmaceutical Society when inspecting schools and universities jointly with the University of London, and we have found no difficulty in so arranging those inspections that, although two bodies were concerned, the reports were unanimous and both bodies acted in step, one with the other. I am sure that can be done.
My last point is a rather specialised one that has not yet been dealt with in this Debate, except by the hon. Member for Warrington (Dr. Morgan), when he said that the one function of the General Medical Council that is well done is the supervision of the British Pharmacopoeia. Curiously enough, that is one of its functions which the General Medical Council does not perform, but hands over to someone else to perform. Had the hon. Member for Warrington realised that, his condemnation of the G.M.C. would have been complete and absolute, and I am glad to make that little present to him.
§ Mr. Linstead
Originally, in 1858, the British Pharmacopoeia was a book of compounded medicines primarily. As the years have passed it has changed and become a book of simple substances and chemicals which are used as ingredients of medicine. As the years have passed it has become not a book for doctors, but a book for manufacturing chemists and public analysts, and I think that very few general practitioners will find it necessary to refer to the British Pharmacopoeia. The General Medical Council were, originally, quite an appropriate body to supervise the production of this book, but with the passage of years they have ceased to be the appropriate body and have handed the duty over to the Pharmacopoeia Commission, composed of one or two doctors, but mainly of chemists and pharmacists.
I hope that the Under-Secretary of State for Scotland will be able to assure us that we are not crystallising by the chance reference to the British Pharmacopoeia in this Bill the existing method of producing the Pharmacopoeia which is by no means suitable in all quarters. I sincerely hope that the Bill will have a Second Reading, and that we may make what little improvements are necessary in Committee.
§ 9.41 p.m.
§ The Joint Under-Secretary of State for Scotland (Miss Herbison)
It has been a very pleasant and agreeable Debate. The last two-and-a-half hours in the House have been very different from those that went before. I think that with only one exception this Bill has received acceptance from both sides of the House. There has been much criticism of the overloading of the curriculum in the medical schools, and I feel that the Debate may bear some fruit in that matter. I am certain that those who have discussed it did so from a very full knowledge and from their own experience, and I hope there will be some examination of the curriculum.
I should like to take up the points made by the hon. Member for Warrington (Dr. Morgan). He said that there ought to be a power of direction, possibly vested in the General Medical Council, to direct universities and medical schools as to what should be taught in them; and he referred particularly to the teaching of industrial medicine. I am sure that everyone in the House agrees that industrial medicine is of the greatest importance. The Trades Union Congress are seriously considering this matter and they feel that sufficient time is not given to it, but I think that the hon. Member for Warrington was a little less than fair when he suggested that in our medical schools and universities almost nothing was being done in the field of industrial medicine. We find that in the Universities of Glasgow, Manchester and Newcastle there are departments of industrial medicine.
§ Miss Herbison
I listened very carefully to the hon. Gentleman, and I am going to follow on with what else is being done. I was particularly interested in the point made on this matter by the hon. Member for Stoke-on-Trent, Central (Dr. Stross) when he suggested that one of the great difficulties was the lack of finance. The three universities that I have mentioned have been provided for in these courses of industrial medicine by the Nuffield Foundation. In addition to the three departments mentioned by the hon. Member for Warrington, it is known that there are one or more lecturers in industrial medicine, industrial health or industrial hygiene in Birmingham 2225 Bristol, Edinburgh, London and Sheffield. We do not say at this point that we are satisfied with that as sufficient, but what we are absolutely satisfied about is that the correct way of getting either industrial medicine or any other subject into the curriculum is not by vesting power of direction in the General Medical Council. That would be a very serious matter indeed, and one which, I am certain, not only the medical profession would object to, but also people all over the country.
There may be one way of overcoming this difficulty. Quite a number of questions have been raised in this Debate about the duplication of visitation. In another place this was discussed and we hope an arrangement will be come to by which there will be, in effect, only one set of visitors. Great improvement is made in the provisions of this Bill by which visitors not merely examine an examination, but really examine what is being taught in the medical schools. We would hope that in that way the General Medical Council will be able by persuasion, not by force, to make those changes in the curriculum which public opinion seems to think necessary.
Another point was raised by the hon. Member for Warrington with which I must deal. He seems to take grave objection to this year which we term the intern period. Other Members have dealt with some of the points he made. He made a very strong point that this would be very hard on the young student from a working-class home. That may have been the case some years ago. I am speaking for Scotland now and perhaps not for England and Wales, but in Scotland today the young man or woman coming from a working-class home is able, with help particularly from local authorities, to take the whole course for a medical degree without costing his parents one penny of finance. That is an important point to remember when weighing this year against the difficulties that may be entailed. We have also to remember that during this intern year the young doctor will be receiving a salary.
A number of points were raised by the hon. and gallant Member for Gosport and Fareham (Surgeon Lieut.-Commander Bennett). I have dealt with one of them—the examinations, where we hope that by arrangement there will be one pretty 2226 big visitation. He wanted to know whether the doctor when provisionally on the register can sign a death certificate. He can. He also wanted to know—and this was also raised by the hon. Member for Putney (Mr. Linstead) who wound up for the Opposition—why there had been selected in the Bill one single case in which the disciplinary committee could not re-examine the evidence. I think the answer was given from this side of the House on that matter; it is that it would create very great difficulties if provision was not made for this kind of case. On the other hand, it may be that after examination we may decide that other cases ought to be put into the same category as this one which we have chosen. This one was chosen because it is the one which in the past has most often come before the General Medical Council.
My hon. Friend the Member for Coatbridge and Airdrie (Mrs. Mann) seemed also to think that this period of a year's intern service was not a good thing. Indeed, she had grave doubts about it, and wanted to know if this year could be spent in general practice as a trainee assistant. This would be completely contrary to the findings of the Goodenough Report, which strongly recommended this intern period. It would also be contrary to the views that have been expressed by the General Medical Council.
We find in our Empire countries, in New South Wales and in South Africa, and I believe also in the United States of America, that the intern period is done in hospitals or in similar institutions. For these reasons we feel that the provision in the Bill is correct. We feel that the best experience can be got in hospitals and in similar institutions, and that if we were to yield to the suggestion that this period might be in general practice there would be very great difficulty indeed over proper supervision. What we would suggest is that it would be much preferable to wait and find what will be the results of the working of the provisions of the Bill before we make any further extension for experience in general practice among doctors. Indeed, I would say that the majority of doctors have had their first year, or two years or even more, as trainee assistants with other doctors.
2227 The hon. Member for Stoke-on-Trent, Central (Dr. Stross), and I think an hon. Member on the other side, were rather afraid that those who served on the penal cases committee would be serving also on the disciplinary committee. They suggested that that would be completely wrong. What we find in other fields does not bear out the contention that it is wrong. There is nothing in other fields to justify the contention that a man's judgment will be prejudiced if he tries in the first instance to find whether there is a primâ facie case for inquiry. If we take the solicitors' committee, we find that they first seek to find whether there is a primâ facie case. Then that same committee go on to hear it. There is another instance among the justices of the peace in England. When they have committed a case for trial at the quarter sessions, they can, and very often do, sit at the quarter sessions. In the case of the solicitors or of the justices of the peace, I do not think it can be contended that they have shown in the past that they are prejudiced; but this is a point that may be worth discussion in Committee.
Quite a number of questions have been asked about the supply of posts. Will it be possible in the near future to begin to make compulsory this one year of intern training? There was much discussion on this question in another place, where the figure of 12 months was taken out. We are still leaving it at 12 months, but we cannot at this stage say how soon we can make the figure work. We decided that it was important to have on the Statute Book power to make preparation. We have gone into the figures. There may in Scotland be more difficulty than in England and Wales because in Scotland we train a third of the doctors produced in the whole of the British Isles. In going into that position, we have come to the conclusion that we may not be able to provide the full number of places in Scotland, and that perhaps England will provide the beds for these other doctors whom we train.
A question has been asked about Ireland and what will really be the position of Ireland. A doctor qualifying in the Republic who wants to get on the Register—that is the important point—must from an appointed day do intern service in the same way as a doctor 2228 qualifying here. That is under Clause 1 (1, a). I hope that makes it clear to those who were in difficulty about this position.
Many other points have been raised, but again, I am certain that they can be brought up during the Committee stage, and I recommend that the Bill be given its Second Reading tonight. There is, however, one point which was raised by the hon. Member for Putney, who was a bit worried that we were laying down for all time what will be the composition of the body which prepares the British Pharmacopoeia. No Act can ever do anything for all time, and all we are doing in Clause 22 is to make adjustments which have been rendered necessary by the progress of science; there is a great deal of obsolete language in the Pharmacopoeia, and the adjustments will also meet practical difficulties. That is all that Clause 22 does in this matter. I again commend the Bill to the House.
§ Mr. Linstead
Before the hon. Lady sits down, may I ask did I understand her to say that the arrangements for producing the Pharmacopoeia have not been re-examined from the bottom and approved, so to speak, in 1950 by the Minister?
§ Miss Herbison
No, Sir. I give the assurance that it was only for the two reasons which I have given.
§ Bill accordingly read a Second time.
§ Committed to a Committee of the whole House for Tomorrow.—[Mr. Sparks.]