HC Deb 19 November 1952 vol 507 cc1958-83

7.49 p.m.

The Minister of Health (Mr. Iain Macleod)

I beg to move, That the Draft Medical Act, 1950 (Period of Employment as House Officers) Regulations Approval Order of Council, 1952, a copy of which was laid before this House on 18th July, 1952, in the last Session of Parliament, be approved. A period of compulsory hospital service for newly-qualified doctors, called at the time the intern period, was one of the major features of the Medical Act, 1950. In particular, the General Medical Council were empowered to prescribe, subject to the Privy Council and to an affirmative Resolution of both Houses, what that period should be.

I think that it is fair to say that the Act itself, when it went through the House, was non-controversial. I do not think that this is the time, nor indeed do I think that there is a need, to stress the arguments for pre-registration as such. I think the House will be agreed, as it certainly was two years ago. But perhaps I might indicate in one sentence on this very narrow Order that the purpose, of course, is to improve the value of medical training and thereby the standard of medical services.

This draft Order for which I am asking approval is made under the Act by the General Medical Council and lays down that the period of pre-registered service, as it is now called, shall be 12 months. It is planned that during that 12 months, the doctor, having passed the qualifying examinations and being provisionally registered, will be required to perform satisfactory service before becoming fully registered.

The only other matters which I should add on this question of the 12-month period are to point out that the Inter-Departmental Committee on Medical Schools, commonly called the Good-enough Committee, did in fact recommend this very period which I am asking the House to approve. Indeed, the Medical Act, 1950, when first introduced, included the provision that there should be a 12-month period. A subsequent Amendment deleted that and left the period to be fixed by the General Medical Council, subject to the safeguards of the Privy Council and Parliament which I have indicated. I think it fair to say that the Amendment was not because there was any difference of opinion about what the time should be, but just so that it should be possible for there to be a variation in the case of any national emergency, or unforeseen circumstance which might arise.

I should also inform the House that, so far as we know, we have had no official objections to the period being 12 months. The General Medical Council, which has the primary responsibility in this matter, has on it representatives of every licensing body which confers medical qualifications. It has representatives from the medical profession, and it has two Members of this House of Commons. All the appropriate official organisations have been consulted and, as I say, we have had no objections to this period of 12 months.

I might add that the appointed day under the Order in Council—which is not strictly debatable, and is certainly not before the House at the moment—is 1st January, 1953. While that Order is, of course, not the subject of this debate, perhaps I might be allowed to add that that date was also decided in agreement between the General Medical Council, and after similar consultation with all the organisations concerned. It seems to me clear that the period of 12 months is the right one, and the object that lies behind it is also right, and I commend this Order to the House.

7.55 p.m.

Mr. A. Blenkinsop (Newcastle-upon-Tyne, East)

We are grateful to the right hon. Gentleman for giving us some short introductory remarks about the Order we are being asked to approve. He is right in saying that there is no sort of division of opinion about the desirability of the main objects, but it is fortunate that we should come to it at such a relatively early hour, because there are one or two quite important issues arising out of it which it is essential that the House should consider.

Indeed, I am fortified in that view by the fact that when the Bill upon which this Order is based was going through the House it was the right hon. and gallant Member for Kelvingrove (Lieut.-Colonel Elliot) who at that time urged that it should be possible for the House to consider some of the problems lying behind this Order in some detail when it was introduced. It was then pointed out, quite appropriately, that it would not be right at that stage to go into any very great detail about the form in which the Bill was passed at that time. But there was a general feeling that clearly the House would want to consider some of the factors giving rise to the decision as to the date and period of operation when this Order came before the House.

Mr. Macleod

I think the hon. Gentleman ought to complete the story. It is true that I and my right hon. and gallant Friend urged that this debate in which we are engaged tonight should go wider. But the hon. Gentleman who was the Parliamentary Secretary at that time, and his Minister, the right hon. Gentleman the Member for Ebbw Vale (Mr. Bevan), did not see eye to eye with us; and it seems to me difficult for the hon. Member to argue now that we should go back to a suggestion made and rejected two years ago.

Mr. Blenkinsop

Is it not strange? Here am I trying to be as friendly and conciliatory as possible, and we have an attempt made by the right hon. Gentleman to raise all sorts of political hares.

But, quite seriously, the proposal put forward at that time did seem to suggest a very detailed consideration indeed at this stage, and I think that my right hon. Friend the Member for Ebbw Vale, who was then Minister of Health, quite rightly resisted that suggestion. But that did not at all rule out the possibility of a proper discussion of matters lying behind this Order, and the choice of the date and the period; and it is on that matter that I wish to say a few words. I am sure some of my hon. Friends will also wish to say something.

This Order does herald a very important new step. Although it is perfectly true that the intern-ship, or the pre-registered service period, has been in operation in other countries, it is new in this country; and it would be quite wrong if it were to be introduced without some further consideration by the House of the importance of it and the preparations which have been made for it, because it is upon that no doubt that the date turns. We are asked to say whether we are satisfied, first, that a year is the proper period and, second, whether it should, or could, properly start on 1st January of next year.

In making this decision the House should remember, as indeed the right hon. Gentleman pointed out, that the recommendation for this period of one year's further training—if one cares to call it that—was based on the recommendation of the Goodenough Committee. But they made it to some extent conditional on other matters raised when the Bill was going through the House and which are very pertinent to our consideration of the time and date of operation today.

For example, they were concerned that when this Measure came into operation it should be possible to ensure that a full use of this period of one year could be made by those responsible for the carrying out of the training and those who will, if the House likes, have imposed upon them—because that is no doubt what some students may feel—this extra year before they are able to take part in active practice.

One point which the Goodenough Committee made at that time, and referred to by several of the right hon. Gentleman's hon. Friends when the matter was earlier discussed, was that at the same time as this proposal for the intern year was introduced it should be possible to have another look at the period of actual medical training, so that we should not be imposing too severe an extra strain upon the student. They made a recommendation that the period of training should be no more than four-and-a-half years.

It is proper for us to ask the Minister, now that some years have passed since the passage of the 1950 Act upon which this scheme is based, whether any progress has been made in having another look at the period of time for qualification, because, as we all recognise, it is a desperately long period. It is rather a serious matter which troubles many of those responsible for the operation of this proposal. It is a serious matter that more and more time is added to the period of student-ship and training, so that the student or the fully fledged doctor grows older and older before he is able to take part in active practice. That is an important point at which we should look again, and I should be glad to hear whether in fact there has been any reconsideration of the period of qualification and whether any experimental steps or any action at all has been taken to review some of the items in the curricula in order to try to get the period down to the Goodenough Committee's recommendation—four-anda-half years.

Another point which we must consider is whether the country as a whole is ready for the operation of this proposal. On balance, I think the Minister is right—or rather, perhaps, I should say the General Medical Council is right—to say that we cannot start the operation of this scheme at different times in different parts of the country. It was suggested by some that it might well be necessary to do that; it was suggested that in some parts of the country they would be ready to introduce the scheme, while in other parts of the country they would not. I well remember my right hon. Friend at that time stating that he could not see how we could operate the scheme piece-meal in that way and that it had to come into force at the same time throughout the country. I am glad, on the whole, that that view has been accepted, although there is a power to introduce different times for different parts of the country.

To my mind, the Minister is right in taking that decision, but it makes it all the more important that we should decide whether or not we are ready to introduce the scheme. While it is true that the main responsibility for the decision falls upon the General Medical Council, I do not think it would be right for the House to let the matter go without making some inquiry into the provisions which have been made to ensure that the best possible use is made of this period.

For example, is the Minister satisfied that suitable posts are available for all those who will be coming out of their training and who will need to have posts found for them for this period? Let us remember that we hoped that those posts would not merely be a continuance of the old house officer appointments. It was felt that something rather more than that was needed and that it should be possible for the interns, to use that relatively simple word, to move around in the hospital and get a valuable extra training in addition to that which he has had during the six years he has already been in the hospital. We need to know whether the Minister is satisfied on that point.

Clearly the position must vary from one part of the country to another. I know that in the part of the country to which I belong the position is relatively simple, because the number of those coming out of training, who will need posts found for them, is relatively small. I do not think there will be any great difficulty in finding appointments for them. But I understand that the position in other parts of the country is by no means as simple, and we need some assurance on the point, all the more because we understand—and here I should like the Minister's views—that discussions are going on at the present time both with the teaching hospitals and the regional hospital boards about the possible freezing of staff in the hospitals. It would be most unfortunate if, just at the time that this new proposal was being set on foot, there should be this freezing of staff. That would be a most retrograde and unfortunate step, because it might mean that the intern might not get that standard of training and that value out of the year which otherwise he ought to get.

We must say, too, that we are concerned about what is to be the form of this period of one year's internship. In what way is it to be divided? Are we satisfied that it will be run satisfactorily throughout the country? Are there to be large variations in practice from one part of the country to another? These are very important matters. I think we all agree that it is vital that the future doctor should get as much experience and contact as possible with the sort of problems which he is likely to face in general practice, and that this period of a further year should not be merely repetition of what he has been doing throughout the previous five or six years. He should have some new experience which has not been available to him before. For that reason, amongst others, it is important that the General Medical Council shall have carefully thought out, as I am sure they have, the content of the courses during this year.

The final point I want to mention is one which I know is in the minds of several of my hon. Friends. It is the question of a proper safeguard for the medical students themselves. This is a matter which was very much to the fore when we discussed the Bill, and I think it is still a very important point to raise this evening, because there may still be some misgivings amongst some of those who are now obliged to take this intern year and who were in the middle of their training at the time the Bill was passed.

We agreed in the House at the time that we could not wait for the long periods which would be necessary before all those who were undergoing training had been able to complete their training without an intern period. We could not wait as long as that before instituting the scheme. But that means that all the more must we be satisfied that there are proper safeguards, particularly for those who are married and have very heavy responsibilities to meet, and who may have planned their lives originally on an understanding that they would be able to go out into general practice a year earlier than in fact will be the case.

My understanding is that the allowances which were agreed were at the rate of £350 a year for the first six months of the intern year and £400 a year for the next six months of the intern year. Has there been any change in those figures? The cost of living has risen, of course. I should like to know whether the allowances have been reconsidered. I understand that there is still anxiety about this point—an anxiety which has not been wholly allayed by other announcements which have been made in the past. It is very important that there should be no anxiety which we can overcome in a proper manner.

I do not think any of the points which I have raised are in any way unreasonable or unnecessary. I am sure that everyone will agree that in parting from this proposal with the greatest good will towards it, and every hope of its success, we are anxious that it should operate in the most satisfactory conditions possible. It is our right, therefore, to know all we can about the provisions which have been made to ensure its smooth operation, and I hope the right hon. Gentleman will take the opportunity, with the leave of the House—which I am sure he will be given—to let us know something more about the detailed working proposals. I am sure, too, that my hon. Friends have many questions which they wish to put.

8.10 p.m.

Dr. Barnett Stross (Stoke-on-Trent, Central)

My hon. Friend the Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) has covered the theme very well in putting points to the Minister. The Minister himself left us in no doubt that he is under the impression that in the discussion which took place in July, 1950, on the Committee stage of the Medical Act, when in all parts of the House we asked for assurances and put questions to my right hon. Friend the Member for Ebbw Vale (Mr. Bevan), the Minister at that time was not willing that there should be any further discussion now. With respect, I think that the right hon. Gentleman is wrong.

Mr. Macleod

Surely, with great respect, it is quite immaterial whether the right hon. Gentleman the Member for Ebbw Vale was willing or not. The right hon. Gentleman is not in the Chair in the House tonight and no undertaking given two years ago is relevant. Surely the point is that we are discussing at the moment, as I understand it, the issue and only the issue of whether the period should be 12 months. There is nothing else before the House.

Dr. Stross

If that really were the case, it would be an interesting example of how, when times change and responsibilities differ, opinions differ. But I am sure the Minister will agree with this other point—that he, like other hon. Members, pressed that when we came to this draft Order we should be careful, and that my right hon. Friend the Member for Ebbw Vale said, in effect, at the time, "I must not have these things for which you ask in the Order, but there must be discussion at the time."

Most of the points have been put thoroughly by my hon. Friend the Member for Newcastle-upon-Tyne, East, but there are questions which I should like to put essentially on behalf of the students who are involved. We accept that the line should be drawn at some time. We discussed in 1950 a year or so, but it is two and a half years now. It has been a longer time than any of us contemplated would elapse before the draft Order was brought forward. Perhaps that is as well because it has given us fuller notice than we thought was possible in July, 1950.

There may be some students who feel a grievance. Certainly some of the married ones may do so, especially if they have family ties and children. There are also women students who are married and who feel that a year of internship, separated from their family, may create a special difficulty. I know that there are not many cases but it is as well for the sake of the few that do exist to state that they feel this special grievance.

I hope that at some time in the future the Minister will consider whether it will be possible for the authorities in charge to give these students special consideration, or to arrange that positions should be found for them as near as possible to their homes or the schools at which they practise. Married women should not have to go 100 miles or more from home to do a year's internship. That is a small but important point.

The year itself is ideal. All of us want it. I should like to reinforce the remarks of my hon. Friend the Member for Newcastle-upon-Tyne, East in saying that this extra year must prove of benefit not only to the students but to the public. During this year it is not new theory that the student wishes to learn, because after the five and a half years, or in some cases six or seven years, during which the student qualifies, he knows as much about theory as he ever will know for the rest of his life. In fact he spends the rest of his life slowly, and perhaps unfortunately, forgetting a great deal of his theoretical training.

During this year the student wants further practical education with responsibility. His responsibility will be limited to a certain extent, but only because he will have protection and guidance from those who are more skilful in the art of medicine than he is. And it is essential that the promise we had two years ago should be carried out. It is that he should not be limited to surgery for six months and medicine for six months but should go as widely round the departments as possible. The medical student does not know very much about treatment as such. There is no time to teach him much about therapeutics but a year's internship will enable him to be taught.

My hon. Friend the Member for Newcastle-upon-Tyne, East quoted the remuneration to be paid to the student as £350 for the first six months and £400 for the second six months. On this question I want to put a point of some substance to the Minister. A medical student with a family may be receiving over £500 a year in grants at the present time. I am sure that the Minister would agree that it is a little anomalous if he drops in the first six months to £350, with exactly the same responsibility, and his total remuneration for the second six months is only £400. The Minister is bound to receive representations either directly or indirectly, and although the number will not be very great I ask him to remember that grievances are not made smaller because the number who suffer are few.

The future of medical services in this country in the long run depends not so much upon buildings as upon the quality of those who serve. In wholeheartedly agreeing, as we do, to this Order, we are asking students that, even though some of them may feel they have a grievance and that it is an inconvenience at the moment, they should realise that the type of service for which we ask from them is the very best they can possible give. I am sure that any of them who feel any umbrage or sense of discomfort will realise throughout the rest of their lives that what is done today on their behalf, commencing on 1st January, 1953, is not only for the benefit of the public but for their benefit, too.

8.18 p.m.

Mr. John Hynd (Sheffield, Attercliffe)

I hope that the Minister will appreciate that on both sides of the House we welcome this Order and will be glad to see it brought into operation. For that reason, I was rather sorry that he adopted the tone which he did when he seemed to be trying to cut down discussion on very important matters that arise from the fact that the Order is now being approved. He seemed to say that the only thing that can be discussed is whether the period should be 12 months and that there is nothing else before the House.

With respect, however, I submit that the Order includes the appointed date, that is, 1st January, 1953. It is on that aspect of the Order that I think most of the queries arise. It would be a pity if this opportunity went by without these points being raised for the benefit of the information we can obtain from the Minister, and also for the benefit that medical students and others who are interested and who will be very directly affected may receive as a result of questions and answers tonight.

The Minister started by saying that fortunately he had had no direct objections to this proposal. If he has not had any direct objections, I can tell him that certain objections were made, because the University of Sheffield, with which I have the honour to be associated as a member of the Board of Governors, made certain objections to the operative date. I believe that other objections were also made on the ground that the posts could not be made available in time.

Mr. Macleod

I do not want to be misunderstood. I was referring to objections to the period of 12 months. It is quite true that the University of Sheffield and perhaps two or three teaching hospitals in London had different views about January, 1953, but there has been no objection to the period of 12 months.

Mr. Hynd

I misunderstood the Minister, and I apologise. It is quite clear that there have been no objections to the period. There have been queries put by my hon. Friend about what is to be done during that period. I do not think much objection will be raised about that. I understand that six months of the period is to be served medically and six months surgically, or, alternative to either, on midwifery. That would provide a very effective and useful training for any student taking up any of these house officers' posts.

There was some misapprehension about whether this could be brought into effect by 1st January, and whether the lists of available posts could be made public in time for them to have effect. I understand that lists have been made available and were published in September, and that they do show, so far as I can find out, that at least at the beginning there will be more than sufficient posts available for all the students likely to go through the schools in the course of next year. That is very satisfactory for those who support the proposition.

It is also extremely satisfactory to note that most of the Commonwealth countries have already brought in, or are bringing in, similar legislation. I do not know what the position is about India, which is extremely important. Perhaps the Minister could give us some information about that, because the degree of reciprocity between Commonwealth countries is very important.

There are one or two things about which I should be happy to get some assurance from the Minister. First, there is the question of maintenance allowances and grants. My hon. Friend has already referred to the married student and the difficulty he will be in during his intern period. The amounts laid down are £350 for the first six months and £400 for the second six months. I think that for married students with families an additional grant should be made, as hitherto, to enable them to meet their family responsibilities.

I am more concerned, however, about the position, particularly in the early stages, of students who are entirely dependent for their maintenance at the present time on Government or education authority grants, who even under the present arrangements have to wait at least two weeks before hearing the result of their examination. Under the new arrangement they may have to wait a considerable number of weeks before getting intern posts. I understand that their grants finish when they pass their examination. If that is so and they are unable to find a post in one of the hospitals for a period of several weeks, or may be even months, what will happen to them?

One suggestion is that the grants will be continued after they qualify and go on to their pre-registration service. I should like the Minister to interpret that. Does it cover this point? Does it only mean after they have obtained an appointment in a hospital? Does it, indeed, cover the gap between passing their examination and obtaining an appointment to a pre-registration post in a hospital? This is extremely important, because between 70 per cent. and 80 per cent. of the medical students are largely dependent on these grants, and it would be a tragedy if they were left without any kind of maintenance because of this new scheme.

Under the present arrangements they can, immediately they have qualified and passed their examination, get a job as a locum, which enables them to earn something until they can set up in practice or obtain a hospital post. That will no longer apply under the new arrangements, so that factor becomes extremely important.

Secondly, I refer to the advertising of posts. My hon. Friend the Member for Stoke-on-Trent, Central (Dr. Stross) has referred to the difficulties of married women students who might have to go 100 or 200 miles away from their home to take up posts. I do not think that that is likely to arise a great deal, because the advertising of posts and the facilities given to students for taking up places in hospitals would, presumably, be done on a regional basis. Nevertheless, there is the question of how far the advertising of posts can be extended. I, personally, think that all posts should be advertised.

I recognise that in a scheme of this kind, with students coming from the university and seeking posts in a hospital, a great deal of assistance can be given by co-operation between the medical school and the hospital; but there is bound to be a considerable delay, whether the post is advertised or whether it is fixed up by mutual agreement between the hospital and the teaching authority.

Is that to be overcome, as probably it could be, by encouraging the students to apply for posts before they pass their examination, and by encouraging hospitals to offer posts to students before they have qualified? If that is done—and I understand that suggestions are being made that the regions might consider that idea—I can foresee a great deal of difficulty, but although I appreciate the problem I cannot quite see the answer to it. Perhaps the Minister can assist us.

I understand that in the London region, in the last four examinations for the, I think, M.D. degree, there were no less than 50 per cent. failures, or about that. That would mean that, if students had applied for posts in hospitals before taking their examination and been given these appointments dependent upon their success, 50 per cent. of the posts, or thereabouts, would be unfilled after the examination, and then further applications would have to be made by other and successful students.

But what about those who had already accepted what might be called not quite so satisfactory posts elsewhere? They would be barred from those better posts which had become vacant because they would have been given to students who had in fact subsequently failed their examination. I hope the Minister will be able to give us some assurance on this so that we can see a little way through this maze because, frankly, while I do not know the answer, I can see a great deal of difficulty arising.

Reference was made to students being dependent for their final registration after the 12 months' hospital service on satisfactory report from the hospitals. What does that mean? If a student has done six months on surgical work and six months medical practice, or alternatively midwifery, he has completed the 12 months. If he has not been satisfactory, presumably he should not have been allowed to complete the 12 months. The fact that he has completed 12 months should, I imagine, entitle assumption that he has been satisfactory. In my view, these are no longer students when they have passed their examination and gone to the hospital. They are practising doctors taking the first stage of their practical experience in a hospital, where they have special facilities and opportunities which they would not have in ordinary practice.

I do not think they should be regarded as students dependent for their final registration upon having a satisfactory report from, as it were, teacher that they have been good boys and have carried out their duties satisfactorily. A lot would depend on the prejudices of the hospital authorities. If it is felt that something more than a mere record of the fact that they have completed their 12 months is necessary, if it is felt that something should be included in a certificate which goes to the General Medical Council to show that they have completed 12 months' service satisfactorily, at least there should be a compulsory provision that any student who in the course of his 12 months is not satisfactory in any respect should be given a warning as early as possible.

If a warning is given, he will have an opportunity of realising that he had better improve himself or there may be difficulties. If no warning is given, and he finds that at the end of 12 months he has been refused registration by the General Medical Council and inquires why, and he is told that there was no satisfactory report, he is left high and dry with no knowledge of what it is all about. In that case there must be set up some kind of complicated arrangement so that he can appeal and find out what it was about, bring evidence and plead on his own behalf. I think that a warning is probably to be recommended in these cases. May I suggest that it should be made compulsory in any case where it is seen during the 12 months that the student is failing to give satisfaction?

Dr. Stross

This is a very important point. My hon. Friend will remember that in the Committee stage it was glibly accepted, and I use that word advisedly, by all of us that if the student was not found to be satisfactory at the end of the year, he would be free to go on another year. On reflection—and I wonder whether my hon. Friend agrees with me—I find that obnoxious. Why should the student not receive his first certificate at the end of the first six months and the final one at the end of the year, so that if he falls into trouble in the second six months, he will only have a further six months to do? Would he not agree that that would be the right course, and that at least it would be some protection to the student?

Mr. Hynd

I can think of a great number of arrangements that could be made to try to overcome this difficulty, but I think that the most satisfactory one would be to drop the reference to satisfactory service altogether, assuming that the student is allowed to continue and finish his 12 months, so that the responsibility is on the hospital authorities, or, if that is going too far, it should at least be included in the Regulations that during the course of the 12 months, if for any reason the student or doctor is found to be unsatisfactory, he should be given adequate warning so that he will know exactly what is going on and be able to correct any shortcomings he may have.

I conclude by going back to the first point which I made concerning the question of carry-over grants. I make three suggestions. When the student has passed his examination and is waiting for a post in a hospital, if he has not already got one before he passed his examination, there should be an arrangement for a special fixed grant to be made; alternatively, a limited grant should be made for a further period to enable the student to obtain a satisfactory post. If neither of these proposals can be adopted, then, at least some arrangement should be made whereby a grant should be given to him as a loan on future salary.

Whatever is done, I think that it is very important that there should be some arrangement for carrying over from the period when the education grant finishes to the time when, because of the legislation which we are bringing in and imposing on the student, he obtains a post, as this might mean a gap of several weeks or several months.

I think that the Minister will agree that these and other points with which I have not been able to deal fully are very relevant to this Order, and I hope that he will be able to give, through the records of the House and, I hope, the Press, some assurance to the medical students who will be so directly and drastically affected that these problems with which they are faced will be covered.

8.34 p.m.

Mr. Somerville Hastings (Barking)

We are being asked in this Order to agree that the time in which a student who has passed his qualifying examination should act in a resident capacity at some hospital should be 12 months. I suggest that whether that time is sufficient or not depends on how that 12 months is spent. If we turn to the Act, we read that the young doctor who has received his qualifying diploma before registration must show evidence that during the time the applicant—and here I am quoting— has been so employed as aforesaid"— that is in a resident appointment— he has been engaged for such period or minimum period as may by regulations of the Council be prescribed in medicine, and for such period or minimum period as may be so prescribed in surgery. As far as I know, I have seen no statement of what these minimum periods must be, and I think that the Minister ought to tell us what they are tonight. It is most important that the student should spend a sufficient time in both medicine and surgery, and I should not regard it as sufficient if he spent only one or two months medicine or the same period in surgery.

I will tell the House of my experience which shows how important that is. When I was qualified, I spent three and a half years in hospital undertaking resident appointments. But they were all surgical, and therefore, right through my professional life, I have had little or no medical experience, a fact for which I am quite sure I have suffered as, in all probability, have my patients also.

In my opinion, whether this time is sufficient or not must depend not only on the time, but also on the conditions of the appointment. These young men and women will not learn what they ought to learn unless they have time for thought and study. The Goodenough Committee make this point very definitely in their Report. I will read what they say, because they have put it so much better than I could. They say: He needs 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. The last point is particularly important because the period of pre-registration house-appointments can provide a most favourable opportunity for establishing firmly in the minds of future practitioners the habits of social medicine. I think we would all agree with that. But not only must the student have time for study and thought; he must have time for rest and recreation as well. For the first time after becoming qualified, he has to deal on his own responsibility with patients and has to make important decisions which is the most tiring and difficult time of his life. I recall from my own experience that I have never been so tired either before or since, not even after an all-night Sitting, as when I held my first six months' surgical appointment.

For these reasons, I feel that the young intern, as he has been called, should have time for thought and study, and also time for rest. As I have said, the Goodenough Report makes this point very strongly and suggests that in a teaching hospital the young man should only be in charge of perhaps 20 beds, and in a non-teaching hospital of perhaps 30.

May I deal with a point which has already been dealt with once or twice tonight, and that is the question of the satisfactoriness of a resident officer's appointment. The Act says that his services while employed must have been satisfactory. I feel that if his services are not regarded as satisfactory during one of the two appointments he should be given another chance. As my hon. Friend the Member for Attercliffe (Mr. J. Hynd) suggested, it would be advantageous if he could be told early in his career that his services were not approved of. If they have been decided as unsatisfactory, he ought to be told and given another chance.

I have suggested that he should be in charge of a relatively few beds, and he may have only one senior consultant to whom he is responsible. He and the consultant may be temperamentally unsuited to one another, and the consultant might, for no good reason, take a dislike to him. If I may draw on my own experience, I do not think my first surgical appointment was at all satisfactory. My senior did not think so because he entered in the hospital "black book," with very good reason, statements about me. If I had been turned out of the profession and never had another chance, I do not know that the profession would have lost much, but I should have lost a great deal. I feel that in all the circumstances where services are not satisfactory, there should be another chance. It is a matter which the Minister wants to look at very carefully indeed, as has been shown by the number of times it has been raised today.

There is one final point with which I should like to deal, and that is the medico-legal relationship of the intern. We know very well that litigation for alleged neglect in hospitals has increased enormously since the appointed day. These young men and women, will, of course, be able to get another opinion in most cases, but there are many times, perhaps at night, when a young doctor will have cases of great difficulty presented to him. He will have to ask himself, "Shall I take the case into hospital or chance it?" If he calls his superior from his bed he will not be thanked. If he admits the case into hospital when it is some trifling affair, he will not be thanked any more.

I am afraid that those who live on litigation will soon learn that there are such things as unregistered interns. They will be very ready to apply for compensation in cases where these junior people have been involved. What I want to ask the Minister, therefore, if he can insist upon it, is whether it is possible in all hospitals for every resident officer under this new set-up to be insured in a medical protection society. It is done in all the hospitals with which I am connected.

Finally, I would like to explain that I am not disagreeing with this Order in the smallest bit. It will be of great advantage. Already we are turning out better trained doctors in this country than any other country in the world, because our training is much more practical. The Order will enable us to turn out doctors who are still better trained than in the past.

8.45 p.m.

Mr. Iain Macleod

Perhaps I may speak again, by the leave of the House. I admit frankly that I did not realise that it was possible to go as wide as we have done in this debate, but I make no complaint about that. I will do my best, though here and there rather impromptu, to answer some of the points that have been raised. I am delighted in any case to have converted the party opposite to my point of view of two years ago that we should not have a narrow debate on this subject.

Perhaps the first point we might take is whether or not posts will be available next year, and matters of pay and other things that spring directly or indirectly from that. The House will be aware, as the hon. Member for Attercliffe (Mr. J. Hynd) has pointed out, that the General Medical Council have published a list of all the posts in which pre-registration service can be given at hospitals not only in England and Wales but in Scotland and Ireland as well. It is everybody's opinion that there will be enough posts, but it does not follow that there are enough posts exactly in the right places. There is a concentration of teaching hospitals in various parts of this country, notably in London. It follows that some areas will be exporting areas, and probably London and Scotland will be included in them, and many others will be importing areas. By and large, there will be enough posts.

On the question whether we have given sufficient notice, I cannot do better than recall what was said by the right hon. Member for Ebbw Vale (Mr. Bevan) about two and a quarter years ago, that this was not going to be sprung upon students immediately, but would take between a year and two years to make the arrangements. The right hon. Gentleman underestimated a little, because it will have taken about two and a half years, when 1st January comes. There is no case to be made of inadequate notice having been given.

I very much agree with the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) that it is desirable that one date should be selected for the whole of the country, though there is a proviso in the Act. There are great advantages in selecting 1st January in any particular year, in part because of its obvious administrative convenience, but more important because few students qualify in the first few months of the year. That is an important point. I am advised that only about 200 students will qualify in the first three months of next year.

I do not think for a moment that the scheme will work perfectly from 1st January. There will be lots of teething troubles and we must face that fact, but it will be possible to bring the scheme in when comparatively few people are qualifying, in the first few weeks of the New Year. We shall see whether we have made any particular forms of mistake.

I come next to the question of how the students are to get the posts and whether it is desirable that they should apply for posts, and perhaps be interviewed before the examination is taken. The hon. Member for Attercliffe pointed out, quite rightly, that this is an extremely difficult problem and one to which he himself saw no quick solution. Frankly, nor do I. In many things we shall have to learn from experience.

But very often the student, when he qualifies, will be able to spend part of or, with luck, all his pre-registration year in the hospital where he studied as an undergraduate. The lists that have been published show exactly where all the vacancies are, and the dean of the medical school will be in a position to advise the student whether any posts are available at the hospital to which the medical school is attached.

I visualise a considerable development, as envisaged by the hon. Member for Attercliffe, in co-operation between all the various bodies concerned. Already one gets the co-operation and consultation between, say, the dean of a medical school in a provincial area which is going to be an importing area and, perhaps, the officials of some of the teaching hospitals in London. I think hon. Members will agree that this should not be done by regulation or by fiat by the Minister. That sort of co-operation will have to grow, but I myself have invited hospital authorities to co-operate with the universities and medical schools to ensure that the newly-qualified doctors do not have to wait an unreasonable time before they take a hospital post. There may, of course, be some gap.

The point was raised—perhaps I may take all the financial points together—about what is to happen in that period. The position, as two hon. Members opposite have mentioned, is that the rates that are agreed for house officers are £350 for the first six months and £400 for the second six months, although, it must be added, there is a deduction of £100 for board and lodging, which is a not inconsiderable item.

The overwhelming majority of those who might be in financial difficulties will be ex-Service students. They have been eligible to receive modified allowances from the Ministry of Education during the period that they spend as house officer after obtaining medical qualifications; and that is to be continued for the pre-registration service.

Perhaps I may indicate some of the extra amounts that can be obtained, though this is primarily a matter for the Ministry of Education. There can be an extra £25 a year for keeping two homes, an extra £44 a year for the first dependent child and £27 a year for a subsequent child. That works out—the comparison was made between somebody at the university and someone in the pre-registration year—that at the university a married man who has one child, which can, perhaps, be taken as a fairly typical example, receives during training £427 untaxed.

The same person, on being a house officer, would get an average of £375 for the year—more, of course, for the second half year—£25 for the double residential allowance and £44 for the first child. That comes to £444. Tax and National Insurance together come to £29 7s. 6d., leaving a net amount for this hypothetical doctor of £414 12s. 6d., which is a fair comparison with the £427 that he is receiving. In addition, it is possible for him to have an extra grant—although I admit that the qualification for this is exceptional hardship, and that should be stated—of £25 a year which, although small, as, of course, these sums are, does cover the gap between the two to which I have referred.

I now come to the other point mentioned by the hon. Member for Attercliffe about what is to happen in the period—and I admit there will be such gaps—before an officer is enabled to obtain a post or perhaps—which I think even more serious—if he has to export himself, while he is uprooting himself and taking up the new post. In such a case my right hon. Friend will also pay a sum that is based on the usual vacation allowance to newly qualified men who cannot get a house post as soon as they qualify. This is to be paid for a period not exceeding two months and it will be the appropriate proportion of the vacation allowance previously paid, plus dependant's allowance. I am afraid that vacation allowance varies so much that, with the best will in the world, I cannot give precise figures of what it is. But this does show that there some provision for this gap up to a period of two months in which special allowances can be made through the Ministry of Education.

I noted with great care what was said by the hon. Member and I think that perhaps the best assurance I can give is that I will satisfy myself, if necessary in consultation with my right hon. Friend, that as far as we can we will see that any particularly difficult cases are met. But I think it also fair to say this. We should not over-estimate the hardship that may conceivably be caused. It would indeed be a very great mistake if, because of some temporary embarrassment—and that is going to happen—the medical student were not to take advantage of the year of pre-registration service which I think we have had general agreement is desirable and which I am asking the House to approve tonight.

I come to a rather different subject, although one of extreme importance. Let us take first the question of the certificate. Practically everything relevant is contained in it. The hon. Member for Barking (Mr. Hastings) made some reference to Section 2 of the 1950 Act. I do not propose to read it, although I will refer to parts of it. There is the question of a satisfactory report. I seemed to get an inkling from the hon. Member for Attercliffe and from another hon. Member opposite that it would be desirable if in some way there were some sort of appeal against an unsatisfactory report. I do not think that is an idea which can be entertained.

Mr. J. Hynd

Let me get this clear. I suggested that, unless it were made obligatory that the warning should be given in any case of unsatisfactory service before the end of the service, we might find ourselves at the end of the service with a man with an unsatisfactory report and have no alternative but to accept it, without there being some kind of machinery by which he could appeal. I suggest that that is what we should avoid by giving a warning.

Mr. Macleod

I am glad that the hon. Member agrees that an appeal is a very bad idea. I was deeply dissatisfied with the degree I was given at the university but I know of no means by which I could appeal against it.

The question of the warning seems to me to be very sound indeed, but I think we are on a little difficult ground here. I shall not, as Minister, be responsible for laying down what the content of medical education should be; I am sure I carry the House with me in that. It is beyond doubt desirable that these matters should be widely discussed, but there are appropriate authorities—and I frankly do not consider that I am or should be one of those—for deciding precisely what form the curricula and indeed this certificate should take.

Mr. Hynd

Has not the Minister in fact already instructed the medical schools and teaching hospitals that in such cases a warning should be given? My emphasis would be on "must be given." Surely the right hon. Gentleman has only given such instructions?

Mr. Macleod

I am prepared to look at that point, but I was not talking exactly on the point of the warning, on which I have considerable sympathy with the hon. Gentleman.

I was asked a particular question by the hon. Member for Barking about whether regulations had been made as to the way in which this year was to be spent. That is a most important point but they are not regulations made by myself; they are, and again perfectly and properly, for the reasons I have just given, regulations made by the General Medical Council. That is made perfectly clear in Section 2 (2, a) The answer is that regulations have been made, but it is not particularly helpful to the point which the hon. Member has in mind, because the regulations empower licensing bodies to approve particular posts and within that it is a matter, as indeed is made clear in the Medical Act, 1950, for the licensing bodies who are to issue or are not to issue the diploma, as the case may be, at the end of the year.

Mr. Hastings

Cannot the Minister do something to see that the time spent in medicine and surgery are approximately equal, because if only a short time were spent in one or the other I think we should not get a well-trained doctor with a balanced experience?

Dr. Stross

Might I intervene before the right hon. Gentleman answers that point? I think that the Act lays down six-monthly periods and that medicine or surgery may replace one or the other. I feel that it should not be rigid like that. The right hon. Gentleman has been dealing with the question of the certificate of satisfactory work. If a student has, for example, done six months' surgery and left his chief with a satisfactory certificate, would it not be reasonable, if anything goes wrong afterwards with somebody else, for the Minister to use his influence to suggest that if that student has to do any work beyond a year he should have his six months' satisfactory work credited to him in any event?

Mr. Macleod

On the first point of the hon. Member for Stoke-on-Trent, Central (Dr. Stross), my recollection is that the six months to which he refers is not in the 1950 Act but that it is left, as I have said—and I insist on this point, that it is right—to the medical authorities themselves to decide this matter. A difficult point is raised as to whether an interim certificate should be given, say, after six months—and another should be liven for the second six months if the student is doing half medicine and half surgery. Tonight, I will go only as far as this. I say quite certainly, and I must claim that this is correct, that it is not for me to interfere in this particular matter, but I will undertake to see that the views expressed by the House tonight are brought to the attention of those responsible in this field. I think that probably that is the best way of leaving that particular issue.

One more point, and a most important one, was raised by the hon. Member for Barking, who raised a number of what I might call medico-legal points in matters concerning the risk which an officer might have to take, perhaps in some problem that might arise in connection with giving certificates, and we can all think of other examples, such as the administration of dangerous drugs. Some of these points, if I remember rightly, were raised by the hon. Gentleman in the course of our debate in 1950, but I take note of them, and I will examine the particular possibility which he put forward that every resident officer should be compulsorily insured by a medical protection society. I will gladly look at that matter, and let the hon. Gentleman know the results of my examination.

There are one or two final points which I think should be made. I do not think it is possible, even if you, Sir, were to permit me, to go into the intriguing questions raised by the hon. Member for Newcastle-upon-Tyne, East (Mr. Blenkinsop) in relation to some recent Circulars that have been issued from my Ministry, and which, as a matter of fact, follow precisely the lines that had been already started by my Socialist predecessor. I do not think, with great respect, that they are particularly relevant to the period of 12 months which we are considering.

Mr. Blenkinsop

I do not want to go into it in great detail at this time, but surely it is relevant to ask whether, in fact, this might have any effect upon the standard of post that might be available to interns, not only for the interns themselves, who, no doubt, will be safeguarded, but in regard to the actual quality of any training which they may get. Is there any risk that the quality of training might be endangered by this possible proposal of freezing staff?

Mr. Macleod

I am satisfied that there would be none at all; certainly, no thought is or has been for a moment in my mind.

We have had a very good debate. I have tried to answer in as detailed a manner as I can the questions which, I frankly acknowledge, are of very great interest to medical students throughout this country, and they will find some of the matters I have dealt with, concerning pay and methods of application, in the OFFICIAL REPORT tomorrow, and I hope that will help them.

If I may go back to the Order which I am asking the House to approve tonight, whatever differences there may be about 1st January, 1953, about the method of application, about hardship or allowances, I have heard no word tonight—and I take it that there is none—against the period being 12 months. It is that period which, I freely admit, is part of a much more considerable pattern, that I am asking the House, in this draft Order, to approve.

Mr. Blenkinsop

Before the right hon. Gentleman concludes, might I ask him to say a few words on the one point which I think he has missed? I refer to the question whether, to his knowledge, there has been any inquiry at all about the length of general medical training which links up with the further period of training which we are discussing?

Mr. Macleod

Not as far as I know, but there are a number of committees on allied subjects to this which are due to report in the near future.

Resolved, That the Draft Medical Act, 1950 (Period of Employment as House Officers) Regulations Approval Order of Council, 1952, a copy of which was laid before this House on 18th July, 1952, in the last Session of Parliament, be approved.