HC Deb 06 November 1953 vol 520 cc559-70

Motion made, and Question proposed, "That this House do now adjourn."—[Mr. Studholme.]

4.0 p.m.

Dr. Horace King (Southampton, Test)

It is unfortunate that I have to begin my speech by explaining, to the public and not to hon. Members of this House, just who are registrars, about whose employment problems I wish to speak this afternoon. The word suggests somebody whose duty is to keep a register. But "registrar" is the name we give in our hospitals to men who are qualified doctors, serving a kind of apprenticeship for posts as consultants. Their work in the hospital is two-fold. They assist and observe the consultant in his specialist work. If the work is surgical, in time they perform operations themselves. If the work is medical, in time they take over a number of beds for which they have complete responsibility in the hospital. So that they are assistant specialists, assistant consultants, handling, inside a specialist team, as their experience grows, more and more of the work of the specialist.

It is through this system of registrars that the Health Service will, as time goes on, recruit almost the whole of the next generation of specialists. There may be growing pains in the process, but the Health Service is, rightly I think, developing its hospitals so that many are becoming specialised hospitals. The steady recruitment of able consultants is then of paramount importance.

When the National Health Service began, not so long after the war, ambitious doctors who had gained good academic degrees and who aimed high, took up posts as registrars in hospitals rather than go into general practice. The general impression was that we were going to expand the consultant service, as indeed we have done, to a remarkable extent. The difficulty was that it was impossible to foresee just how great the expansion would be.

I do not wish to revive any of the controversial issues that rose in 1951 when it was discovered that we had more apprentice consultants, more registrars, than the Service could absorb. The matter was debated in the House at that time. In the long run, I think, everyone agrees that it was a wise decision that my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) made when he decided to cut the intake of registrars and to equate or approximate that intake to the number of consultant posts likely to occur vacant from year to year.

But I am concerned with the men who had already, in good faith, entered this apprenticeship and who now find it very difficult to obtain posts of any kind. Recently when I raised with the Minister of Health the particular problem of one registrar in my constituency, I went further into the matter and I found just how grave is this problem which confronts a group of 300 or 400 men.

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

Is my hon. Friend confining himself entirely to senior registrars—that is to say, those who already have high qualifications?

Dr. King

The special problem with which I am dealing is the problem of senior registrars, although the general problem does arise. When the cut in registrars occurred, the then Minister said that those who failed to get consultant posts need not be alarmed because they could either go into the Colonial service or into general practice.

Let me deal with the Colonies first. We need doctors in the Colonies. One of our moral duties is to take to the backward millions under our care modern medicine and surgery. We all pay homage to Schweitzer. We need to export British Schweitzers to our Colonies. It is a great and noble calling for young doctors. But the men of whom I am speaking are ex-Service men, most of them having just finished their college career when the war broke out, or having had it interrupted by the war and finished it just after the war.

They are now men of 35 to 40 years of age. They have family responsibilities. What might have been undertaken lightly—and what I hope our young doctors will undertake for humanity's sake—when a man was 25, is not so easy to embark upon after a man is married and has young children. These men ought to be settling down, not starting a career in a new world. If they had gone into general practice they would now be beginning to earn competent incomes and rearing their families in security. But, as things are, the hospital group in my area has just lost an excellent surgeon-registrar who, in desperation, not because he wished to go, has taken a post in Australia. Men should go to overseas work because they want to, not because they are driven to it.

It is when it comes to trying to get into general practice that the position of the registrar, his period of service in hospital coming to an abrupt end, becomes really alarming. Recently I took up the case of a doctor—a registrar in one of our local hospitals—a man I ought to know, as he saved my life when I was foolish enough to try to throw it away one night in the last Parliament.

This man applied for a vacant post in the Dorset area. His academic qualifications are excellent—superior to those of many general practitioners. In addition, he has a varied hospital experience in general medicine; in fact, he has been dealing for several years with patients beyond the aid of the ordinary general practitioner. Yet he did not even get on to the short list of candidates for the post, and the man appointed had neither his experience nor his academic qualifications. Incidentally, although he appealed, as is possible, the appointment was confirmed while his appeal was still pending.

In our same hospital group is a registrar who hoped to become a consultant in general medicine. Again, he is a first-class man, academically and from the point of experience. His post as registrar ends this year. He has now switched over to pathology and is taking up a registrar's post, in some other hospital, as an apprentice pathologist. He has the fearsome prospect that in two or three years' time, if he has failed to become a consultant pathologist, there is very little likelihood of any employment for him. This is not the way to recruit consultants or to treat ex-Service doctors.

Lest this should appear to be a layman's picture or a local picture, I turn to the British Medical Journal, which, I understand, is the official organ of the British Medical Association. On 3rd October this year it published a bitter but revealing letter from a doctor, who gave tragic pictures of the fate of three registrars.

The first took a degree in another faculty before taking his medical degree. In his medical examinations he was first or second in every major subject, and he graduated with honours. He served five years as an officer in the war. On returning, he took in his stride his M.R.C.P. and became a registrar. This man has failed to obtain a consultant post and has also failed to obtain a post in general practice. I quote from the letter: Thirteen years after graduation he earns about half the salary of the average general practitioner in Britain, but lacks his security. All this has happened simply because he is well-qualified and was ambitious enough to wish to become a specialist.

The second man was similar in experience and qualification. Failing to become a specialist after several years as a registrar, he had six months as a house surgeon in a maternity hospital and, on the strength of that, he obtained with some difficulty an assistant post in general practice. The third, similarly qualified and with similar experience as a registrar, has abandoned the medical profession altogether.

A leading article in the same journal, commenting on this letter says: There is more than a grain of truth in the jocular remark—which came from a good source—that to the applicant for a G.P. vacancy the possession of a car is more important than the possession of M.C.O.G., F.R.C.S. or—most dangerous encumbrance, M.R.C.P. The article continues: It would be deplorable if a few but influential people should heap up more barriers to free and easy movement in the Health Service. It is a parlous state of affairs when a medical journal can poke cynical fun at academic medical qualifications. It is bad for the health of the medical profession and it is bad for the health of the Health Service. I do not blame the Minister. Vacancies are filled in the first place by a joint committee consisting of members of the health executive and the local medical committee. The former may be laymen; the latter are entirely members of the medical profession.

This joint committee prepares a short list, sometimes interviews the candidates, sometimes does not. On this local joint committee local doctors can exercise the fullest influence over the laymen. The short list then goes to a medical practices committee, a national body consisting, I understand, entirely of doctors, and it is this committee which finally appoints. So, if a wrong is being done by the Health Service to the registrars, it is being done by the members of the medical profession to which those men belong. The B.M.A. may be a very old trades union, but it is not as loyal to all its members as are trades unions to which people like myself belong.

The Minister can help to put the wrong right. I know the polarity that has grown up between the general practitioners and the consultant service. I hope this polarity is going to break down some day, that we are going to bridge the gap that exists between both sides. The differences are of weight, but it is a pity if, in the meantime, the general practitioners are hurting these registrars out of their emotional reactions to being kept out of consultant work in general hospitals. This seems to be what this small but influential group of people on the medical practices committee are doing.

I know that academic qualifications and clinical experience are not the be all and the end all of a general practitioner's great work, but surely they are not handicaps. Surely a greater knowledge of medicine and surgery, and clinical experience of acute disease, do not unfit a man for a general practitioner's work. I know that not every registrar can expect automatically to obtain a consultant's post. There are not enough to go round. Older men are staying on longer. The development of the part-time consultant service has brought advantage; it is right we should not appoint a man merely because he entered an apprenticeship; we ought to have power not to appoint a man because he does not make the grade.

However, all these factors do mean that being an apprentice does not guarantee a post as a registrar or as a consultant; but the man who has failed to become a consultant is not a failure: he has merely failed to obtain one of a limited number of posts demanding extra high qualifications. This does not unfit him for general practitioner work. Indeed, I believe these registrars can bring into general practice a great deal of useful, special experience and better qualifications.

I would, therefore, appeal through the Minister to the medical profession on behalf of this special group of deserving and able men. The solution of the problem of their entry, I think, lies largely in the hands of the profession which dominates the Minister's committee which itself, independent of any control, fills partnership and assistant posts as they become vacant. I understand that especially difficult is the lot of registrars who have not been in teaching hospitals, but experience in non-teaching hospitals, even if it does not include teaching and lecturing, is often wider and gained more arduously than in the limited sphere of a teaching hospital.

But if the medical profession is to blame the Minister is responsible, for these young men entered from war service and post-war medical schools into the National Health Service. They are the hon. Lady's employees, and I think she must take an interest in their future welfare. I would, therefore, urge her to use what influence she can by direct instruction, by exhortations to the medical practices committee and the local joint committees and to the B.M.A., and by direct action, if necessary, to see that the older registrars in our hospitals get a square deal.

I have been dealing with a small group, some 300 senior registrars, for whom at present the outlook is bleak. But it has wider implications. There must be some sense of security, some feeling of certainty of finding a post either as a consultant or in general practice, if we are to attract into the consultant service our best young medical men. Registrars are doing a grand job of work in hospitals. We have an obligation to those who came in—in good faith—and we must reassure those who are thinking of using registrar-ship as an avenue to specialist work in the future.

4.16 p.m.

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

I rise for only one minute to ask the Minister, when she replies to the request of my hon. Friend the Member for Southampton, Test (Dr. King), to consider something which he did not stress, namely the fact that many senior registrars find difficulty in obtaining consultant posts because of a reluctance on the part of established consultants to allow them into the field at all. I think I am correct in what has been reported to me.

Before the Health Service came into existence consultants made a living partly by work at the hospital, some of which was unpaid, and for the rest from fees which they received from private patients, but since the emergence of the National Health Service all work is paid for, and it is fair to say that the consultants' incomes have increased, sometimes in a spectacular fashion.

Despite this—and this is the point of my request to the Minister which I hope she will note—there has been a very decided reluctance on the part of established consultants, particularly in the countryside, to allow any new men to come into this field of work. They have not permitted themselves the pleasure of sharing with any new men this new and increased source of income, and I suggest that that has been to the detriment of the public as a whole and of the Health Service itself. If the hon. Lady can help in any way in that direction, then part of my hon. Friend's complaint will be met.

4.18 p.m.

The Parliamentary Secretary to the Ministry of Health (Miss Patricia Hornsby-Smith)

I am grateful to the hon. Member for Southampton, Test (Dr. King) for initiating the debate, and particularly for his courtesy in letting me have very full details of the points he wished to raise. This is a useful debate, because the subject has given rise to considerable thought and consideration both by the previous Administration and by this Administration.

I should first like to clear up what I think may be some confusion in the minds of the public—although I am sure not in the mind of the hon. Member for Southampton, Test—concerning the very clear difference between the senior registrar and the registrar. The senior registrar can generally be considered to be aiming, at any rate ultimately, to make specialist and consultant status. It is true that more went into that grade than it is possible to absorb into consultant posts in the hospitals. That has been the subject of negotiation with the profession, and it has now been agreed that there should be an intake of approximately 270 new senior registrars each year. This is the true training specialist grade—the senior registrar; but that cannot be said of the registrar grade.

There has been considerable inflation in the number of senior registrars and, appreciating that problem, we have met it in two ways. First of all, there has been a considerable expansion in the Health Service and the number of consultant posts which has mitigated the problem to some extent. Secondly, the situation has been met by a temporary extension of some of the senior registrar posts to enable a full and fair opportunity for those men to obtain consultant posts in competition with others.

The number of senior registrars in the early years of training is now very closely in line with the number laid down and approved by the plan agreed with the profession. The number in the later stages of training, to whom the hon. Member referred this evening, is still in excess of the vacancies available, and there is a limit to the vacancies which can be made for them. It is, however, true to say that those in the senior registrar group have had a greater opportunity to find specialist vacancies, or a better opportunity, in the past five years than they had before because of the increased number of vacancies, or than they are likely to have in the future. Therefore, they had no less opportunity under the Health Service than they had hitherto.

The hon. Member stressed the point that consultants were staying on longer. That is not borne out by the facts. The actual number of consultants who are 65 and over and who were still serving in the Service in 1950 was 129, in 1951, 95 and in 1952, 78. So there is a lessening tendency for consultants to stay on over 65 and thereby keep younger men out of promotion by taking over their jobs.

The largest problem is undoubtedly the second classification of registrars. I think that we must make it clear at the outset that it was never thought that all those who took registrar posts could ever possibly become specialists. The development of medical treatment and of the hospital service generally has called for many more registrars, and we have a very grave shortage of this classification in some areas.

This problem is under very close examination by the profession and the Ministry, but it is clear that the remedies must include an increase in full-time and part-time registrars. For the part-time registrar we have to look to the general practitioner and those who have just started in practice and who are prepared to do part-time work while building up their general practice.

The increased need for full-time registrars in our hospital service means that to the medical man or doctor a registrar's appointment is a normal step in the very early part of his career before going into public health practice or going to the Colonies. Many of them will have to pass into medical posts outside the hospitals.

The hon. Member's, main complaint was that there is not a proper opportunity or that there is some discrimination against these registrars when they attempt to get into general practice. I think that far too much emphasis has been put on the advertised vacancy which relates in the main to the single-handed practices, where the Executive Council advertises a single-handed practice which is available and which is often one vacated by a practitioner of long-standing who has a fairly substantial practice.

I do not think that it is surprising, therefore, that preference is often given in these cases of single-handed practices to the man who has had general practitioner experience. There again, I say that too much emphasis has been put on the advertised practice. The majority of vacancies for general practice occur not in the single-handed practices but in partnerships and for assistants who ultimately intend to become partners with their principal.

Looking at the figures, one finds that of all the vacancies 60 per cent. occurred in partnerships. It is the common practice in our country for doctors to practise in partnership, and I think that this is not likely to lessen and that the single practice is going to remain a minority of the general practice appointments in this country. Therefore, registrars must look beyond the advertised vacancies and realise that the larger field lies in the other appointments.

In March and April, 1952, 70 new partners were introduced, 34 assistants became partners of their former principals but only 28 advertised vacancies were filled. In March and April, 1953, 154 new partners were taken into partnership, 238 assistants became partners with their principals and again there were only available 24 advertised vacancies. So the wider field is unquestionably more in partnership than in advertised vacancies. I think that there is a far greater scope for a registrar to obtain an appointment in partnership, because it is a little unrealistic to think that the medical practices committee should overlook, when assessing the ability of a doctor to take over a practice, the doctor who has already had general practitioner's experience and select instead one who has had no general practitioner experience at all.

One has to accept the facts as they are. Generally speaking, a registrar may have higher qualifications in other fields, as the hon. Member has pointed out, but it must be realised that a registrar's first steps in general practice would be far more advisably taken in a partnership. Then, having obtained general practice experience, he will, with his additional qualifications, be a very strong candidate indeed for a single-practice partnership.

Dr. Stross

I accept whole-heartedly what the Minister says, because I am sure it is true, but will she say whether any method is available by which registrars looking for posts of this kind may know where they can apply? Is there any way open to them?

Miss Hornsby-Smith

It is open to the partnerships to advertise, but I will look into the question of the extent to which, by consultation with executive councils, registrars; may know of vacancies which are imminent.

I know that the hon. Member for Southampton, Test feels very strongly about the cases which have not been successful in his area, but I must point out that competition is particularly strong in the South of England where, for these single practice vacancies, we have had as many as 70 applications. Many good men in those 70 will have been disappointed. On the other hand, in places like the industrial North and in Wales, we have had difficulty in getting one application for a designated area. One has to realise that competition is particularly keen in the South of England, and that in the area represented by the hon. Gentleman there will very often be disappointments.

I must disagree with the hon. Gentleman in some of his strictures on the medical profession. As he said, the profession has a dominating position on executive councils and on the medical practices committee. Although he has referred to correspondence in the "British Medical Journal," in which one or two letters have protested against this present method, I am sure that if it were reversed there would be enough letters to fill the entire journal from people who opposed the idea that anybody other than members of the medical profession were qualified to judge the suitability of those who wish to take up medical practice.

In making their selections the medical practices committee and the executive councils are doing a very good job. There are many variations. Able men congregate in those areas of the country where practices get taken up more quickly, and the selection there is harder because they are better practices. Selection may be much easier where it is more difficult to build up a practice, as in a sparsely populated area.

It is usual and reasonable for the committees to choose men of general practice experience for these vacancies, and it is a little unreasonable for an ex-registrar to expect to step straight into a large, advertised general-practitioner single practice. The main field through which ex-registrars may best obtain their vacancies would be with the individual doctors in partnerships. We have no evidence that these doctors are discriminating in any way against ex-registrars, many of whom have obtained posts. We admit there was a period when there was an influx of registrars and it was difficult to absorb all of them, particularly those who wished to stay in England in this sphere of the medical service. We recently introduced provisions for giving financial encouragement to the formation of partnerships which will be of very real help in encouraging doctors to take partners․․

The Question having been proposed at Four o'Clock, and the debate having continued for half an hour, Mr. SPEAKER adjourned the House without Question put, pursuant to the Standing Order.

Adjourned at Half-past Four o'Clock.