DOCTORS (UNEMPLOYMENT) (Hansard, 24 April 1956)

§ Dr. Donald Johnson (Carlisle)

I am extremely grateful for the opportunity to raise the matter on which I have the Adjournment—the question of unemployment among doctors. I should like to apologise to the Parliamentary Secretary to the Ministry of Health for the fact that she has yet another Adjournment debate to answer, for she has had a great many recently.

I have two reasons for bringing this matter to the notice of the House. The first is that I feel that the Questions which I have asked on the subject in the past couple of weeks were perhaps not regarded as the serious issue which I felt they were in view of the facts at my disposal, which I now propose to place before the House.

The second and subsidiary reason is that though I have been a Member of the House for eleven months I find that we have not so far had an opportunity to debate the National Health Service and there is some doubt as to when we shall have that opportunity. Therefore, in view of the urgency of this problem, I have no alternative but to take this opportunity to bring the matter forward.

The question centres around the number of 35 doctors drawing unemployment benefit. This figure was given to me in reply to a Question which I asked the 1740 Minister of Pensions and National Insurance. The number has been starred in the Press to some extent as "Doctors on the dole." It is obvious, however, that this small number is only a token figure, because it is clear that a professional man does not register at the employment exchange unless he feels desperate and has no other alternative.

Therefore, the figure of 35 represents a much larger figure of doctors who are not attending the employment exchange for obvious professional reasons, but are hanging about, either unemployed or under-employed, hoping for something to turn up. They are perhaps doing odd jobs for a day or two, or, if they are young men, perhaps living with their parents and even, in the last resort, turning to money lenders to keep them going. It represents, too, a still larger number of doctors working as assistants in jobs without prospects. For it is obvious that the spectre of unemployment has the same effect on the labour market in the medical world as it does elsewhere, and affects the position of employment amongst the unestablished members of the profession.

I wish to dispel the idea that these unemployed doctors are merely down and out and good for nothing. I was a little shocked by the statement put out by the British Medical Association in the only statesment it has made on this subject. It appeared in the Londoner's Diary of the Evening Standard. In it a B.M.A. spokesman merely remarked that in any professions there are bound to be a few unemployables and people who are not satisfied with the employment available to them.

Now I want to quote a short extract from two letters from young doctors addressed to me, one by the doctor himself and the other by the father of a young doctor. The first wrote: I am thirty years of age, English, married with two children, and qualified L.M.S.S.A. from King's College Hospital in 1951. I have five years' experience in general practice and good references. I had to leave my last Assistantship on 30th September last, to make 1741 room for the Principal's son and since then have been working about half the time as a locum, the rest of the time drawing benefit. I have large debts, received an interest-free loan of £45 from the Hastings Fund of the B.M.A. last Christmas, and expect to make my first acquaintance with money lenders next week when my first locum work ends. The second one, from the father of the young doctor, stated: I have a son who qualified in 1951, has done three years in hospital and completed his 'Trainee Assistantship' at the end of last year. He has excellent testimonials, including many unsolicited, received from patients, and I have solid grounds for believing that he is thoroughly competent. Since September last he has been trying to obtain a partnership, assistantship or locum, but so far without success. I can quote a third instance, of a personal friend. He is a doctor, my own age, who has returned from working in tropical Australia because of his wife's health. He has been looking for a post in the National Health Service for six months and is still unable to find one. He has been everywhere, but he has been unable to find a place. These are only letters which have come my way, but with a little effort one could multiply them many times. I shall quote only one more before proceeding with further arguments.

The Parliamentary Secretary said that vacancies are notified, and undoubtedly they are. However, what happens when vacancies are notified? A letter appeared in the columns of the B.M.J. from a young doctor in which he said: During the last 18 months I have answered 90 advertisers, all hidden behind the 'invincible armour of a box number,' and I have had no replies from no fewer than 46 of them. He goes on to say that in 24 he enclosed a stamped addressed envelope and still had no reply, and that each advertiser no doubt received anything from 50 to 100 replies. There is little doubt that that is the case, and that a person who wishes to dispose of an assistantship can not only pick and choose his person but can also make his own terms, which are frequently unsatisfactory to the person seeking a practice.

In ventilating this subject, one is bound to contrast these stories with those of doctors who complain that they are overworked and have no time to see their patients. This contrast leads me to represent that this is a more immediate and more urgent problem than will be met by the appointment of a committee which the hon. Lady mentioned and 1742 which will deal more with the long range prospect. Young men are qualifying and older men are returning from overseas, and they are unable to find places in the National Health Service.

It may be that more doctors are qualifying at present than are needed, although that is belied by the statement I have just made. I suggest that there is another reason, which perhaps the Parliamentary Secretary will consider and discuss with the requisite authorities. That is the question of the falling-in of individual practices and the number of different practices at the present time. I am very anxious to avoid invidious comparisons with other days, but in the old days, although practices were bought and sold rather haphazardly, practices hung together somehow.

In every purchase and sale there was an agreement for goodwill to be handed on. There was an introduction clause, as the result of which the practice was kept together, and there was a definite incentive for the vendor, or perhaps for the widow of a deceased doctor, to keep the practice together and to hand it on intact. Under present conditions, there is no such incentive on anybody's part. A vendor merely gives notice and goes and the widow of a doctor who died suddenly has no particular interest in the practice and, far from holding it together, may decide to hold on to the house and create difficulties in that way.

It is left to executive committees to make selections, which often makes the obtaining of a vacancy in a practice rather more difficult than obtaining of a political candidature. If there are appeals against selection and that sort of thing, the time between the practice being given up and the successor being appointed is increased, with the result that the practice often dissipates itself and patients drift to other doctors, or the practice is coalesced to other practices and multiple practices are formed, with the result that fewer doctors are employed and openings are closed down in that way.

It is equally difficult for a doctor to establish himself in an under-doctored area at the present time. There may perhaps be a need for doctors in such areas, but any doctor who wishes to set up there still needs money; he needs the purchase money for a house, and obviously, with uncertain prospects in front of him, he is 1743 not a good risk in any way for a building society or anyone to advance money to him on mortgage.

Those are the difficulties facing doctors today which I have tried to sketch out and put before the House. I hope that the hon. Lady and her right hon. Friend will consider them and perhaps discuss them with the medical authorities to see whether something could be done. There is an ever-expanding, crying need for medical attention to be available for everyone in the country, and I would ask that something should be done to make the fullest possible use of the medical manpower available.

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

My hon. Friend has raised a question in which he has a dual interest. as a professional medical man himself and also as a member of this House who has taken a great interest in this problem: but I do feel he has painted too gloomy a picture when we come to consider the overall position of doctors today.

May I first of all make one very important point? As I think he will be the first to agree, medicine is an entirely independent profession. It is a complete misunderstanding to suggest that the Minister is responsible for ensuring that every doctor is employed; he does not employ doctors directly, and very many of them appoint themselves by setting up in practice wherever they wish. Indeed, the profession would certainly fight to retain the liberty of choice as to the type of practice doctors may enter or the places where they should practise.

In the general practitioner service, most doctors are appointed by other doctors in partnerships. A few appoint themselves, by opening up in single-handed practice, though the tendency now is for partnerships of doctors to be established. Therefore, to calculate the overall number of practices as such is not to give a fair indication of the total number of practitioners in practice.

A small number of doctors come into the Service through vacancies advertised by local executive councils. Over 60 per cent. of doctors in general practice in the Service are working in partnership, and they appoint their own successors and 1744 their own replacements. Certainly, that is a principle which the medical profession would be the first to uphold, and they would be the first to object if there were any suggestion of selecting the partners with whom they would have to work in the closest contact and with the utmost confidence. They would certainly demand that they should retain the right to select their own partners when vacancies arise.

Single-handed practices which become vacant in the Service and are big enough to retain as single units are advertised and go to doctors in open competition. Clearly, we cannot lay down that any particular doctor, employed or otherwise, must have an automatic right to a vacant practice. He may or may not be a suitable candidate. Nor do we in any way direct doctors. There is inevitably disappointment to a doctor who has failed to get a post, perhaps in a locality where he would particularly like to practise, and unfounded suggestions are then sometimes made of ill-luck or ill-treatment in not being able to obtain a particular practice

I would like to assure the hon. Member that the number of doctors in practice is certainly not decreasing. May I give him an analysis of what has happened in the year from 1st January to 31st December, 1955? Practices which have become vacant owing to death or retirement or resignation numbered 259. One hundred and seventeen successors were appointed. Seventeen amalgamated with other small practices. That left a residue of 125 dispersed. Some of them were single-practice doctors who had died and whose practices had been given up. Against that, of the practices dispersed. 40 had no patients on their lists, so they would obviously have had no goodwill assets to pass on; 51 had under 300 patients, and perhaps the age and incapacity of the doctors had led to their practices running down in their later years; and 14 practices had lists of 700 or more, but in the majority of them certain significant factors applied, such as their being situated in a rehousing area and diminishing because of the population moving to other districts. That comprises the total of 125 dispersed.

During the year 613 doctors were admitted to the list to practise in partner ship. Of these, 297 were assistants entering into partnership in practices where they were already working. Therefore, the 613 shows a substantial balance 1745 of increase of doctors in practice against the 125 practices dispersed.

In a recent reply to a Question I told the hon. Member for Carlisle that out of 53,000 doctors in active practice, 35 were registered for unemployment benefit. Of doctors recently registered, the majority were so registered for under 13 weeks and only two for over 26 weeks. I have gone into the details of these cases with my hon. Friend at the Ministry of Labour. There are great difficulties in finding suitable vacancies for some of the 35 doctors. Some of them suffer from severe disablement, which makes it extremely difficult to fit them into active private general practice at present.

In some spheres, however, there is still a shortage of doctors. The number of doctors employed in the hospital service in England and Wales, which it is estimated was about 13,500 in 1949, is now 3,000 more. The number is still rising. In many areas great difficulty is being experienced in obtaining sufficient junior medical staff in the grades of registrar, junior hospital medical officer, senior house officer and house officer.

There are still many vacancies in certain areas. Some hospital doctors, of senior registrar status, have had difficulty in obtaining consultant appointments. This occurs mainly in the major specialties of general medicine, general surgery, orthopaedics and obstetrics and gynaecology. It does not occur in specialties such as anaesthetics, radiology and mental health, where the very reverse is true, there being still a shortage of fully qualified candidates for consultant posts.

I accept that these difficulties are evidence of some maldistribution of medical manpower as between the specialties. But any man going into the profession may choose the specialty where he thinks there will be scope and opportunity in the future. The problem is not one for solution by any directive from the Ministry.

There is no evidence of any real unemployment problem among doctors generally. Further, there is yet another field where there are vacancies. The Waverley Report on the Forces Medical and Dental Services made it clear that the medical branches of the Armed Forces have been unable to recruit an adequate number of medical officers for Regular and short-term commissions. So 1746 there are fields where there are genuine shortages. There are specialties where we want more medical staff, though there are certain grades which are adequately staffed at present.

The problem is therefore not an overall one of unemployment, but one primarily of distribution. This is particularly the case in general practice. The hon. Member complained in his recent Question that for every vacancy there have been between 80 and 100 applicants. In England and Wales in 1955 there were 84 advertised vacancies in general practice, and the average number of applicants was 43. Many of the applicants were already in practice and were applying for what they thought was a more favourable area because they wanted a change or because they wanted to enter a practice to become partners or principals.

My hon. Friend has quoted figures which are true only of a limited number of advertised vacancies in the South of England, because competition for vacancies is much higher there than in the North. The South of England appears to attract doctors, so much so that in fact my right hon. Friend the Minister of Labour and National Service, when addressing a British Medical Association conference, stressed the great opportunities and advised young doctors to go North.

In the North of England there are often as few as ten applicants for a vacancy; in the South the number may reach a hundred. In one case which was recently advertised in my, apparently, extremely popular home County of Surrey there were 150 applicants. Obviously, it would be a good thing if young doctors would concentrate their attention more on practices in the North, where there are the best opportunities and vacancies.

My hon. Friend complained about the difficulty of obtaining accommodation. We consider that to be a responsibility which any professional man faces, and it was a responsibility of doctors before the National Health Service, when they also had the responsibility of buying a practice.

There are only about 1,500 assistants working for general practitioners in the Service, and it is clear from the evidence published in the Annual Report for 1954 1747 that the turnover from assistant to principal is normally quite fast. Of the assistants who had been in post for one year or two years in 1954, there were 53 per cent. who changed their status. Nearly 75 per cent. of the assistants are in the age group of 30 to 35.

The number of doctors unemployed is a very small proportion of the total, and that figure is really not surprising if one considers that all doctors cannot be assumed to be equally eligible and competent. With all respect to the profession, there are bound to be some doctors not as capable and competent as others, by reason of age or some other handicap which might well mitigate against their chances of obtaining alternative practices.

Because of the future possibility of an over-production of doctors, a committee was recently set up under the chairmanship of the right hon. Henry Willink To estimate on a long-term basis and with due regard to all relevant considerations, the number of medical practitioners likely to be engaged in all branches of the profession in the future, and the consequential intake of medical students required. That is an important committee of investigation coming seven years after the 1748 start of the Health Service, and one which will certainly have to make such recommendations as it thinks fit on the possible future needs of the Service, and perhaps the expansion of certain specialities, such as those of mental health, which will no doubt have a bearing on the choice of specialities, and on whether students will aim to be consultants or go into general practice work.

I believe this to be a most important investigation, but I assure my hon. Friend that the evidence that we have at present is not such as to warrant the suggestion that there is severe unemployment among doctors. Certainly, in many branches of the profession there are vacancies still to be filled. I should not like the suggestion to go out from the House that there is significant unemployment in the profession or, indeed, that there is not wide scope at least in many parts of the country for the vast majority of qualified medical men.