§ Order for Second Reading read.
§ 3.32 p.m.
§ The Minister of Health (Mr. Derek Walker-Smith)
I beg to move, That the Bill be now read a Second time.
In its own context, this is an important Bill. It is not, of course, a Bill of the stature or social significance of the Mental Health Act, which I had the privilege to commend to the House earlier in the year, and, fortunately, I shall not need 70 minutes to explain it, as I did on the occasion of the introduction of the other legislation.
This is an important Bill in its own sphere; it will probably affect at least 30,000 people. It is also important in the general development of professional status and standards. Parliament has several times interested itself in providing an appropriate professional structure for callings which, in their diverse ways, contribute to the well-being of the nation. For example, arrangements have been made in respect of doctors by medical Acts from 1858 onwards, and last year we celebrated the centenary of the General Medical Council.
With chemists, the process started even earlier with Pharmacy Acts from 1852 onwards. There have been Dentists Acts from 1878 onwards, the most important being in 1921 and the most recent in 1956. The Midwives Acts date from 1902 onwards and the Nurses Acts from 1919 onwards. The most recent was the Opticians Act of last year, due to the enterprising initiative of my hon. Friend the Member for Wembley, South (Mr. Russell).
The examples which I have given are drawn from the health field, but there are others. For example, there are the Acts relating to architects in 1931 and 1938. I recall that in connection with the 1938 Act my father played some part. All this represents a massive contribution to diverse professions extending over the years. Now, in this Bill, we are doing it on an unprecedented scale, for eight professions at once. They are all making a distinctive contribution, but they are making it in the same general 873 sphere, of the promotion of health. These are not old-established callings, but their techniques have advanced and the scope of their activity has expanded significantly in recent years.
Perhaps the best known of these bodies, though not the most numerous, are the chiropodists. Their services are in big demand, and I was glad to be able to say, last March, that I was now able to approve schemes under Section 28 of the National Health Service Act in respect of chiropody. Dieticians are a small but useful body of people. Medical laboratory technicians work under the direction of pathologists. They are employed in the National Health Service laboratories and also in the National Blood Transfusion Service and in the Public Health Laboratory Service.
Occupational therapists are concerned with furthering recovery from disease or injury by recreational activity or work, including craft work, the activities of daily living and graduated industrial work. Physiotherapists are the most numerous of the eight and do valuable and important work, both in the hospitals and in rehabilitation centres. They treat disease and injury by means of massage and exercise and also by electro-therapy.
Radiographers are also a fairly numerous body, doing useful work, both of diagnostic and of therapeutic radiography. The latter involves treatment of patients by means of X-rays, radium or radioactive isotopes, in which the radiographer assists the radio-therapist or gives the treatment prescribed by him, under his supervision. The remaining two categories—remedial gymnasts and speech therapists—are relatively small, though the attitude of the latter is not as yet finally decided, but both make a useful contribution in their respective spheres.
The fact that there are eight professions, not linked in any common organisation, is one reason why it has taken rather long to bring the Bill before Parliament. It was better to wait for a Bill which represents the highest common factor of agreement and fairness to all than to have rushed forward with a Bill founded on less deliberate preparation, a less thorough examination of points of view and a less patient effort to promote agreement. Short cuts in such 874 matters may lead later to difficulty and dissension in the operation of the scheme.
There is a further conflicting factor in this case. In most schemes of this sort there are, I suppose, three main interests to be borne in mind. There is the interest of the general public, as potential consumers, clients or patients, whatever it may be; secondly, there is the interest of the already qualified practitioner; and, thirdly, there is the interest of the practitioner without degree, certificate or the like, whose only qualification is his practical expertise. In these eight callings we have those three interests to consider, but we also have a fourth interest, as, indeed, the name of the Bill implies; we have, in this case, to consider the medical profession, because these are professions supplementary to medicine.
Broadly, the position is that the doctor is responsible for the diagnosis of a patient's condition and for the prescription of appropriate treatment and the general supervision of that treatment. The members of the supplementary professions have specialised skills, gained from special training, in strictly limited parts of those fields, either in the performance of diagnostic tests or in carrying out particular forms of treatment. Such investigations or forms of treatment may, of course, form only a part of the general management of a particular case, and that general management must remain a medical responsibility, however completely parts of it may be delegated.
These considerations—the number and the diversity of the professions and their relationship with medicine—have necessarily complicated the formulation of our scheme. We have, however, been at pains to evolve a structure at once carefully balanced and workable. It has involved some delicate legislative engineering but we believe that the end product is good, satisfying alike tests of fairness and practicality.
Work has in fact been going on for a number of years. In 1951 the reports of the Cope Committees recommended that there should be a unified system of statutory registration. Subsequently a Working Party was set up to evolve a scheme acceptable to the supplementary professions. Both the Cope Committees under the distinguished chairmanship of 875 Sir Zachary Cope, as he now is, and the Working Party put in long periods of hard work resulting in valuable Reports, and I am sure that the House wishes to join in a warm tribute to their disinterested and useful labour.
Professional status gives added honour, but carries enhanced responsibility. It involves adherence to general standards and submission to common procedures. It requires, to support it a scheme of registration. This, in turn, requires approved qualifications and approved courses and examinations in respect thereof, for those seeking to enter the profession; and it requires a code of conduct for observance by those practising the profession, together with disciplinary procedures to enforce it.
All this the Bill provides for these eight professions, with the machinery to operate it. The right to use the title "State Registered" and the restriction of its use by those not so entitled, with the appropriate penalties for so doing is provided in Clause 6. We intend that the Bill should make it possible to distinguish people eligible for employment in the public service—health, welfare, school health and education—but I should like to make it clear that the Bill does not seek to ban the employment of other than registered people. The desired result can be achieved either by administrative means or by making regulations under existing powers, for example the powers in Section 66 of the National Health Service Act.
Similarly, the Bill does not prohibit private practice by unregistered people but merely protects the title "State Registered". Most of the professions concerned do not, in fact, engage in private practice. There is not, across the whole field, uniformity in the matter of prohibition amongst professions, but these supplementary professions will, under the provisions of the Bill, be in the same position as the medical profession, in which an unregistered practitioner is prohibited from using certain titles, such as "doctor", but is not prohibited from practising medicine as such.
I come, then, to the mechanics of registration. These are dealt with in Clause 2. The main burden of registration necessarily falls on the boards, of which there is to be one for each profession, 876 but certain functions also fall to the Council, which the Bill sets up to coordinate and supervise the work of the boards, and to the Privy Council, too. The functions of the Council and the boards are defined in Clause 1. Clause 1 (1) defines the general function of the Council and Clause 1 (2) defines the general function of the boards. Clause 1 (3) gives details of the general functions of the Council, broadly by way of advice, suggestion, recommendation and guidance. Its specific powers are set out later in the Bill. We feel that, by reason of its membership, the Council should be well adapted for its task of coordinating and supervising the work of the Boards and generally bringing a broad view to bear.
In respect of registration, and the matters requisite for it and leading up to it, the Council and boards have defined and complementary functions. The Council, after consultation with all the boards, makes rules with regard to the form and keeping of the registers, the making of applications, the prescription of fees, and so on. These rules, however, under Clause 2 (3) are subject to confirmation by the Privy Council. This done, the board receives and considers the applications for registration, prepares and maintains the register—Clause 2 (1)—and arranges for its printing, publication and so on under Clause 2 (4).
To achieve registration in the future, an aspirant will have to apply after the appropriate date to the board under the provisions of Clause 3 (1) and to satisfy the board that he has the appropriate qualifications set out therein. These will be broadly that he has attended an approved course of training and holds an approved qualification.
There is also the important matter of who shall be entitled to admission to the register initially. The applicants entitled to this will be those who have, at the material date, one or other of the qualifications set out in Clause 3 (2). Such qualifications are, in effect, eligibility for employment in the National Health Service under the regulations of 1954, or an appropriate qualification accepted by the board, or a combination of a qualification and practical experience. An applicant who is refused initial admission to the register will have a right of appeal to the Council. That deals with initial registration.
877 A future registration will depend on attendance at approved courses at approved institutions and the attainment of approved qualifications. This is dealt with by Clause 4, which is the longest and most difficult Clause of the Bill. Clause 4 provides separate machinery for the approval, first, of institutions and, secondly, of courses of training and qualifications. Institutions can be approved by boards, subject to an appeal, in the case of refusal, to the Privy Council.
Courses of training and qualifications are matters of major importance, because they provide, in effect, the basis of registration and entitlement thereto. The Council and the Privy Council, therefore, have vital parts to play, and the consent of the Privy Council is a necessary part of the machinery of approval and of withdrawing approval.
§ Mr. Kenneth Robinson (St. Pancras, North)
Will the Minister give examples of other registration Bills under which the Privy Council has the same kind of powers of approval and appeal as under the Bill?
§ Mr. Walker-Smith
Not in detail. I have here copies of some of the Acts which I have mentioned, but not all of them. The Privy Council has some part to play. For example, I think that I am right in saying that an appeal lies from the General Medical Council to the Privy Council in the case of a doctor struck off the register. It would be wrong to make an attempt at an "off-the-cuff" assessment of the exact part played by the Privy Council in these matters, but I will certainly bear in mind the hon. Member's interest in that aspect.
I was about to deal with withdrawals of existing approvals. Since the withdrawal of an existing approval is a particularly serious matter, the machinery for it has to be somewhat complex. Our intention is that the matter of withdrawal should not be embarked on without proper cause and that the body or person from whom approval is proposed to be withdrawn should know in detail the case he has to answer.
Coming to a little more detail, the procedure in the case of approvals of training courses and qualification, will 878 be this. The applicant—that is, the professional organisation applying for approval—will send the application to the board, which will send it together with its recommendations to the Council. The Council, in turn, will send it, together with its own recommendations, to the Privy Council which, after referring again to the applicant if it is minded to refuse, will determine the issue.
Withdrawal of approval can, under the provisions of the Bill, stem from the initiative either of the board or the Council. If it is the board's initiative, it must refer to the Council. If it is the Council's initiative, it must consult with the board. In either case, it is for the Privy Council to decide if there is a prima facie case to proceed. If it so decides, it will afford an opportunity to the person or body concerned to submit representations and to comment on the observations of the board and the Council. It is the Privy Council which makes the final decision in this important question of the withdrawal of an existing approval. If it decides that there is not a prima facie case, the matter lapses.
Having dealt with registration, I come to another matter to which I referred when I said, earlier, that one of the requisites of professional status is a code of conduct with disciplinary procedures to enforce it. The necessary safeguard of a disciplinary code and power to remove from the register is contained in Clauses 7 and 8. The mechanics of this comprise two committees under the provisions of Clause 7 (1), whose constitution and procedure are defined in the Second Schedule. The committees are committees of the board, but the rules regarding them require consultation with the Council and approval by the Privy Council.
§ Lord Balniel (Hertford)
My right hon. and learned Friend said that the procedure of the investigating committee is laid down in the Second Schedule. Will he tell us where? I can find the procedure of the disciplinary committee, but not of the investigating committee.
§ Mr. Walker-Smith
My hon. Friend is wrong, or more probably I am wrong, because if I said what he thinks I said I inadvertently misled him.
The constitution of both bodies is provided in Part I of the Second Schedule. 879 The procedure of the disciplinary committee is set out in Part II of the Second Schedule. It is not necessary to have a statutory code for the functioning of the investigating committee. The procedure of the disciplinary committee includes various safeguards to assure the appropriate judicial requisites of a fair hearing, and so on. Paragraph 3 of the Second Schedule provides those necessary procedural safeguards to ensure a fair hearing—that is to say, the right to be heard and represented, normally in public session.
Each committee will have a legal assessor, as provided for under paragraph 4 (1) of Part II of the Second Schedule. Under Clause 8 (3) an appeal will lie to the Judicial Committee of the Privy Council against "striking off". This, as I mentioned earlier, in answer to the hon. Member for St. Pancras, North (Mr. K. Robinson), is the same procedure as in the case of doctors dentists and opticians.
I come now from the disciplinary code to the important question of the membership of these bodies. The membership of the Council is dealt with in Part I of the First Schedule and that of the boards in Part II of the same Schedule. Provision as to tenure, expenses and other ancillary matters is dealt with in Part III, the supplementary provisions.
The Council is to have 23 members, composed in this way. Eight will be representatives of the supplementary professions—that is to say, one chosen by each of the eight boards. There will be eight medical practitioners and seven laymen, including a lay chairman.
Appointing will be done in this way. Of the 23 members, the Privy Council will appoint four laymen, including the chairman. The Health Ministers will appoint two laymen and two doctors, and the Governor of Northern Ireland will appoint one layman. Employing authorities—that is, hospital authorities and local authorities in the context of their health, welfare and education functions—have a proper interest in the affairs of the supplementary professions. In making the appointments for which they are responsible, Ministers will have regard to the desirability of securing 880 the representation of the interests of employing authorities.
On all the boards the supplementary professions will have a majority of one. Hon. Members can see that set out in a visually easy and graphic form in the table on page 16 in the First Schedule. They will see from the numbers listed in column 3 that in each case they represent a bare majority of the number given in column 2. This seems reasonable in view of the intimate concern of the boards with the affairs of the professions and their members. The minority—that is, those other than the supplementary professions—will consist of doctors, experts in professional education, and such additional specialists as are appropriate to the individual board.
§ Dr. Barnett Stross (Stoke-on-Trent, Central)
Have all these professions now agreed to the table and to inclusion in the scheme and the Bill? Most of us have been circularised by the speech therapists, who appear not to be willing to come in.
§ Mr. Walker-Smith
The position of the speech therapists, as I indicated earlier when I referred to the work that they do, is still an open one. I have received an official letter from the Speech Therapists' Association asking that I should receive a deputation to discuss the suggestion that the Bill should not, after all, apply to them. The hon. Gentleman may have seen the letter in The Times this morning setting out certain views, but he will also perhaps have seen the comment in The Times' leader that there seems to be no conflict between statutory registration, on the one hand, and these appropriate academic courses, and so on, on the other.
That is a view which might well commend itself, and I hope that in the event the speech therapists will themselves agree with the editor of The Times that there is no such conflict and will remain in the Bill, where they are at present. I do not think that I can comment further on it now, having received that letter from them.
So far as the other professions are concerned, the representatives of the supplementary professions met together at the Ministry last week, a reasonable interval after the publication of the Bill, and they are substantially in agreement with it. 881 The medical profession, as the hon. Gentleman may know, took the view that there should be either equality of representation between doctors and the supplementary professions on the boards, or that the Council should have over-riding powers.
As the hon. Gentleman will see from the Bill, I have not been able to meet either of those requests; but, on the other hand, I have strengthened the provisions in the Bill relating to the Privy Council, which, I think, should in another way meet the points that the medical profession has in mind. I am encouraged by a perusal of the leader in the British Medical Journal this week which, while still taking those points, does accord quite a warm welcome in principle to the Bill.
§ Mr. Arthur Holt (Bolton, West)
I wish very much to ask the Minister's help about remedial gymnasts. Perhaps I am under a misapprehension in thinking that all those modern teachers of physical education deal with remedial work in the ordinary course of their duties. Are not remedial gymnasts a specialised branch of those who teach physical education and may not there be some conflict between the work of these two groups if remedial gymnasts are classified purely as a branch of the medical service?
§ Mr. Walker-Smith
I do not think that the hon. Gentleman is quite right in what he is putting forward. All the professions with which we are dealing in the Bill were known formerly as "medical auxiliaries" and under that title they were inquired into by Sir Zachary Cope's Committee. They are supplementary to medicine, to use the contemporary term, in the sense in which I sought to describe their relationship with medicine.
The Bill is not designed to interfere with the inherent relationship between medicine and these professions. Clearly, no Bill either could do that or should set out to do it. The Bill is concerned with giving proper professional status and all that goes with it, by way of added honour and also added responsibility, to these professions. If the hon. Gentleman is still in doubt, perhaps he would seek an occasion to amplify his point when we have proceeded a little further.
§ Dame Irene Ward (Tynemouth)
Will my right hon. and learned Friend deal with what will happen if he is unable to persuade speech therapists to come into the Bill? Would not it alter the whole basis of the argument in the House today if there were to be someone going out of the group specially mentioned in the Bill? Will my right hon. and learned Friend deal with that before he reaches the end of his speech, but not at the moment?
§ Mr. Walker-Smith
When it is possible, I always like to deal with my hon. Friend's points as soon as I can. I do not think that it would alter everything. My hon. Friend is quite right in saying that if they do withdraw from the Bill—if I may put it in that way—it will have certain consequential results on the membership of the boards and of the Council, but I do not think that that would be any basic detriment, because, my hon. Friend will see that in Clause 9 we make provision for changes, either by increase or by diminution, in the number of boards once the scheme is in operation and the Measure is on the Statute Book.
That, of course, does not apply to the speech therapists. If they withdraw while the Bill is still going through the House, the convenient course would obviously be to amend the Bill both in relation to the specific references to speech therapists and to those consequential passages to which I have referred. That would be a decision for the the House to take. However, as I have said, I hope that on further consideration the speech therapists will decide to remain in the scheme and that we shall not need to make those amendments.
Before those helpful interventions, I was dealing with the membership of these boards and of the Council, and perhaps I should add that there are special arrangements in the Bill both to provide alternate members for the representatives of the supplementary professions and to deal with the transitional period before the registers are established. Alternate representation is important to the supplementary professions, whose individual members may well be prevented from time to time from attending because of, for instance, hospital duties, and they are, naturally, 883 anxious that their representation should not be jeopardised by any personal difficulties of that sort. Before the registers are established, the representatives of the supplementary professions will normally be elected by the registered members of the profession, but, in the transitional period, they will have a special arrangement.
It is right that I should refer to the medical interest in this matter. While it seems right that the supplementary professions should be in a small majority on the boards, for the reasons I have given, special consideration has been given to the position of the medical profession in view of its great interest in the training of the supplementary professions whose members assist in diagnosis and treatment. The Bill gives the medical profession a better position than that which it normally now has. At present, it is a purely informal one, in the sense that it has no statutory basis, and doctors are often weaker numerically on bodies dealing with educational matters than they will be on these boards.
I ought to make some reference to the financial position. Clause 2 (3) gives the Council power to prescribe registration fees, after consultation with the boards and subject to the approval of the Privy Council. Paragraph 17 of the First Schedule puts the financial aspect mainly in the hands of the Council. There will be a central secretariat, serving all nine bodies, to be appointed by the Council.
Not only is this administratively convenient, but it is economically advantageous that these matters should be dealt with centrally rather than by each body piecemeal. Economy is important in this connection as, indeed, it is in most contexts, because although, as a professional scheme, this must be self-supporting we are anxious that the fee should not be too high—an anxiety, I may say, fully, and perhaps principally, shared by members of the professions themselves.
In answer to my hon. Friend the Member for Tynemouth (Dame Irene Ward), I referred to Clause 9. The House will see that although the Bill sets up machinery for the professions listed in Clause 1 the position is not thereby frozen, because Clause 9 makes it pos- 884 sible for the application of this Measure to be extended—or, indeed, restricted, if need be—by order of the Privy Council on the initiative of the Council. This provides, for example, for the possibility that a new profession might develop sufficiently to merit registration, and also covers the possibility of the amalgamation of any two of the professions at present listed, thereby reducing the number of boards required.
I have dealt with the various activities, and the part to be played by a Privy Council in this procedure, so I need refer only briefly to Clauses 10 and 11. Clause 10 gives default powers to the Privy Council. This, of course, is common form, but I do not envisage the probability that these powers will, in fact, ever have to be used.
I think that I have given a sufficient, but, I hope, not too tediously long, explanation of the purposes and provisions of the Bill. It is a Measure that serves a useful purpose, and one that we hope will give a good deal of satisfaction to those primarily concerned. I do not think that it is a Bill that invites party difference, but that, I know, does not mean that it is necessarily and in all respects a non-contentious Measure. Indeed, I have enough experience of such Bills to know that they often give rise to keen debate on differences of views sincerely and often strongly held.
It is certainly my view that the Government should pay full attention to the views expressed in Committee, and should seek to strengthen and improve the Bill by incorporating all suggestions, from whatever quarter, that will have that effect. I think that I have given some practical evidence of this approach in two long and complex Measures—on the Mental Health Bill during the last Session of the last Parliament, and on the Copyright Bill, in 1956—in both of which, I remember, I had the constructive and sometimes critical help of the hon. Gentleman the Member for St. Pancras, North,
I do not anticipate a Committee stage on this Bill of more than a fraction of the length of the Committee proceedings on the two Bills that I have just mentioned, but I shall certainly approach my task in this case in the same spirit as I did then. I would just add that the Bill as we now have it represents the highest 885 common factor of what is appropriate and acceptable, worked out after close consultation and long endeavour. I hope, therefore, that hon. Members will recognise that, and will, after the appropriate scrutiny that it is their duty to give to the Bill, agree to its main essentials in the form in which I now commend it.
§ 4 15 p.m.
§ Dr. Edith Summerskill (Warrington)
It has been said on many occasions in the House that the House of Commons is at its best when discussing social Measures. I think that we can include this Bill as an important social Measure, and I thank the Minister for going into considerable detail and explaining some of what I might call the cumbersome machinery that it has been thought necessary to inject into this piece of legislation. The Minister will probably agree with me when I say that any Amendments relating to administration are suitable for discussion in Committee, so I propose to postpone to that stage anything that I have to say on detailed Amendments.
The right hon. and learned Gentleman reminded the House of legislation for the registration of other professions and supplementary professions. Although this is a short Bill, it is a significant one, because it will always represent a landmark in the progress of medicine. While we pride ourselves on our scientific advances and our increased expectation of life, we sometimes fail to recall that doctors themselves were only registered under the Medical Acts of 1858 to 1886.
In his opening remarks, the Minister recalled the part that his father had played in the framing of those Acts. My father was one of the first to be registered under them. Indeed, his first assistantship as a registered doctor followed on an unqualified practitioner who, besides making the pills and doing a little medicine, drove the coach and went to see how the confinement was progressing.
Then came the Medical Registration Acts. Later, midwives and nurses were registered, and it was, I think, in 1924 that the unqualified woman was finally prohibited from conducting a confinement and we said "goodbye" to the 886 Mrs. Gamp. I suppose that it is impossible to estimate how many lives have been lost or shortened by the ministrations of the well-meaning but unqualified dabbler in medicine who was free to practise in a chosen field without adequate training and control.
Although we now propose to register eight professions supplementary to medicine, the unqualified practitioner will still be allowed to practise. However, the Minister will probably agree that our experience in this respect is that when State registration is established those who are anxious to enter into one of these professions aspire to be State registered, and the unqualified man or woman gradually disappears.
The Bill also emphasises the diagnostic and therapeutic advance in medicine which calls for increasing specialisation in more and more limited fields. There is a tendency for members of the public sometimes to become a little irritated with the number of examinations that have to be undergone when their doctor suspects that they are suffering from a certain condition. The fact is that in medicine today more and more specialisation is being introduced. That is a mark of our progress, and I have no doubt that there will be more of these professions subject to the provisions of the Bill.
According to the Reports of the Committees on Medical Auxiliaries set up in 1949 under the chairmanship of the gentleman who was then Mr. Zachary Cope, all the professions then concerned accepted statutory registration as a desirable objective, and I feel quite sure that, despite the speech therapists whom we shall also probably discuss in Committee, all those engaged in these professions recognise that a State-registered qualification is the only way to avoid confusion and danger caused by large numbers of people professing to have some kind of qualification to practise.
I do not want to digress, but I only wish that we could somehow control drugs, or those who prescribe them, by means of a Bill like this. It is very necessary to protect the public. Medicine is progressing. New drugs, new methods of diagnosis and new approaches to therapeutics are almost daily being discovered, and it is more than necessary 887 to protect the public who have no means of evaluating the training or the skill of any individual.
It seems that so far as the broad principles are concerned, seven of the professions accept the Bill. The exception of the speech therapists I will leave to my hon. Friend the Member for St. Pancras, North (Mr. K. Robinson) to deal with later. I have a letter from Professor Court on this subject. The speech therapists brought a deputation whom my hon. Friend saw, and I am sure that he will raise the matter. No doubt, hon. Members in all quarters of the House saw in The Times a letter which went into some detail on this subject.
May I say, in parenthesis, to the Minister that he knows this question has dragged on for years, and I was a little surprised and very disappointed that he gave us only a week between the presentation and the Second Reading of the Bill. Some of us who have had engagements over two weekends have found ourselves literally with only five days in which to study the Bill, and these excellent people, quite understandably, wanted to see us and bring their deputations. They wanted also to discuss with their members before they came to see us. It is difficult to understand why the time has been so limited. I ask the right hon. and learned Gentleman, when the Committee stage comes along, to be a little kinder and to give us a little more time in which to consider the details of the Bill.
I wish to grasp a nettle which the Minister has failed to grasp. I must confess that, having been a Minister myself, I would have adopted a different approach and grasped this nettle strongly, because it is very important. The fact is that the strongest objections to this Measure come from the British Medical Association. I understand that these objections have been conveyed to the Minister and to the organisations of the professions represented in the Bill. As this is a Government Measure, with a powerful majority prepared to go into the Lobby to support it, objections to the Bill from whatever source could be totally disregarded and the Bill put on the Statute Book. However, it would not be in the traditions 888 of this House or in the best interests of the professions concerned if we did not carefully examine the opposition coming from representatives of the medical profession.
As I have said, these negotiations with the medical profession and with these other professions which are mentioned have been going on for a long period. It appeared at one time as though all the difficulties had been resolved. However, there seems to be a change of heart by the British Medical Association at the eleventh hour, and a change of heart on a fundamental principle. I feel that this calls for some clarification when the hon. Lady the Parliamentary Secretary winds up the debate. The Minister, to my surprise, treated it a little lightly in saying that he thought, in view of the article in the British Medical Journal last week, that the British Medical Association was now placated.
I have received a communication from the spokesman of the British Medical Association and I think I should read it, at the risk of boring the House, because it does not convey to me what the Minister has endeavoured to convey to the House. The letter says:We are very disturbed to find that the constitution of the Council and boards proposed in the First Schedule is quite contrary to the carefully considered advice given by the medical profession. In the individual boards the supplementary professions have an overall majority. In the Council the supplementary professions have parity with the medical profession and even a majority of one should the General Medical Council representative not be a doctor. In the vast majority of cases the members of the supplementary professions work in association with medical practitioners. The General Medical Council permits such association subject to the guidance of paragraph 5 d (3) of the Notice of its Disciplinary Committee:'… provided that the medical practitioner concerned exercises effective supervision over any person so employed and retains personal responsibility for the treatment of the patient.'Thus the doctor must bear responsibility for the actions of these members of the supplementary professions. Yet in this Bill the medical profession may well be denied the last word in deciding standards of education and professional conduct of these same people. The position could in our view become dangerous for all concerned, especially the patient, and calls for profound alteration of the terms of the Bill.889 I consider this to be very strong language which cannot be lightly dismissed.
Furthermore, the British Medical Journal, on 28th November, in an article on registering medical auxiliaries, stated:The medical profession is right to claim that professions supplementary to it should remain under its wing, because the ultimate responsibility for treatment must lie with the doctor.Having given the opinion of the British Medical Association I would say to their spokesman that there, in the British Medical Journal of this week, is the fallacy. The Bill does not deal with treatment. It deals only with the task of promoting high standards of education and conduct. From the point of view of the treatment of the patient, the relationship between the conscientious doctor and his colleagues working in one or other of these fields will not change. The regional hospital boards, the hospital management committees, even the house committees, exercise the greatest vigilance over the relationship of the staff and the treatment offered. Apart from the high sense of duty of those who work in the field of medicine, it must not be forgotten that the patient also has powers which he can invoke if he believes that he has not been given proper care and attention.
It is implied in the article in the British Medical Journal that, unless doctors predominate on the registering bodies, the standard of work will deteriorate. Hon. Members generally attend health debates and have considerable knowledge of hospitals and the world of medicine, either from their own professional experience or from the experience that they have gained from administration, and I would say to them: does any radiologist believe that a radiographer would be less conscientious in her work if she were given the right to determine the educational and ethical standards of her profession? I cannot believe that she would.
The control which is now demanded by certain representatives of the British Medical Association cannot reflect the opinion of all fair-minded doctors who work in harmony with these other professions. Indeed, the original Report on which the Bill is based proved this. The Zachary Cope Committee presented a 890 majority and a minority Report, and in both it is recommended that medical auxiliary members should be in a majority on the professional committees. This, perhaps, might have been disregarded if the medical profession had not been represented or consulted, but it had a distinguished surgeon in Mr. Cope—now Sir Zachary Cope—as the chairman, and doctors were represented on every one of those committees.
It certainly took plenty of time to consider the aspects which the British Medical Association presents in its protest. The Committee was set up in May, 1949, and reported in April, 1951, and eight years have now elapsed before we have this Bill before us. I believe that the Minister, last March—and, again, perhaps the hon. Lady will tell us more about this when she winds up the debate—heard the opinion of the joint consultants' committee with representatives of certain specialised medical associations. I should like to hear whether the Committee reiterated what it said previously, or whether this year it adopted an entirely different attitude.
I ask this question because, five years after the Cope Committee had reported, in 1956 the association of the professions mentioned in this Bill were given permission to publish the provisional scheme for the statutory registration of professions supplementary to medicine. The composition of the co-ordinating Council and the registration boards was explained in the various journals, and this was all known, no doubt, to the right hon. and learned Gentleman's Department. Of course permission was given to these professions to give this publicity in their journals. It appears that, after the professions had agreed on what was thought to be the final draft, they have now been asked by the right hon. and learned Gentleman to consider one of two proposals put forward by the British Medical Association.
I have here the proposal that was circulated by the Joint Council of the Associations of Occupational Therapists of Great Britain. After all these discussions for years, the Minister asked them to put to their members these proposals:That the number of medical members on each Registration Board should be equal to the number of members of the Supplementary profession concerned, and that each Board should have an independent lay chairman; or891That the Co-ordinating Council would be given overriding powers in relation to the Registration Boards.Those professional bodies which have had time to communicate with me are extremely disappointed, after all these years of negotiation, to be asked to reverse a previous decision.
The Minister explained in detail the purposes of the Bill, and has made it clear that he proposes to go forward with it, but, in the profession of medicine, it is extremely important that there should be harmonious relations. With this history, which I have tried to abbreviate, it is unfortunate that suspicions should now have been injected into the minds of members of these professions. I think that this is a time—because HANSARD will be very well read tomorrow—when the Minister and the Parliamentary Secretary should endeavour to remove all these suspicions, and, indeed, should endeavour to explain to the British Medical Association why its fears are unfounded.
For instance, this question should be posed to the British Medical Association from this House. Would it suggest that doctors should control the nursing profession? Of course not. Has it even been suggested that the nursing of patients suffers because of a lack of control of nurses by the doctors outside the wards, so far as their ethical code and their education are concerned? If nurses are fitted to make decisions concerning the conduct of their profession, are not radiologists, occupational therapists and others, who work so closely with the nurses?
May I now deal with some of the fears of the doctors about the composition of the boards, having myself served on a number of committees on which are represented various groups with some interests in common. I have observed that there is no guarantee that these individuals will act in concert when a vote has to be given. The doctors need have no fear that the representatives of these different professions with such differing functions—the laboratory technicians, the chiropodists and the occupational therapists—will necessarily conspire together. On the contrary, they may have entirely different approaches to their problems.
892 Furthermore, in the composition of the Council, it seems to me that the eight doctors on the Council will tend to vote together, but on a serious matter of principle they will have the support of the persons appointed by the Privy Council and the Ministry. I cannot believe that these representatives will give their votes without very careful consideration of whatever principle is involved.
Having given this matter very careful consideration, having examined the objections—and I am very glad to have had the opportunity of ventilating those objections—I believe that it is right for my right hon. and hon. Friends to support this Bill. The professional bodies mentioned in the Bill should be given the right and the responsibility which goes with it to decide matters closely affecting their professional lives. I should like any hon. Members who entertain any doubts about the capacity of these men and women to control their own affairs to examine the syllabus of their training. I have found that many of these people, formerly known as medical auxiliaries, have a true vocation and a deep interest in medical matters. On further inquiry, one often elicits the information that only limited financial resources have denied them an opportunity of studying medicine.
In my day—and hon. Members on both sides of the House who are members of the medical profession will agree—parents had to be prepared to spend a fairly large capital sum before they could allow one of their children to enter a medical school, but here, in these auxiliary professions, we sometimes find people who are more dedicated to medicine than even the doctor who went into medicine because his parents were able to afford a medical education. It is true that a doctor has a more extensive education, which takes a longer time, but, because of that, doctors cannot claim a moral superiority. The doctor with a superior education is not necessarily a more worthy person. His liability to err, as we often see in our newspapers, is not known to be any less than that of those people who are devoting themselves to these auxiliary tasks.
I believe that the fears which have been expressed by the British Medical Association are unfounded and that we look forward to the medical profession giving a helping hand to the men and 893 women in the younger professions—the people whose skill and industry are so helpful to the doctors and so beneficial to the public.
§ 4.39 p.m.
§ Sir Hugh Linstead (Putney)
I have taken part in many health debates in the House in which the right hon. Lady the Member for Warrington (Dr. Summerskill) has also participated, and it is, to me, a particular pleasure to find an occasion when, at long last, I can endorse wholeheartedly every word that she has spoken. I only wish that her eloquence today could have been mine.
The professions which are concerned in the Bill rather rapidly formed themselves into a committee in the hope that they could deal with these things together, and I had the honour of acting as chairman of that committee. I think that I can say, on behalf of all of them, to my right hon. and learned friend that they thank him very warmly for the way in which he has been able, after a good many months of very complicated negotiations, to meet their point of view and to give them what I believe to be an excellent hope of development in the future.
It is a pity that there are three doubts connected with the Bill, one being related to the position of the speech therapists, another being about the attitude of the British Medical Association towards the Bill, and a third being concerned with finance, which, I know, still causes concern in the minds of members of the professions.
Before I come to those three matters, I wish to refer to the position which the Privy Council and the Judicial Committee of the Privy Council are given under the Bill. It is, I think, particularly valuable that the Privy Council, which has gathered under its wing over several centuries the professions incorporated by Royal Charter, should now take under its wing these professional people who are just reaching statutory standing.
I notice that there is, in Clause 11 (1), a provision—my right hon. and learned Friend did not refer to it—which lays down that the quorum of the Privy Council shall be two. I suspect that that is probably my right hon. and learned Friend and the Secretary of State for Scotland. But, at any rate, they will be wearing their top hats; in 894 other words, when they are acting as the Privy Council for the purposes of this Bill, they will be a little divorced from the day-to-day Departmental hurly-burly in which they decide things as Departmental Ministers. I am very glad that, even with that slight nuance, which, perhaps, not everyone has yet noticed, it is the Privy Council and not Departmental Ministers who are to be concerned here.
The hon. Member for St. Pancras, North (Mr. K. Robinson) was justified in raising a question about the very substantial powers which the Privy Council is given. They are quite unusual. Like my right hon. and learned Friend, I have not had an opportunity of looking back over other registration Measures, but I have the impression that nowhere will we find such heavy additional powers, nor will find so many matters reserved for the approval or disapproval of the Privy Council. Nevertheless, when one considers that we have brought together in this Bill a substantial number of professions, not all yet at the same level of development, it is probably wise that the Privy Council should have a general co-ordinating power over and above that of the proposed Council. One expects that those powers will never need to be used, but they are there, and they are unusual.
There are about 1,000 speech therapists today, and it is curious that, at the very last moment, a professional body of people, so far from asking for statutory registration, should actually be backing away from it. I am glad to hear the speech therapists have asked my right hon. and learned Friend whether he will meet them. I assume that, if a meeting can take place, a discussion will follow, completely free and without commitment on either side. I hardly think it possible to bring a profession within the ambit of the Bill against its will. It would be a grave error to try to find certain people who would serve on boards and councils against the wish of the bulk of the profession.
§ Dr. Stross
The hon. Gentleman has said that there are about 1,000 speech therapists. Has he the up-to-date figures for those in the hospital service? In the Report which we have all studied it is said that, in 1950, there were 20 whole-time and 92 part-time.
§ Sir H. Linstead
That is relevant to the next point I wish to make.
If the speech therapists maintain their position, that will be, I am sure, because they regard the natural area for the great bulk of their work as being education rather than health. My understanding is that over 80 per cent. of speech therapists today act through the local education authorities, not within the hospitals or the National Health Service. In a sense, they have a good and logical ground for saying that they do not fit into the picture of which the Bill is part. Nevertheless, there is the opportunity for statutory registration. If they do not take it now, they could, conceivably, take is later on, under the provisions of the Bill, and I hope that they will find, when they meet my right hon. and learned Friend, that it is possible to reach an understanding with him.
After what the right hon. Lady the Member for Warrington has just said about it, with which I entirely agree, there is very little I wish to add about the attitude of the British Medical Association. It is a very great pity that, on the one side, these auxiliary professions should have reached the stage when they could say, "If we are to have medical superiority on the boards, we are not going to work the Bill"—they took as extreme a view as that—while, on the other side, the British Medical Association should, in effect, have said, "This is a bad Bill because we have not a numerical majority."
It seems to me that both these extreme points of view are really untenable. The Bill will work, if it is to work at all, not on the numerical basis but on the basis that doctors want to help the professions and the professions recognise only too well their position in relation to the medical profession. Neither extreme point of view is tenable.
I am quite certain that my right hon. Friend is right here. We are trying to set these professions on their statutory feet and give them an opportunity to develop their own future. By and large, that can be done only if they feel that they are mistress in their own house, under the guidance of doctors but not under their direct control.
The claim of the doctors to have responsibility for what is done by the members of the supplementary profes- 896 sions was entirely answered by what the right hon. Lady said. The analogy with the nursing profession does, I am sure, provide the final practical test. Nobody would suggest that nurses act otherwise than in accordance with the instructions of medical practitioners, but, equally, no one will concede that the work of the nursing profession suffers at all or is, indeed, other than advantaged by the fact that its registration and its examinations are controlled by the best members of the profession itself.
The question of finance is causing much concern to the professions at the moment. They estimate that about 20,000 of their number will be registered under the Bill. My right hon. and learned Friend gave 30,000 as the figure. A sum of £2 10s. has been mentioned as the registration fee for the first year, the initial registration, and £2 for subsequent years. Those figures are regarded by the professions as being high, and what concerns them is that there is, apparently, no other way of financing the working of the whole scheme except by the fees which they will have to pay.
In other words, they envisage, in theory at any rate, a limitless call upon the professions. They are not highly paid professions by any means. Each of the professions has its own professional association, and they are afraid that, if the registration fee is too high, the effect will be that members of the professions will seek to economise on their subscriptions to their own professional associations.
It would be a very great loss if that happened, because nothing is so revivifying to the professional man as membership of a live professional association. We must, for example, think of the start of this scheme. There will, presumably, have to be an office building somewhere, and office buildings, and all that goes with them, are by no means cheap.
I should like to ask my right hon. Friend why he did not accept the recommendation of the Cope Committee that the original cost of setting this machine on foot should be borne, if not by the National Health Service, by the Ministry. If that could be done, it might not be unreasonable for the professions to carry on the current expenditure year after year. I hope that when my hon. Friend the Parliamentary Secretary 897 replies she will say whether that recommendation can still be accepted and, in particular, whether the Minister has power to help if it becomes really necessary. Has he barred himself completely from giving a subsidy if the cost is found to be too high? After all, as Minister of Health, he has an interest in getting these professions on their feet.
A small question which my hon. Friend may be able to answer is this: in the first year, does a practitioner have to pay a registration fee and a retention fee for that year? I think not, but there are those who hold a contrary view, saying that a person pays a fee to get on the register and immediately becomes liable for the retention fee for the first year of registration. It would be helpful if my hon. Friend could clear up that small point.
I have only two further points, one of which I think is important. If my right hon. Friend would look at page 8 of the Bill he will see that by Clause 6 (1) we are giving the persons we are discussing entitlement to use the titlestate registered chiropodist or state registered dietitian.The people concerned are very happy about that. Subsection (2) lays down descriptions that may not be used by people who are not registered. There is no prohibition clearly set out in Clause 6 (2) upon the use of the word "Registered" without the word "State." It is possible that that is caught under subsection (2, b) by a person pretending that his name is on a register established under the Act, but it is not by any means certain. It was interesting to note that my right hon. and learned Friend said that the scheme does not seek to ban from employment persons other than registered people. He used the phrase "registered people" because it came naturally to his tongue. I think that the word "registered" should be clearly and specifically barred from being used by those not registered under the Act.
The other point to which I want to refer, perhaps a little lightheartedly, seeing that it is St. Andrew's Day, concerns paragraph 5 in Part II of the First Schedule. It will be seen that it is provided that there shall be at least one representative of Scotland and one of Wales on the Council and, I think, two representatives on the boards. There is 898 no provision for a representative of England. Surely it will be occasionally necessary for a representative of England to have a place on the Boards. What would happen on the Occupational Therapists Board if all the representative members came from the West Coast of Scotland, I shall leave my right hon. and learned Friend, in horror, to contemplate.
§ Mr. George Lawson (Motherwell)
Would not the hon. Gentleman agree that then English would be spoken as it should be spoken?
§ Sir H. Linstead
Having listened to the hon. Member, I cannot agree.
Finally, I should like to commend the Bill to the House and to thank and congratulate my right hon. and learned Friend on having brought it before us.
§ 4.55 p.m.
§ Dr. Barnett Stross (Stoke-on-Trent, Central)
I heartily agree with the fears of the hon. Member for Putney (Sir H. Linstead) about the lack of financial provision for assisting the setting up of a group of organisations ancillary to medicine. As the hon. Member rightly pointed out, 50s. for registration for the first year and 40s. for each and every other year is a fairly large sum for professional people whose salaries are rather mean, since the Ministry of Health is acknowledged not to pay very well. If the Minister will accept what was urged on him by the hon. Member, namely, that assistance should be given in setting up the organisation, I am sure that we on this side would agree wholeheartedly.
The Bill, which we have had with us for only a short time, has given me an opportunity to read something which I had not read before, namely, the Cope Report. I am delighted to have had the opportunity of reading this Report, because I found it full of most interesting information, and was well worth while perusal. When I first looked at the Bill, I thought that it was a narrow, small Bill which would not evoke much interest in the House, that it was a piece of machinery for registering members of the profession and for regulating their educational and professional conduct.
Having heard the Minister and my right hon. Friend the Member for Warrington (Dr. Summerskill), however, I accept completely that it is a triumph 899 to have brought these organisations together. I hope very much that none of them will secede but will stay under this vast umbrella, for reasons which I propose to give.
I was shocked by something that the Minister said about dietitians. I took down his words. He referred to them as a small but useful group of workers. It is the word "useful" which I find objectionable, for this reason. The Minister, of all people, should be the greatest enthusiast for preventive medicine. If he wants to save the country money, and to preserve the nation's health, he must want to prevent disease, and, of course, dietitians and their knowledge, which is available in greater measure compared with pre-war years, are a very powerful therapeutic weapon. The right hon. Gentleman should give them great priority and not merely dispatch them as a small but useful body. I shall gladly give way to the right hon. and learned Gentleman if he wants to say that he did not wish to cast any aspersions upon this remarkable group of people.
§ Mr. Walker-Smith
I certainly did not mean to cast any aspersions. After all, in the vocabulary of politics, with which we are all familiar here, we would take the description "a small but useful body" as being reasonably laudatory. I certainly think that they do valuable work. It is not a large body numerically and that is what I meant when I used the epithet "small". As I say, they do very valuable work, and I am grateful to the hon. Member for supplementing any deficiences of mine in giving them due recognition.
§ Dr. Stross
On behalf of anyone who is dietetically interested, I am sure that that is a handsome reparation.
As a rule, we in this House use carefully-controlled words. We are rather like the Royal Fine Art Commission, of whom it is said that a tepid criticism means that its members dislike a project lock, stock and barrel and do not want anything to do with it, as must be true about Piccadilly Circus, concerning which they made a tepid criticism which really meant that they could not bear the sight of the project.
I will follow the Minister's tribute by quoting what was said about dieting a 900 little over 200 years ago by a famous Frenchman, Lemery. He said:In the mean Time, if Foods contribute so necessarily, to the Preservation of Life and Health; they also produce the greatest Part of those Distempers, to which we are subject, and many Times, by the ill Use of them, cause even Death itself. All which being set together, we may easily see, that the Groundwork of our Preservation, consists chiefly in a knowledge of suiting Foods to every Constitution, as it best agrees with it; and so the Knowledge we ought to be most desirous of, should be that of Foods.Having made that quotation from an old authority, I will go on with my speech.
In the machinery of the Bill, it is absolutely right that each of the professions should be, as they are now, represented on the Council. Originally, in the Cope Report, that was not to be the case and the professions with which we are dealing found it objectionable to be left out. The way that they behaved to each other in their discussions is interesting For example, the physiotherapists were a very large body; there were many thousands of them on the register and at study. The remedial gymnasts, on the other hand, were a tiny body. The physiotherapists said, "For the sake of unity, we will accept that they should have the same representation as we have, one representative for them and one for us."
With that attitude and with that desire for unity, I again feel that it would be a great mistake for speech therapists to break away and not take advantage of what they may well get out of these proposals in more ways than one.
§ Colonel Sir Malcolm Stoddart-Scott (Ripon)
The hon. Member spoke about the remedial gymnasts as being a tiny body. He did not say that they were a useful body, too.
§ Dr. Stross
The hon. and gallant Member ought to know that I shall make a considered speech. I hope to discuss the question of remedial gymnasts in Athens and Rome in olden days and make comparison with our knowledge now and I hope that before I sit down, I shall have satisfied the hon. and gallant Member and the House.
At the date of the Cope Report, in 1950, there were 200 remedial gymnasts and the figure for the physiotherapists, 901 including those at study and those in practice throughout the country, was roughly 13,000. This adds point to what I have said about the desire for unity. In an intervention, I have pointed out how few speech therapists there are in hospital practice. It is true that most of them find their work in the education departments of local authorities and this, I think, will always be so, but that is no reason why they should not come in with the other seven organisations.
In the letter in The Times this morning, which we have all read, and which is signed by Muriel Morley, lecturer in speech pathology, Donald Court, and so on, all eminent people, there are one or two sentences which I must quote, because behind their feeling of disagreement this may be playing an important part. They write of their organisation that it has maintained a high standardin spite of the failure of the Whitley Council to give adequate recognition to the status and responsibilities of the profession—an indifference reflected in a salary scale from £455 to £815 per annum. This inadequate remuneration excludes men in this country from entering the profession, induces many speech therapists to seek employment oversea, and creates a serious problem of understaffing for many education authorities and hospitals.If this be true—and I am sure it is—I would have thought that this was an added reason for them coming in and accepting State registration with all the additional power that it would give them; for it will have been noticed that whenever the affairs of one of these organisations is to be considered, it will not only be their one representative on the Council who will be present, but two others may be brought in without voting power on to the Council while discussion takes place. Surely, therefore, the very argument in the letter which I have quoted is a good reason why they should come in.
In the letter and the circular that we have had from the speech therapists, they speak of the fact that there is not by any means complete knowledge about speech mechanism, that a good deal of physiological and pathological work must be done at the universities and that they are looking forward if we leave them alone and do not ask them to come in, to having diploma and, I suppose, later, degree courses in speech therapy. Why not?
902 There again, the article in The Times—not the letter but the leader—is quite right. The speech therapists can do all this and still have State registration and do nothing but gain by it. If, however, as a last resort, they refuse, we cannot help it. They will be free if they insist upon it. I can only say that I hope they will listen to what some of us in this House are saying and to what we shall say in Committee and realise that they can do nothing but gain. We cannot see how they could possibly lose.
Concerning the medical practitioners, I listened with great care to my right hon. Friend the Member for Warrington. I am sure that she is right. I was interested that the hon. Member for Putney agreed with her, too, and I am glad he did. I do not give second place to anyone in my pride in the profession in which I was trained and practised for so many years. If, however, there is one thing that can do us harm in the profession, it would be to make excessive demands upon organisations similar to our own who, according to the Cope Report, must have a high standard of education before they are allowed to start training and who, before they are allowed to begin, must have two or three gruelling years and then only get their full registration after further years of practice. At the end of it, radiographers, for example, will start at £10 a week, after many years when they have a senior position they may get £14 a week and, perhaps, they will never be able to reach £1,000 a year.
We in the medical profession must be a little careful. In any case, my right hon. Friend was absolutely right when she asked what there was to be afraid of. On the Council, there is to be parity and after parity the Privy Council is to be responsible for four nominations, the different Ministries for two and the Governor of Northern Ireland for one. So there are eight medical and seven non-medical members. I cannot imagine the rest not being influenced by these learned medical men and women who will be sitting and advising on the medical aspects whether of education or of ethical conduct.
I think that the Minister has gone as far as he need or should go in this matter, and I would strongly support him. I think that it is well known, from the fifteen years I have been in this House, that I have always supported my 903 own profession. I have always thought most highly of it, and I am very proud that I was ever allowed to train in it, but I think that in this case something has gone wrong in its thinking. I think that it is mistaken, just as, on the other hand, I think that the speech therapists are entirely mistaken in taking exactly the opposite lines. They say they will not come in at all unless they have absolute autonomy.
Both sides in this matter seem to be wrong. After all, the Privy Council is just as likely to think of the interests of the patients as doctors are, and really it is the patients we are talking about here, for this Bill is a piece of machinery to assist patients through all time wherever they need it.
When we look at this list of professions we have to be honest with ourselves and ask, "How much do they owe to medicine pure in their own evolution?" The Minister said they are not very old. I think that he said that the chiropodists were the oldest.
§ Dr. Stross
Yes, the best known. They are the best known and have been established a long time. I think that they started in the eighteenth century in separate practice.
The dietitians, I think, evolved originally without a tremendous amount of assistance from medical practitioners as such. The work of dietitians depended, I think, in the main, upon a handful of devoted and skilled physiologists, both medically trained and non-medically trained, and chemists. It is a quite recent science. The old world knew a good deal about nutrition, but knew it only through practice, through trial and error, rather than by scientific method. Yes, apart from chiropodists, the remainder of the others are less than a century old.
I was asked a question about remedial gymnastics, and I think that I have got to say that any physician in Rome 2,000 years ago knew much more about it than any practising medical practitioner does today—any medical man practising as a general practitioner. For obvious reasons. We know they used them extensively and that they had very great experience.
904 As for the dietitians, there is a note on page 49 of the Cope Report which is extremely interesting. It says:Even as recently as 1939 it was the usual practice in hospitals to provide for patients but one full meal each day.I know that this is true. My right hon. and learned Friend knows it is true. For breakfast and supper patients who could afford it arranged for eggs, butter and fruit to be brought in. There was one full meal each day, and for it there was bread and tea, or bread and jam and scrape—for supper and breakfast; and if one wanted additional things one had to have them brought in. That was as late as 1939 and yet by 1950, the Minister knows, we had only 134 whole-time and five part-time dietitians in the National Health Service.
This is an extraordinary thing, and this accounts for my outburst at the beginning of my speech because the Minister used, I thought, a rather patronising term about the dietitians, although he has given them an amende honorable already. Compare diet and the way we treated people in hospitals before 1939 or in 1939 with the way they were treated hundreds of years ago in Britain. I have looked up the sort of diets they had in St. Bartholomew's in 1550, quite a long time ago. I found out only today in whose reign that was. I asked in the Library. Nobody knew. We had all to look it up together.
§ Dr. Stross
It was Edward VIth's. [HON. MEMBERS: "Hear, hear."] I am not taking any credit. I thought that it was in the early days of Elizabeth I. I was wrong. In the accounts for 1550 at St. Bartholomew's they ordered meat, salt fish, cheese, beer, bread, pork, mutton, ribs of beef, barrels of herring both salted and pickled This was regularly the central part of the diet. The annual accounts at Christ's Hospital show that in or about the same year they were ordering mutton and beef, whiting and plaice, herring and other fish, and, of course, beer.
§ Mr. Brian Harrison (Maldon)
Would the hon. Gentleman tell us whether, from his researches, he has discovered whether all this was for the doctors and staff, or for the patients?
§ Dr. Stross
I can assure the hon. Gentleman, in answer to his most important question, that it could not have been for the doctors, because in January, 1554, Christ's Hospital ordered 154 gallons of milk at 3d. a gallon, and I am sure that the doctors drank beer rather than milk.
So, all in all, we may take it that there was an attitude towards patients which was good in those days. There may have been wrong ideas about nutrition scientifically, but they certainly did their best for their patients in those days.
May I, if I do not bore the House, and to keep the debate going a little, quote to the House what was said in 1797 by Sir Frederic Eden on this matter? He, in turn, was talking about the state of the poor. This is what was going on not at St. Bartholomew's or Christ's, but in a similar sort of institution. They called it a house of correction. It was rather similar in a way. It is really amazing to see how thoughtful and up to date people were. This was at a house of correction in Suffolk and the year was 1588. That is a date we all know. I think that it was that of the Armada.
This was an order at that house of correction in 1558:Item, It is ordered, that every person committed to the said house, shall have for theire dietts, theis portions of meate and drinke followinge, and not above, (viz). At every dynner and supper on the fleshe daies, bread made of rye, viij ounces troye waight, with a pynte of porredge, a quarter of a pound of fleshe, and a pinte of beare, the rate of iijs. a barrell, every barrell to conteyne xxxvj. gallands"—which, I presume, means "gallons"—and on every fyshe daie at dynner and supper the like quantitie, made eyther of milk or pease or such lyke, and the thurd part of a pound of chese, or one good heringe, or twee white or redd, accordinge as the keper of the house shall thinke meete.
Very good. It is interesting to see that people who did their work were to have extras in between meals, but if they did not work—it is quite obvious that we were all of us Socialists in those days, and they were great days—It is ordered, that they which will not worke shall have noe allowance but bread and beare onley, untill they will conforme themselves to worke.It is very interesting. I hope that the Minister will be encouraged to see that more money is spent in hospitals on 906 food, particularly—and I think he has already done this in part—in the mental health service, where it is more important, I should imagine, to spend an extra few shillings each week on the diet of the patients.
I know that I have mentioned beer twice already, but I have not said how much of it was given in hospitals. The Minister may think that they were extravagant in those days. It was three pints except on Sundays when an extra pint of strong beer was given, making four pints in all. I know very well that water was not considered a very safe drink in those days, and that is why they drank beer.
As a young medical man I once had 200 beds under my care in a local hospital. Most of the patients were chronics. I could not do much for them, but I found that there was a plentiful stock of brandy in the cellars. Before I left that hospital there was not much brandy left. My patients received 2 fluid ozs. of brandy every night, and I was very popular with them.
The Minister, of course, will accept from me that where preventive medicine is concerned—of the type about which I am speaking, how to nourish people and how to prevent disease by a suitable type of nutrition—we owe a great deal to the women of this country and, strangely enough, to the women's magazines who have made this thing popular, to American women who started it and to the handful of doctors and technicians who showed them the way. That is why we drink tomato juice and other fruit juices and why we have milk bars, although I suppose that we are now going over to coffeee bars.
Up till recently slimming diets consisted of fruits and vegetables. These diets were far better than the wretched, miserable slimming drugs which are foisted on to people today. Some people think that they can take their appetites away and that they lose weight by swallowing certain types of pills. Slimming by that method is certainly not as safe as the act of slimming was ten years ago, when people went on good diets to slim. In Britain, we have learned our lesson on that score.
I know that I am now going a little wide of the Bill, perhaps even on this subject, but it is interesting because we 907 are concerned with dietitians in the Bill. We have learned to control our appetities. We eat less than people did a century or two ago and we eat much more selectively. We stay young much longer. We do not need procaine to be injected into our muscles to rejuvenate ourselves. We do not dig our graves with our teeth, as our ancestors tended to do at one time.
I have used this rather long illustration to show how much all of us, including the medical profession, owe to those non-medical experts who very often have paved the way. I welcome the Bill wholeheartedly. It will be most interesting to see if we can improve it in Committee. I do not know whether we shall, because it is a bit early to consider a Committee stage.
As I said at the begininng of my speech, I hope that all these eight bodies will remain in the Council. I am delighted that the Minister has left the door open ultimately for others to come in.
I would say, lastly, that we have made a great mistake in not recognising that the remuneration we are offering is insufficient. It is up to those organisations to accept State registration. If they did they would be much more vocal and would have much more influence.
§ 5.25 p.m.
§ Lord Balniel (Hertford)
It is a great pleasure to follow the hon. Member for Stoke-on-Trent, Central (Dr. Stross), although I find it a little difficult to compete with him in references to the changes in diet. He may know, perhaps, that in Fife, the county from which I come, it was not so very long ago that the unofficial trade union of domestic servants insisted in their terms of contract that they should not be fed on salmon more than three times a week. I think that situation has changed.
§ Dr. Stross
I think that was a very proper thing to strike about. It was not a wildcat strike. No one can eat salmon three times a week throughout the whole season without feeling sick.
§ Lord Balniel
I wish to return more directly to the contents of the Bill. It is true that the controversy in Committee will centre around the point which the right hon. Lady the Member for Warrington (Dr. Summerskill) commented 908 upon and to which my right hon. and learned Friend referred—the composition of the professional boards and of the Council. I do not wish to comment on this matter in any detail except to say that I entirely agree with the right hon. Lady. It seems reasonable to me that if we are establishing professional boards and laying down codes of conduct for the professions the majority of members of those boards should be members of the professions themselves.
Like my right hon. and learned Friend I agree with the contents of the Bill rather than with the views which have been expressed by the British Medical Council. I welcome the Bill. I do not wish to appear to be at all churlish in welcoming it, but, like the right hon. Lady, I think it slightly regrettable that only eleven days have elapsed between its publication and its Second Reading. After all, the Cope Committee reported in 1951. There has been a whole sequence of discussions behind the scenes leading up to the Bill.
I can only think that, rather luckily, I do not have a very voluminous correspondence with speech therapists and remedial gymnasts. Indeed, in the eleven days which have elapsed I have not received a single communication from any of my constituents in these professions, who, in normal circumstances, would wish to communicate with me and who, I am quite sure, will do so before we reach the Committee stage.
My hon. Friend the Member for Putney (Sir H. Linstead) said that three doubts had arisen in connection with the Bill. My doubts in connection with the Bill are not those which have been mentioned so far. My doubts arise in connection with the disciplinary provisions laid down in the Bill, and I hope that we may be able to dispel these doubts—perhaps my right hon. and learned Friend will be able to assuage the doubts or in winding up my hon. Friend will be able to do so—in the course of the Committee stage.
Clause 7 lays down that each of the professional boards shall establish an investigating committee and also a disciplinary committee. My right hon. and learned Friend has clearly thought it necessary that originally these two committees should be separate in membership. Indeed, I think the whole House 909 would agree that there should be separate membership of these two committees. One of them virtually undertakes the work of the police force, a detective force, and the other corresponds to a judicial committee. It would be extremely undesirable if to all intents and purposes the police, the detective and the judiciary were all co-ordinated in one committee.
My right hon. and learned Friend has laid it down that the membership of both committees shall be different. Of course, it looks very nice on paper, but, in practice, this differentiation in the composition of the two committees will be extremely vague and it will be extremely difficult to create a real differentiation in membership. Take, for instance, the example of the board of remedial gymnasts. This board is to be composed of eleven people. They will be people who will know each other professionally and who, professionally, will meet each other frequently. They will presumably meet as a board, say, once every month. They will meet socially extremely frequently. Out of this tiny number of eleven people have got to be set up two committees, one to do the investigating work and the other to act as the judicial body.
It is really stretching the imagination a long way to assume that when they have a particularly lurid case to investigate, members of the investigating committee will not mention any of its contents to their close colleagues on the Remedial Gymnasts Board. Even if there is no gossip between the members of the two committees, I do not think that this complies with one of the basic if very hackneyed tenets of justice—that is should be not only done but patently seen to be done. I think that any practitioner summoned before the disciplinary committee will automatically assume that conversations have taken place between members of the investigating committee and members of the disciplinary committee.
What are the powers of the investigating committee? I know that the Bill provides that rules will be laid down for the membership of the investigating committee. Rules will be made setting down die quorum and the times and places of meetings, and that kind of thing, but there is not a word in the Bill about the 910 procedure of the investigating committee, although a whole section is devoted in the Second Schedule to the procedure of the disciplinary committee. Not only is there no word about the investigating committee's procedure but there is no word about its powers. I hope that my hon. Friend the Parliamentary Secretary will refer to these powers when she winds up the debate. I hope that the investigating committee has no powers at all. If it has not, it will be merely a body of snoopers with no powers, unpleasant but quite harmless.
§ Mr. Charles Doughty (Surrey, East)
When complaints are made to professional bodies, they are not examined by snoopers but by a small committee to find out whether there is a prima facie case. These people are not in any sense people who will investigate on their own initiative. It might be that members of the public lay a complaint and then the investigating committee inquires whether the complaint is sufficiently serious and in accordance with the truth to lay before a disciplinary committee. That committee then decides whether disciplinary action is required.
§ Lord Balniel
To some extent, my hon. and learned Friend is making the point which I am trying to make, but I am not sure that this procedure is adopted by all other bodies.
§ Mr. Doughty
In my profession the complaint is investigated by an investigating committee in the profession which, if necessary, will forward it to a disciplinary committee.
§ Lord Balniel
I intended to refer to the law in a moment.
Section 32 of the Medical Act, 1956, establishes a disciplinary committee. No investigating committee is established. I was trying to make the point that I hope that the investigating committees under this Bill will have no powers at all. If, for instance, they have powers to take statements from parties in dispute they are virtually inquisitorial committees which, to some extent, are conducting a trial of their own to establish whether there is a prima facie case to be answered. My own case is that this preliminary investigation and the actual adjudication should be conducted by one body only—the disciplinary committee.
911 Clause 8 (1, a) and (1, b) contain further disciplinary provisions—
§ Mr. Walker-Smith
Before my noble Friend leaves that point, has he got in mind the provisions already contained in Section 37 of the Medical Act, 1956, which refers to the disciplinary committee making rules and in particular requiring that before any matters are referred to the committeethey shall, in such manner as may be provided by the rules, have been brought before and investigated by a committee of the General Council constituted in accordance with the rules …Therefore, it seems that my hon. and learned Friend the Member for Surrey, East (Mr. Doughty) was right in the generalisation that the pattern of these procedures is broadly the same.
§ Lord Balniel
I am, of course, prepared to accept such distinguished legal opinion from my right hon. and learned Friend. I would not dream of disputing it, but in my opinion original statements from parties in dispute should be taken, and then considered for the purposes of deciding whether there is a prima facie case, by the disciplinary committee itself. Two bodies should not be established virtually to conduct two trials—one to establish whether there is a prima facie case, and another, the disciplinary committee, to adjudicate on it.
§ Mr. Doughty
It happens in cases before the courts. Magistrates investigate and take statements to decide whether there is a prima facie case to go before a superior court. They investigate it by taking statements from witnesses and, if necessary, from the accused person and decide whether there is a prima facie case to go to trial. In every criminal case the matter then goes before a superior court. That is exactly the same thing as is suggested in the Bill but on a larger scale.
§ Lord Balniel
I should have thought that was a different situation. A magistrate is very different from a body of four remedial gymnasts who have no qualifications whatsoever in law.
My criticism of Clause 8 (1, a) and (1 b) arises from the wording, which I hope we can correct in Committee. Clause 8 (1, a) is perfectly clear. It says:
912 "Where—(a) a person who is registered by a board is convicted by any court in the United Kingdom of a criminal offence which, in the opinion of the disciplinary committee set up by the board, renders him unfit to be registered …Then if the disciplinary committee considers him to be unfit to be registered, he can be struck off the register. I have no objection to that at all.
On the other hand subsection (1, b) provides that wheresuch a person is judged by the disciplinary committee to be guilty of infamous conduct in any professional respect …he can be struck off the register.
If the words "such a person" refer to the whole of subsection (1, a), that is to a person registered by a board and who is convicted by a court, there is no objection. If, on the other hand, the words "such a person" refer only to the first few words of subsection (1, a), which reada person who is registered by a board …there is considerable objection to giving such unique powers to a disciplinary committee, particularly since that committee is a very small one when compared, for instance, with the disciplinary committee of the B.M.A. which consists of eighteen people.
My third point in connection with the disciplinary provisions arises out of Part II of the Second Schedule, which provides that it is open to any party to the proceedings to sue out writs of subpoena. I think that my right hon. and learned Friend will confirm that not only any party to the proceedings but the disciplinary committee itself will be able to sue out writs of subpoena. Therefore, under the Bill, we are setting up eight and possibly twelve courts which will have the right to subpoena any citizen to attend before them.
We are also setting up eight courts which will have the right to administer oaths. The administration of oaths is an important function in disciplinary proceedings. For example, it is not even granted to the General Council of the Bar. It means that any citizen of this country can be subpoena'd to attend any of these courts. He can be forced to give evidence on oath. Should he refuse to do so he is in danger of perjuring 913 himself. He can be forced to give evidence which will render him liable to legal proceedings outside these courts.
I hope that in Committee my right hon. and learned Friend will look at the disciplinary provisions. The general effect of the Bill is beneficial. I wonder if it is necessary to give such strong disciplinary provisions to people who are not in the slightest way qualified to exercise disciplinary provisions of this kind.
§ 5.41 p.m.
§ Dame Irene Ward (Tynemouth)
I am very glad that the House is in general support of the Bill. Statutory registration has been discussed for a long time and it is always satisfying to realise that a large number of people are interested in matters of this kind and that at last their desires are coming to fruition. I am, therefore, glad to offer to my right hon. and learned Friend my warmest support for the Bill.
There are one or two points only that I should like to make. I sit on the Council of the Chartered Society of Physiotherapists and I am delighted to tell my right hon. and learned Friend that this society is fully behind him. It has, however, asked me to raise one or two small matters, and in particular the financial commitments. Several hon. Members and right hon. Members have referred to that point and I want to reinforce the view held by the Chartered Society of Physiotherapists.
As the Cope Committee suggested, it seemed that, at any rate in the initial stages of the setting up of a council, there should be made available finance for its establishment. The society wishes me to say that it is entirely desirous of standing on its own feet. I cannot speak for any other body mentioned in the Bill, but the society feels that in the initial stages only there should be a financial gift to arrange the general housing of the various registers and to make provisions for establishing and setting up the appropriate machinery.
I hope that my right hon. and learned Friend will realise from the various speeches that have been made that it appears to be the general view of the House that such an arrangement, which has the support of the Cope Committee, should be made. I hope that when my hon. Friend the Parliamentary Secretary 914 winds up the debate she will be able to say that that position has been accepted. If the hon. Lady cannot give us the information tonight, I hope that she will do so before we reach the final stages of the Bill.
The other point on which I want to spend some little time is the position of speech therapists. I have had a number of letters from, and telephone conversations with Dr. Morley, who, as my right hon. and learned Friend knows, is concerned with the position of speech therapists, and who speaks for their interests.
In addition to the letter which has been circulated, and the one which appeared in The Times this morning, I have had a personal letter from Dr. Morley which I think ought to be placed on record. I might add that I have no particular reason for speaking for speech therapists, because I wholeheartedly believe in the principle embodied in the Bill, but this is the House of Commons and it is right that everybody's point of view should be heard.
Dr. Morley comes from my part of the world, though she is not a constituent of mine. She has played a leading part in putting forward the professional side of speech therapy and she asked me to mention the speech therapists' point of view today.
Having heard the speeches of the hon. Member for Stoke-on-Trent Central (Dr. Stross) and my hon. Friend the Member for Putney (Sir H. Linstead), I feel that it is the wish of everybody that we should seek to persuade speech therapists to remain within the ambit of the Bill. However, I am a little perturbed that they have found themselves included in the Bill without having agreed that they should appear in it. It is a little difficult to understand how it has happened except that, as several hon. Members have pointed out, the last stages seem to have gone with a gallop after years of pressure for a Bill of this kind.
These are the paragraphs to which I want to draw my right hon. and learned Friend's attention:When the Minister of Health 'took over' the profession in 1948 there were probably not more than four or five speech therapists employed full-time in hospitals, and even now less than twenty per cent. of our profession are so employed, that is under the National Health Service, whether full or part time.915Because we have increasingly felt that the Minister of Health has not understood our professional position, in spite of many efforts on our part, we resigned from the Board of Medical Auxiliaries some years ago. Since 1957, when we also resigned from the Whitley Council, we have repeatedly told the Minister of Health, or his representatives, that we wished to be excluded from statutory registration as proposed in the drafts, and now in the Bill before the House.This failure to understand the professional status of the profession would seem to be apparent in one clause of the Bill, page 17, lines 29–31. I know of no one who is 'expert in the field of speech disorders and their treatment' who is not on the Register of Speech Therapists of the College. This would therefore increase the number of speech therapists on the Board to nine. In this country there is no professional body other than speech therapists who has this knowledge.What perturbs me is that I had a long conversation on the telephone yesterday with Dr. Morley and she told me that the Ministry had been told specifically that they did not want to be included in the Bill. That is why I am intervening in the debate on their behalf. It seems extraordinary that a professional body of this importance should suddenly have found itself included in a Bill in which it did not wish to be included. I understand from my right hon. and learned Friend that in Committee it will be possible to remove this body from the Bill, but at the same time its inclusion is regrettable because it sounds as if there was some opposition to the Bill, which I do not believe is the case.
I do not know how this trouble has arisen. Until Thursday night, when I received a telephone message here at the House, I had no idea that it had arisen. Perhaps my right hon. and learned Friend or my hon. Friend the Parliamentary Secretary will be able to go into a little more detail. When I questioned Dr. Morley as definitely as I could, it seemed to me that at a much earlier stage than the collecting together of the deputation, which we understand is now to be received by the Minister, it ought to have been possible to explain the advantages that the speech therapists would derive from being included in the Bill. If we all work together to try to persuade them that they would find support and help in the objectives of their own profession by being in the Bill we might be able to persuade them to change their minds, but it was obvious 916 to me from what Dr. Morley said that they resigned from the Whitley Council because of their claim that the salary scales were not satisfactory. They thought that they were not in the right group.
In the short notice available I have not been able to get to the bottom of their difficulties, but it must be on the cards that when my right hon. and learned Friend considered their problem they had the feeling that the whole national machinery, including the Whitley Councils and the proposals contained in the Bill, were unacceptable to them. The more I consider the matter the more I feel that, somehow or other, either the Ministry or the House of Commons has failed to make sufficiently close contact with the speech therapists, in order to convince them that they are not out on a limb and that their interests and objectives are of very great importance to all hon. Members interested in their profession. If my right hon. and learned Friend can find any way of convincing them that they would derive strength and advantage from coming within the ambit of the Bill, I should be much more satisfied than I am at present.
There is another point which flows from this problem. If the speech therapists finally decide that they do not want to come within the terms of the Bill, thus reducing from eight to seven the number of professional bodies cited in it, will the balance of representation on the Council be altered? The Chartered Society of Physiotherapists is satisfied with the proposed balance, but it wants to be sure that that present balance will be maintained whether or not, finally, fewer or more professional bodies are covered by the Bill. I hope that my hon. Friend will be able to confirm that later this will be so. The society also asked me to emphasise how glad it was that the Privy Council had been associated with the Bill.
Like all hon. Members who have spoken, I wish the Bill well, and I hope that the professions which are to be associated with it will go from strength to strength, and continue the valuable work which they are carrying out in their own fields.
§ 5.54 p.m.
§ Mr. Arthur Holt (Bolton, West)
I should like the Parliamentary Secretary to tell us why the Bill has been produced at such short notice. I should also like to raise a point in connection with speech therapists. Unlike the hon. Member for Hertford (Lord Balniel), I have had some communication, at very short notice, from one of my constituents. This week I had a lady—a dietician—coming in to see me, and I thought that there would be plenty of time to hear what she said about the Bill before it came up. I was forestalled. I also had a telephone call from a speech therapist who was concerned about the Bill.
Will the Minister make it quite clear that if the accredited representatives of the College of Speech Therapists tell him that they do not wish to be included in the Bill he will take them out of it? I hope that it will not be a case of pressure having to be exerted by the House.
§ Mr. Walker-Smith
Once a Bill is before Parliament any such question would be a matter for the House. The House would decide what should happen. I agree with my hon. Friends that we would not want to compel any organisation to come within the terms of the Bill. If we are not able to persuade the speech therapists of the advantages of remaining covered by the Bill I will take the responsibility of moving an Amendment to exclude them. But the decision is for the House, and not for me.
§ Mr. Holt
The right hon. and learned Gentleman could not have put the position more clearly. Perhaps the Parliamentary Secretary will tell us why the speech therapists have been included, apparently without their agreement, while the other seven bodies have been included with their agreement.
Again because of the early date at which the Bill has been placed before the House, I have been unable to inform myself of all the arguments for and against its proposals. Having listened to the speech of the hon. Member for Hertford and collected my own thoughts during the debate, however, it seems to me that the Bill is a very cumbersome affair. I can appreciate that there is sometimes a necessity to set up this kind of organisation, but I would have thought that if the various professional 918 bodies were adequately serving the needs of their professions and were also serving the medical requirements of the nation, it was unnecessary to bring in this extra machinery for carrying out disciplinary measures.
Can the Minister tell us what kind of offence a speech therapist is likely to commit that would require this cumbersome machinery? What sort of offence is liable to be committed by medical gymnasts, or dieticians? Are they going to go around poisoning people? If so, surely they can be dealt with under the ordinary law. There may be some professional sins which they can commit and which cannot be dealt with adequately by their professional colleagues but, if so, I should like to know what they are. If I had had a little more time I might have been able to find out for myself. I hope the Parliamentary Secretary will clear up some of these difficulties, which have been caused by the short time we have had to prepare ourselves for an examination of the Bill.
§ 5.59 p.m.
§ Mr. Charles Doughty (Surrey, East)
In the course of the debate we have wandered over the centuries. I am sorry that the hon. Member for Stoke-on-Trent, Central (Dr. Stross) is no longer in his place. He took us back to the days of the Armada and before. He drew a happy picture of conditions, from the point of view of dieticians, in hospitals and houses of correction in those days.
I hope that hon. Members do not believe that everything was as rosy as the hon Member painted it. He would have been appalled if he had investigated some of the conditions in hospitals and houses of correction. In some cases, they were such that not only were the inmates wiped out in large numbers, but the infections also spread to judges.
I should like to bring the House back to the Bill. It is an excellent one, because it comes at the right time—a time when these bodies have reached a position in which they are entitled to professional status. When one talks of professional status, what does one mean by it? It means that a body of people interested or trained in a particular subject are entitled to form themselves together, and to have professional rules. 919 A professional body has, first, to decide upon entry into its profession, to deal with the conduct of the members in it and their qualifications, and, if necessary, to strike their names off the list of that profession.
It must be an independent body not under the control or influence of anybody outside it. That is why I agree with my hon. Friend the Member for Tynemouth (Dame Irene Ward), and do not agree with hon. Members who spoke in the contrary sense. It would be quite wrong for any Government Department to give any money at all, however small it might be, to help any of these bodies to set up and influence any professional organisation. No professional organisation as such ought to accept money from any outside body, whether the Government or anybody else.
So far as qualifications are concerned, I think that we are in a position, as we always are when any body of people demand professional status to which they are entitled, to say that it must first take in those already practising, and that from then on those who desire to be admitted must produce professional qualifications and prove to the professional body that they have them.
It may be that some of these bodies are not large enough to have their own teaching curriculum and examining body, but I think that as soon as it is possible each board should set up its own examining body to examine the qualifications and professional knowledge of each person presenting himself for registration. If that is done, we shall then increase the professional value of the expression "State registered", whether it is an occupational therapist, or whoever it may be.
I must cross swords with my hon. Friend the Member for Hertford (Lord Balniel) who, I regret to say, displayed some ignorance upon the workings of professional disciplinary bodies. All people who have any charge brought against them of any kind—I am not referring to minor matters, which can be dealt with in the magistrates' courts summarily—in the criminal courts, or professionally before their own body, have the matter examined first by an investigating committee.
920 Many complaints against professional people have no foundation at all. It is quite wrong that a professional person should be brought before the disciplinary body of his profession—a very large and powerful body—upon a trivial and trifling complaint, and for that reason the matter is inquired into by an investigating committee, a small body, first. In many cases, the matter goes no further—the complaint has no substance in it at all. The investigating committee has no decision which it can make. It can only refer the matter and say that there is a prima facie case which requires investigation by the full investigating body.
§ Mr. Brian Harrison (Maldon)
I should like my hon. and learned Friend to make clear whether the investigating committee presents the case to the disciplinary committee, or whether it is presented by someone else.
§ Mr. Doughty
If the investigating committee says that there is a prima facie case to go forward, then the details of a charge of unprofessional conduct are sent forward to the disciplinary committee to inquire into. In all probability it may have taken statements, as happens in a magistrates' court before a case goes for trial. This is the usual procedure and there is nothing in the Bill that is out of the ordinary at all.
There is one matter on which I should like to have my mind set at rest. That is the power which the disciplinary committee has to strike off—that is to say, to remove a person's name from the list. It may be that that is too drastic a remedy and I should like an assurance that in appropriate cases it has the power to suspend, maybe for six months or a year, to caution, or to take whatever it may think the appropriate remedy. To strike a person's name off the register is a very severe penalty and it may not meet a particular case, although some form of minor punishment, if only a caution, is required.
I think that my hon. Friend the Member for Putney (Sir H. Linstead) was right about Clause 6. He has found a slip there, which I am sure my right hon. and learned Friend will put right in Committee. Clause 6 (2, a) states that any person whotakes or uses any such title (either alone or in conjunction with any other words) when he 921 is not registered in respect of the profession to which the title relates; …He could excuse himself by saying that he was registered with a quack body which had been set up to collect registration fees. I think that this is only a slip in wording, and I am sure that it will be put right in Committee.
I shall refer briefly to speech therapists, because they have sent a document to all hon. Members. One can see that they are anxious to come within the provisions of the Bill, but they have their own college, syllabus and examining body and their own committee. They are not anxious that it should be abolished, and I do not think that it will be. They would, in any case, have a majority and there is not the slightest reason for supposing that members of the board would vote unanimously against them. I am sure that the Minister will be able to give them the assurance for which they have asked. It would, of course, be in their interests that their professional status should be regularised and that they should be able to describe themselves as State registered speech therapists rather than just speech therapists.
I am sure that we shall all welcome the setting up of these boards, enabling people to be State registered. In time, although it is not yet the time, it may be possible to prevent people practising these professions if they have not the necessary qualifications and are not State registered. That must be the ultimate object of whatever Government is in power. It can be done when the professional bodies concerned consider that the time is ripe. I am glad that the Bill has had such a happy passage so far and I do not propose to delay its progress by speaking any longer.
§ 6.9 p.m.
§ Mr. W. A. Wilkins (Bristol, South)
Although my hon. Friends have commented that the Bill has been sprung upon us, nevertheless it is a welcome Measure and we congratulate the Minister on reconciling the difficulties existing between the different organisations sufficiently to make him feel confident in bringing the Bill before the House.
I wish to refer to Clause 3 which deals with qualifications for registration. It is easy to understand the qualifications set out in subsection (1). They will be 922 obtained from the approved institutions and therefore we need have no anxiety about that. We believe that the standards required will prove adequate to meet the needs of the professions. Subsection (2), as I understand it, makes provision regarding people who would be practising in various services indirectly connected with the National Health Service. I have chiropodists particularly in mind. Up to the present there are a number of people who provide this service and I believe it true to say that in the past some have been able to obtain qualifications by means of a postal course. I am not suggesting that they are inefficient because they obtain their qualifications in that way, although it seems to me rather an indirect method of obtaining a professional training.
In Clause 3 (3) there is a provision, which the Minister elaborated to us, for people to appeal if for any reason the board has already refused to grant qualifications to them. The period of twelve months which is mentioned seems to me rather a long one, although it may be all right, and I am not arguing about it. They may be accepted if they hold necessary qualifications granted outside the United Kingdom if the board so requires, and they have sufficient practical experience in the profession.
If I remember rightly, the Minister said that if for any purpose the board refused to register these people, they would still be free to practise. I realise that this House is hesitant about taking any action which might imperil the possibility of anyone in this country being able to earn a living. But Clause 3 appears to be drawn very widely, and I do not think that it will prove too difficult for someone who has been practising chiropody for two years, five years or ten years to become registered. However, that only increases my anxiety about the position of those people the board may refuse to register. If they cannot be accepted and registered under what appear to be wide provisions, one wonders whether they are sufficiently efficient to be allowed to continue to practise.
I am endeavouring to phrase by remarks in cautious terms because I am the last person who would wish to deprive anyone of the means of earning a living, but we know that unless people 923 are skilled even, for example, in removing corns, serious trouble may result. There may be trouble if the work is not properly done or unclean instruments are used. I am, therefore, anxious about this matter, especially as I understood the Minister to say that these people would still be allowed to continue to practise. I should have thought that if it were possible to allow them to continue to practise, they ought to have the qualifications required for registration by the board.
The hon. Member for Putney (Sir H. Linstead) suggested that some members of professional bodies were anxious about the registration fee which would be initially £2 10s. and afterwards £2. I have been trying to find that figure in the Bill. He suggested that if they were called upon to pay £2 a year they would seek to reduce the quality of their service in order to cover the fee.
§ Sir H. Linstead
The point I was trying to make was that if these people had to pay a heavy registration fee, they might try to economise by stopping their subscription to their professional association. I did not suggest in any way that they would cut their service to the public.
§ Mr. Wilkins
I apologise to the hon. Member. I misunderstood what he said. I did not think there would be any dispute about having to pay 9 3/5d. per week in order to be registered under the scheme. Perhaps the Minister will clarify that point later.
§ 6.16 p.m.
§ Mr. R. H. Turton (Thirsk and Malton)
I wish to congratulate my right hon. and learned Friend on bringing in this Bill though I do not congratulate him on its Long Title. Most Bills have a Long Title and a Short Title. This Bill has two Long Titles. I had hoped that during his clear opening speech my right hon. and learned Friend would give some reason why the Bill did not bear the name by which it was referred before its birth—the Medical Auxiliaries Bill. I can understand that the members of the profession represented by the right hon. Lady the Member for Warrington (Dr. Summerskill) may not have liked to be mixed up with some of the remedial professions which are mentioned.
§ Dr. Summerskill
I am sure that the righ hon. Member for Thirsk and Malton (Mr. Turton) will recall our exchanges some years ago. But I think that the Title is an improvement. It shows that we have moved on. In the past we regarded these people as auxiliaries but now they have reached professional standards.
§ Mr. Turton
The Minister made one remark which was not absolutely clear. He said that the majority of these people were not in private practice. I wish to follow what was said by the hon. Member for Bristol, South (Mr. Wilkins) about chiropodists. They are nearly all in private practice and that will raise problems about which I wish to question my right hon. and learned Friend.
There are about 4,500 chiropodists belonging to the Society of Chiropodists and the Institute of Chiropodists and there are probably another 3,500 to 4,000 who do not belong to either body. Some of the latter have been trained by means of the S.M.A.E. correspondence course. At the moment in the National Health Service only half of the members of the society and institute have qualified under the 1954 Medical Auxiliaries Regulations. I wish to ask whether, after the Bill becomes law, those Regulations will be amended in order to permit those who are qualified and registered under the provisions of this Bill, to take part in the National Health Service.
In my view this is an important matter because we are desperately short of chiropodists in this country. Not only that, but the number of chiropodists varies between town and country and between town and town. I have the honour to serve on the Advisory Council of the National Corporation for the Care of Old People. We have been working with the profession to see whether it is possible to provide a chiropody service for the old people. We had difficulty in discovering where chiropodists practice. We conducted a survey to find out whether there was an adequate number of chiropodists in the country. We assessed that the minimum number of chiropodists needed 925 to treat the old people in the population was one for every 10,000.
We found that of 770 areas, in about 450 the supply was adequate, which was encouraging. But there were 137 areas where there were no chiropodists at all—that is, not members of the society or the institute. The other fact of interest which we discovered was that in a town of 100,000 inhabitants, like South Shields, there were only two chiropodists, whereas in a town of a similar size like Blackburn there were 14.
There is such a shortage of chiropodists that it would be a great pity to dissuade people from practising chiropody. We ought to encourage more people to enter the profession and to go in for the full training which is so necessary in order to carry out this work properly. I wish to ask the Minister whether the Board will have power to encourage recruiting.
When we were discussing legislation relating to dentists we spent some time debating how we could get more dentists. Now that chiropodists are to have a professional status it will encourage more people to enter the profession and the number of chiropodists may be spread more evenly over the country. There is also the problem of the rural areas which is a difficult one because they are worse served than are the urban areas. It is also more difficult to give treatment in the rural areas.
The National Council has recently been conducting an experiment in Dorset, which is limited to two years. This is giving a full domiciliary service in chiropody in a rural district. It has been working with three chiropodists and the results have been most encouraging. Patients have been treated in their own homes. Starting with about 370 the number has gone up to 450 patients. The chiropodists travel to the homes of the patients, we find that this is a more economic method than bringing the patients to a clinic or a surgery.
I wish to ask my right hon. and learned Friend to ask the board to consider the whole question of chiropody in the rural areas. I am sure that hon. Members are anxious to ensure that a full chiropody service is provided for old people in all parts of the country. The National Council has been helping about 123 schemes on a promise from the Nuffield Trust of assistance for three years. We 926 have carried only eight of those on for another two years. Most of the other schemes have lapsed or will shortly lapse, and I find that the number where work is being continued is very small. I hope that the Minister realises that.
I believe that even from the point of view of chiropody alone the Bill is an urgent and necessary Measure, and it has my full support.
§ 6.25 p.m.
§ Colonel Sir Malcolm Stoddart-Scott (Ripon)
I want to add a few words of welcome to the Bill and to assure the Minister of my support for it. We have been waiting a long time for such a Measure to be brought before the House. It is eight years since the Cope Committee reported, and it may be that some of the delay is due to the Cope Committee itself, in that it recommended that a comprehensive Measure should be brought before the House. I know that some people feel that this problem should and could have been dealt with more appropriately and satisfactorily by separate Measures dealing with each of the supplementary professions, but it has probably been wise to wait and to bring before the House this one comprehensive Measure.
It is a little difficult to include in one Measure such different professions. They have in common the fact that they look after the welfare of the patient and that they help with preventive medicine, but some of them are wholly employed in the Health Service, some have a majority of their members serving the educational service and some, like the chiropodists, to whom my right hon. Friend the Member for Thirsk and Malton (Mr. Turton) referred, are mostly employed outside the Health Service.
Wherever they are employed, their work is vitally important, and it is important that we should have a Measure such as this. I do not agree with the description given by one of my hon. Friends, who said that it was cumbersome. The work of these professions is vital to the medical profession. I am sure that without their assistance the doctors could not have achieved so much or have done so much work.
The medical profession is legally responsible for the action of all these auxiliaries. I agree with the right hon. 927 Lady the Member for Warrington (Dr. Summerskill) that the Measure does not deal with medical treatment. As well as being responsible for their action, however, the doctors are to a great extent responsible for the education of these auxiliaries, and it is therefore of significance that the doctors wish to be well represented upon the boards and upon the Council.
I am glad that my right hon. and learned Friend has given them a parity upon the Council, but they have a parity on the Council only if the representative from the General Medical Council, whose appointment is laid down in the First Schedule, is a member of the medical profession. The General Medical Council has many lay members, and I hope that in Committee we shall be able to obtain an assurance, if not an Amendment to this effect, that the General Medical Council will send a medical representative to this new Council.
I am glad that the Minister has made a decision about these boards, because there is no doubt that the delay in bringing the Bill before the House is due to the lack of agreement on the composition of the boards. I am also extremely glad that he said that he will welcome suggestions and improvements in Committee. I believe that we can strengthen and improve the Bill without upsetting the balance of the boards as laid down in the Second Schedule.
The radiographers' board is to have four medical representatives from the colleges and Scottish corporations. I hope that we shall be able to ensure that some of these medical representatives know something about radiography and radiology, and it may be better to look to the Faculty of Radiologists and the British Institute of Radiology to make sure that we have medical representatives on that Board who are expert in radiography.
I welcome the Bill most wholeheartedly, and I feel that it will be of great assistance to these supplementary professions who, unfortunately, are probably the least well-paid members of the Health Service. I am sure that the Bill will help them enormously, but I would not try to persuade the speech therapists to come into the scheme if they do not 928 wish to come into it. It should be a great privilege to have the words "State registered" added to their names, and it would be a great help to them in the future. As long as we leave some opportunity open to them when they have their second thoughts, in order that they may then come into the scheme, I would not at the moment use any undue persuasion on them or hold up the Bill for a single moment for them, if they do not wish to join in willingly.
The Bill will make an important contribution to the Health Service—and that is what matters most—for it will help the patient. That should be the chief consideration of any medical Measure before the House.
§ 6.33 p.m.
§ Mr. Brian Harrison (Maldon)
I have been in the hands of most of these professions at one time or another.
§ Mr. Harrison
With the exception of the speech therapists. I therefore feel that I have an interest in the Bill.
I welcome the fact that it is felt that these professions can be brought within the category of state registration. I do not want to detain the House long, but I want to make a few points to follow my noble Friend the Member for Hertford (Lord Balniel) and my hon. and learned Friend, the Member for Surrey, East (Mr. Doughty), particularly about the disciplinary committees. My right hon. and learned Friend said that in a number of cases these boards would consist of eleven people. The disciplinary committees will be formed from the boards, and they will be working together with the other members of the boards.
As my hon. and learned Friend said, a disciplinary committee can bring forward written evidence to the other half of the board. It seems to me that such close liaison between the two parts of a small board creates a dangerous situation when disciplinary action is being taken which might deprive someone of his livelihood. I know that my hon. and learned Friend the Member for Surrey, East drew the analogy that this kind of thing went on in the magistrates' court, but that is completely different from a professional organisation 929 which has to investigate unethical practices and other matters to do with a profession.
Secondly, the disciplinary committees have powers under the Bill to subpoena witnesses and to administer oaths. It seems to me that it is a ludicrous situation that professional status now seems to be tied up with the ability to administer oaths, to subpoena witnesses and to take disciplinary action against one's fellows and colleagues.
§ Mr. Harrison
I agree that this is not so in all cases. I was trying to make the point that it looked as though it was now regarded as desirable, if we were to set up a new professional status, that there should be this form of disciplinary action. The hon. Member was right to correct me. Even the Bar Council cannot administer oaths or subpoena witnesses, although I think that I am right in saying that the General Medical Council, the General Dental Council and the General Optical Council have the right to administer oaths and subpoena witnesses.
I do not think that it is desirable that there should be eight new disciplinary committees, with possibly another four to be set up, all with these additional powers to drag any person in the country before them in the same way as the courts of law. It is just possible that this power could be confined to a disciplinary committee of the Council rather than extended to each of eight or twelve boards. That would greatly limit the extension of this power.
I hope that my right hon. and learned Friend will very carefully consider those two points, which are the only two points I want to make, because we need to watch them. With those reservations I welcome the Bill. I may not be quite so uncontroversial in expressing the hope that it may not be long before some of the vacancies on the Council are filled by other organisations and groups of people such as osteopaths and chiropractors, who may well have proper recognition in the near future.
§ 6.38 p.m.
§ Sir Colin Thornton-Kemsley (North Angus and Mearns)
I shall not detain the House for more than two minutes or, at most, three minutes, but I want to say a few words about the speech therapists, about whom other hon. Members have spoken. I do that because I know a number of speech therapists, a member of my family was trained and qualified as a speech therapist, and to some extent I know their feeling about the Bill and about the proposal that they should come into this scheme. I was very glad to hear my right hon. and learned Friend say that he is to meet a deputation from the College of Speech Therapy.
I was in agreement with my hon. Friend the Member for Putney (Sir H. Linstead), who said that it would be a great mistake to compel the speech therapists to come into the scheme if they did not want to do so. As I understood the indication which he gave at that time, my right hon. and learned Friend was also in agreement about that. He did what in Parliamentary language is called indicating assent. It is clear that they will not be compelled to come into this scheme.
Like my hon. and gallant Friend the Member for Ripon (Sir M. StoddartScott), I feel that State registration is worth having and I hope that the speech therapists will feel that, too, when they have discussed the matter round the table with the Minister. Everyone knows that they do magnificent work. Their training is sound and thoroughly approved by both medical and educational authorities.
In brief, their case rests on the fact that 75 to 80 per cent. of them are employed not in the National Health Service, but by local education authorities. I do not need to make their case for them; they can make their own case to the Minister who is, indeed, fully aware of it. Indeed, they have been good enough to provide many hon. Members with a statement of their case.
I am glad that there is no suggestion that they should be compelled to come into the scheme, and I am even more glad that their case will be considered personally by the Minister.
§ 6.40 p.m.
§ Mr. Kenneth Robinson (St. Pancras, North)
As my right hon. Friend the Member for Warrington (Dr. Summerskill) made clear when opening the debate for the Opposition, we welcome the Bill very warmly. We have certain reservations and criticisms, some of which will no doubt emerge as Committee points later.
Like the right hon. Member for Thirsk and Malton (Mr. Turton), I, too, dislike the Title of the Bill very much indeed. It is the most cumbersome Title of any Bill that I can remember. I know that there have been difficulties with the professions themselves about a collective description, and it is true that the Title started off as "Medical Auxiliaries". That was what these people were called by the Cope Committee, and indeed that name was enshrined in the National Health Service (Medical Auxiliaries) Regulations, 1954. Then the professions thought again and there was a suggestion that they should call themselves "Non-Medical Professional and Technical Staff". This was the suggestion in the Minority Report of the Cope Committee. Then there was a third suggestion that they should be called "Professions Associated with Medicine". That suggestion came through the Departmental Working Party. Finally, we arrive at the very unhappy conclusion, "Professions Supplementary to Medicine".
I do not like being merely destructive in my criticism and I wish to offer a suggestion for consideration by the right hon. and learned Gentleman. Has he thought about the possibility of "Para-Medical Professions"—professions that work alongside the medical profession? That is exactly what all these people do. I throw that suggestion out to him for consideration between now and the Committee stage.
The Minister in opening used what I can only call staggering meiosis when he congratulated himself and his Department on not having rushed into a Bill without adequate preparation. As many hon. Members have reminded the House, the Zachary Cope Committees reported in April, 1951, which is nearly nine years ago. I do not think that any hon. Member so far has reminded the House that more than four years ago there was 932 a solemn promise by the party opposite in its 1955 election manifesto. It read as follows:We shall introduce legislation to give effective status to those, known as medical auxiliaries, who assist doctors in investigation and treatment.That is on page 25 of "United for Peace and Progress". [HON. MEMBERS: "Hear, hear."] The 1955 Parliament ran its full course, yet nothing was done. It is being done now, but that pledge was not honoured, and it does not stand alone in that respect. We know that there have been difficulties with the various professions involved, and with the medical profession; there have been complicated negotiations; but there has been a deplorable lack of urgency in considering the problem.
My right hon. Friend mentioned the objections of the British Medical Association to the Bill. I do not want to repeat what she said. I agree with every word of it. I want to make only one observation in this connection arising out of something which the hon. and gallant Member for Ripon (Sir M. Stoddart-Scott) said. He said that doctors are responsible in law for all the actions of these auxiliaries. I wonder whether he is right, because the letter which the British Medical Association sent to some hon. Members quoted only from its own disciplinary code. It is quite clear that that is what their professional code states. I should like the hon. Lady the Parliamentary Secretary, when winding up, to clear up the legal position about whether in law doctors are responsible for all the actions of these auxiliaries. I have my doubts about it.
Having charged the right hon. and learned Gentleman with procrastination, I now propose to have it both ways and charge him with indecent haste. Having waited nine years for the Bill, why was it necessary to rush through Second Reading a mere week or ten days after its publication? I must protest about this. It is a fairly complex Bill and this haste has allowed us virtually no opportunity to have consultations with the interested parties. There are many separate interested parties concerned in the Bill, which deals not only directly with eight different professions, but more indirectly with the entire medical profession. There has been one further 933 difficulty. I do not know whether the Minister knows this, but the Bill went out of print almost immediately it was published. Members representing these professions were unable to procure copies of it for several days, and that also made for further difficulties.
I have heard rumours that it is intended to start the Committee stage before Christmas. I profoundly hope that the rumours are incorrect because, having given us no time to have consultations between publication and Second Reading, the least the Minister can do is to give us ample time to have our discussions before the Committee stage opens. If he cares to deny that rumour now, I will gladly give way to him.
§ Mr. Walker-Smith
The Parliamentary timetable is not a matter for me, as the hon. Gentleman knows. However, I will take full notice of what he has said about the desirability of not starting the Committee stage until after Christmas. In a Bill such as this the time for consultation comes, in a sense, more appropriately between Second Reading and the Committee stage, because the sort of points which will be raised by individual organisations are, of necessity, Committee points. I will certainly bear in mind what the hon. Gentleman says and convey it to the appropriate quarters.
§ Mr. Robinson
I am very grateful to the Minister. It is pleasant at any rate to know whether the bodies concerned agree in principle with the Bill, which one would like to know before Second Reading. We have only just had time to discover that. However, I hope that there will be no undue haste in starting the Committee stage.
We should have liked time before today's debate to have obtained up to date figures about the establishments and vacancies in each of these categories, both in the hospitals and in the employment of local health authorities. We all know that there is a serious shortage in almost all the categories. In this connection I wish to quote the observation in paragraph 3 of the Cope Committee's Report, which draws a distinction between "demand" and "need":By 'need' is meant the numbers required by the National Health Service to give the public a full service in all parts of the country. To distinguish it from 'need', 'demand' must 934 be related to a particular time or period of time and may accordingly be defined as the number of vacancies that employing authorities are likely to seek to fill at present or—say—within the next five years.For all these skills the demand is very great, but I think that the House will agree that the need is infinitely greater and far in excess of these supplies or the likely supply in the near future.
I come now more particularly to the Bill itself. The noble Lord the Member for Hertford (Lord Balniel) expressed anxieties about the procedure of the investigating and disciplinary committees. I do not know that I share all his anxieties, but certainly if the membership of those two committees is to be drawn exclusively from the membership of the professional board concerned he is justified in feeling anxious about being able to keep the two committees separate and independent from one another, particularly in the case of a small board like that of remedial gymnasts. I hope that the Parliamentary Secretary will be able to tell us that it will be open to these boards to draw members for these two committees from outside or to co-opt them.
In this connection I wish to draw the attention of the House to Clause 8 (6), which I do not think has been mentioned and which worries me. The subsection makes it a duty for each disciplinary committee to prepare a statement as to the kind of conduct which it considers to be infamous conduct in a professional respect. It then goes on to say:but the fact that any matters are not mentioned in such a statement shall not preclude the disciplinary committee from judging a person to be guilty of infamous conduct …That is very dangerous indeed. Either one draws up a comprehensive statement which will let people know precisely where they stand or one does not draw up a list or statement at all. To draw up a half-statement saying, "These things are infamous, but so are a whole lot of other possible causes of action", is to get the worst of both worlds. I am inclined to think that this is rather more a Committee point, so I will not pursue it any further today.
I have two questions for the Parliamentary Secretary. First, the House might be told why almoners are excluded from the Bill. I appreciate that their 935 affinities are probably more with the social work field than with the medical. After all, they were considered by the Cope Committee and, so far as one can tell, the Committee recommended a similar form of organisation and machinery to those recommended for the other supplementary professions. Somewhere during the protracted discussions following the Cope Committee almoners have slipped out. I wish to know when this happened and whether the explanation that I have suggested is correct.
Secondly, we might be told at what point remedial gymnasts separated themselves from physiotherapists. My reading of the Cope Report suggests that it favoured an inclusive board embracing the remedial gymnasts. Even the minority Report, which was signed by the representatives of the physiotherapists, thought that both physiotherapists and remedial gymnasts would be covered by the same board.
I want to deal now with a matter which has been very widely discussed in the course of the debate, namely, the problem of speech therapists. Much reference has been made to the letter in The Times and the leader. I had the opportunity on Friday of discussing the whole matter with four leading members of the profession who undoubtedly spoke for the profession as a whole. So far as I can gather, the profession is unanimously opposed to being in the Bill at all. Various objections have been mentioned in the course of the speeches, but I should like to run through them as they were made to me. They add up to at any rate a good case for reconsideration.
The members of the profession believe that they already have a properly organised body, namely, the College of Speech Therapists, which maintains high standards of training and professional conduct. Those standards are comparable with those of the United States and countries of Europe. The College compiles and publishes a Register of Speech Therapists, which is recognised by the right hon. and learned Gentleman's Department and by the Ministry of Education. The members of the profession state, quite justifiably, that they are concerned only marginally with the National Health Service, in that more than 80 per cent. of them are employed 936 in schools by local education authorities. One or two hon. Members asked what the up-to-date figures are. I understand that there are only 82 whole-time speech therapists in the hospital service out of 670 practising in the United Kingdom at the moment.
As the hon. Lady the Member for Tynemouth (Dame Irene Ward) reminded us, the speech therapists have opted, not only out of the board of medical auxiliaries—about two years ago, I think—but, more recently, out of the National Health Service Whitley machinery, where they were represented on Professional and Technical Council A. They formed their own Association of Speech Therapists which is now negotiating with the local education authorities before the Soulbury Committee. Lastly, they pointed out, as they did in the letter referred to, that there is already a Department of Speech Pathology in Durham University, and they cannot see how the Bill would help them to develop their links with universities. Indeed, some think that it might hinder that development.
I understand, as did the hon. Member for Tynemouth, that the speech therapists suddenly woke up to find themselves included in the Bill; and that they made it quite clear to the right hon. and learned Gentleman and his Department some time ago that they did not wish to be so included. I know that they reluctantly approved of the draft scheme produced by the Department and the Working Party at some point of the negotiations. However, since that reluctant approval, changes have been made in the constitution of the boards and in the methods of selecting and appointing them that have served to increase the anxieties of the speech therapists to the point at which they definitely wish to contract out.
I am glad that the Minister has said that he will not press this profession into the terms of the Bill if they do not want to be included. There was a saying in the Navy that one volunteer is worth ten pressed men, and in the context of this Bill I would have thought that one pressed man would rather tend to unsettle the seven volunteers who are happy to accept the provisions of the Bill.
The College of Speech Therapists and the Association are responsible representative bodies which have made out a strong case for exclusion. They are 937 perfectly aware of the advantages that the Bill would convey but, at present, at any rate, they feel that the disadvantages outweigh the advantages. I am pleased that the Minister is to hear their views from a deputation. I am sure that he will listen carefully and sympathetically and that, if he is not able to persuade them, he will move to exclude them during the Committee stage.
The other professions all welcome the Bill. I am glad, because I believe, as they do, that it will enhance their status and qualifications, and will be a recognition of the very important rôle they are playing in the health services. I am very glad that they have been given an 'overall majority on the boards, and parity with the medical members on the Council.
I turn to the rôle of the Privy Council. Was it necessary to have quite so complex a three-tier structure? I rather gathered that the extensive powers of the Privy Council were inserted partly to placate the medical profession for not having a majority on the boards and on the Council, but the rôle of the Privy Council must detract from the authority of the Council. It is surely very unusual to have so many decisions made subject to the approval of the Privy Council—to give the Privy Council such powers of direction—although we know that, under other registration Acts, appeals can be made to the Privy Council. If there are any precedents for such an extensive rôle for the Privy Council, the House would be glad to hear of them from the Parliamentary Secretary.
The Bill conforms to a trend in the health services which, for my part, at least, I welcome. That trend is the increasing attention and emphasis that has been given to training on many fronts. We have recently seen the Report of the Younghusband Working Party on Social Workers, on which we hope to see action from the right hon. and learned Gentleman's Department in the near future. The General Nursing Council has recently undertaken a reappraisal of nurse training, and has published conclusions that have been hotly debated in some quarters, and it is a good thing that they have been.
The investigation made into administrative staffs by Sir Noel Hall recommended the importance of training in 938 order to provide a proper career structure. A good deal more could be done here. We know that the Administrative College of the King Edward VII Fund is doing well, but that is not large enough to do the job that has to be done on the scale required.
In the most important field of all, the medical field, there is little or no sign of any re-thinking on training at all. Medical curricula are, in one respect, not basically different from those of half a century ago. The medical student is still taught within the straitjacket of what one might call the mechanistic theory of disease. He is taught all about the body, but nothing about the mind, and therefore finishes his training not properly equipped to recognise the complex inter-relationship between the mind and the body, or the interdependence of the one on the other. It is not too much to say that at present the teaching on psychiatry received by the undergraduate medical student is cursory in the extreme. We must not forget that mental patients occupy 48 per cent. of our hospital beds.
There is no sign that the leadership of the medical profession will do anything about this without some stimulus from outside, and it is the Minister's job to provide that stimulus. Has not the time now come for a Royal Commission or some other kind of high-powered inquiry into medical education? This is not the occasion to develop that idea in detail, but it is something that the Minister should give thought to in the months to come.
However, I say once again that we welcome the Bill, and shall do our best in Committee to make what improvements are necessary.
§ 7.3 p.m.
§ The Parliamentary Secretary to the Ministry of Health (Miss Edith Pitt)
I am glad to find—as, indeed, I expected to find—that there is general support for the Bill on all sides of the House, but one of my difficulties in a Bill that is not politically controversial is that it stimulates interest in other directions. Hon. Members seek further information or add their particular knowledge, and I am left with such a crop of questions that I doubt whether I have time to answer them all in a winding-up speech— 939 [HON. MEMBERS: "Three hours."] If hon. Members do not mind my keeping them here, I shall be very happy, but as many have been kind enough to suggest that theirs are Committee points, I hope that any with which I do not deal this evening may be dealt with then.
Going back to my expression of pleasure at the reception of the Bill on Second Reading, I think that the members of the professions concerned in these proposals should be very gratified by the appreciation of their services that has been expressed by hon. Members on both sides, and by the recognition of the essential part that members of the supplementary professions play in the care and treatment of the health of the community.
The debate has emphasised the contribution made by the increasing number of persons engaged in these professions, which has been a very marked feature of social service in recent years. They are regarded as an accepted and valuable part of our social services. Indeed, the right hon. Lady the Member for Warrington (Dr. Summerskill) said that there was a call for increasing specialisation in this limited sphere.
The debate has also emphasised what the Bill's Title implies; that the prime responsibility for these professions rests with the doctors, and that though part of the treatment or care may be delegated to members of the supplementary professions who have special skill and training in individual branches, nevertheless, it is essential that it should remain under the control and general supervision of medical practitioners. The hon. Member for St. Pancras, North (Mr. K. Robinson) asked me categorically: Are the doctors responsible in law for what the supplementaries do? I am assured, both on my right and on my left, that the answer is "No."
As has been said so often in this debate, the medical profession has a considerable interest in the training and standards of work of these professions, which has been recognised by the scale of representation of medical interests on the Council and on the boards. As my right hon. and learned Friend said, this delicate balance of interests, together with the large number of professions concerned, has meant a very long period of work and consultation, to take account 940 of all the views, to reconcile different views, and to reach a broad agreement that is both acceptable and workable.
As we have been reminded so often today, the preparatory work has been going on for some years, and, in part, accounts for the delay since 1955 when, as the hon. Member for St. Pancras, North pointed out, this Measure was promised in my party's manifesto. It is only now that we are putting this Bill before the House, but we are keeping our promise—
§ Miss Pitt
Better late than never. The hon. Gentleman is well aware—probably better aware than I—of the reasons for the delay.
The right hon. Lady mentioned the attitude of the doctors to these proposals—not only that but gave the answer—which relieves me of the responsibility of developing that point, except, for the benefit of hon. Members who have shown such a genuine interest in this subject, and for the record, to go into the background of this legislation.
It began in 1949 with a series of eight Committees set up under the chairmanship of one who is now Sir Zachary Cope, to consider the supply, demand, training and qualifications of certain medical auxiliaries employed in the National Health Service. The Reports were published in 1951, and included a recommendation that there should be a unified system of statutory registration for medical auxiliaries. Broadly speaking, the Committees had in mind a registration council representing doctors, medical auxiliaries and others in approximately equal numbers, with advisory committees of the various medical auxiliaries concerned.
In view of the differing opinions as to the form this statutory registration should take, a working party was set up by Health Ministers in 1954 to find out what agreement could be reached among the medical auxiliaries themselves. That working party produced a Report in the form of a draft scheme for the statutory registration of eight classes of medical auxiliaries. The scheme provided for the establishment of registration boards—on which the medical auxiliaries were to be in the 941 majority—for each of the eight professions and for a co-ordinating council which would have the power to veto the boards' proposals but not the power to direct them. The aim was to provide a measure of self-government for medical auxiliaries, and the main emphasis was therefore placed on the registration boards.
There followed a long period of negotiation between the Minister and the representatives of the medical auxiliaries and the medical profession to try to reach agreement. The medical profession wanted equality of numbers on the registration boards and that the coordinating council should have overriding powers over the boards. The medical auxiliaries were not prepared to accept either as denying them their proper position.
There was considerable discussion, too, about the Title to be adopted. My right hon. Friend the Member for Thirsk and Malton (Mr. Turton) said that he did not like the Title, and the hon. Member for St. Pancras, North said the same. I think I can understand their point. It is perhaps a clumsy phrase. But agreement was finally reached on these words "professions supplementary to medicine", and at least they adequately describe the groups that we are considering.
After a number of amendments, the revised scheme was discussed at a conference in 1958 between representatives of all the medical auxiliaries and the medical profession. At that stage the scheme provided for each registration board to have a majority of one medical auxiliary and the co-ordinating council to have only powers of veto over the boards The medical profession agreed to accept the scheme so long as provision was made for disputes to be referred to an independent arbitrator assisted by expert assessors appointed by both sides. That provision has now gone because the Privy Council has been brought in. Subsequently the British Medical Association returned to the line that either there should be equal numbers on the boards or that the co-ordinating council should have overriding powers over the boards. The suggestions they then made were put to the medical auxiliary bodies who rejected them almost unanimously.
942 In the circumstances, the Government decided that the proper solution would be to leave the supplementary professions with a majority of one on each of the registration boards and to leave the Council without overriding powers, but to provide that decisions on certain matters, in particular courses of training and qualifications, shall be subject to the final approval of the Privy Council. Thus there is a third stage if the Council and the boards reach a deadlock, and on important matters the Privy Council is brought into the decision-making process to avoid any deadlock arising. The Privy Council already has wide experience in exercising similar powers in other registration schemes, relating to doctors, opticians, pharmacists and so on, and thus is well acquainted with the kind of problem which can arise. I hope that this explanation answers some of the doubts which have been expressed.
Meantime, pending the formation of the statutory registration scheme, something had to be done and in 1954 the then Minister made Regulations under Section 66 of the National Health Service Act, governing the qualifications of medical auxiliaries for employment in the National Health Service. I think the debate has shown that there is general agreement that the time has now come for the provision of a statutory registration scheme. The Bill is based on the scheme agreed at that July conference to which I referred, with two main departures, both a consequence of the introduction of the Privy Council as the approving body.
On the question of fees, which has been raised by several hon. Members, Clause 2 gives the Council power to prescribe registration fees after consultation with the boards and subject to the approval of the Privy Council. The scheme must be self-supporting but, as my right hon. and learned Friend said, everyone, particularly the professions, is very anxious that the fees should not be too high. I think the scheme must be run as economically as possible, and to help to ensure this it is desirable that finances be dealt with centrally rather than by nine separate bodies. Paragraph 17 of the First Schedule puts financial matters generally into the hands of the Council.
My hon. Friends the Members for Putney (Sir H. Linstead), and Tynemouth 943 (Dame Irene Ward) and the hon. Member for Stoke-on-Trent, Central (Dr. Stross) raised the point whether the administrative expenses could be met from the National Health Service itself, as recommended by the Cope Committee, and the expense of maintaining the register met from the fees. I think it is doubtful whether it is practicable to apportion the cost in this way. In fact, professions are always expected to meet the full cost of their registration machinery, and there is not usually any provision made for the Government to meet any part of the cost.
I am indebted to my hon. and learned Friend the Member for Surrey, East (Mr. Doughty), who said very firmly, as a professional man, that no professional body ought to take outside money. It is the same principle as applies in all recent Acts. The Council, after consulting the boards, may make rules about the amount of fees, and these rules may make different provision for different circumstances. For instance, there could be one rate for initial registration and another for retention on the register.
My hon. Friend the Member for Putney asked whether the practitioner has to pay the registration and the retention fee for the same year. Whether this is so would be determined by the rules made by the Council under Clause 2 (3, c) and approved by the Privy Council, but it seems very unlikely that any rule would require both fees to be paid. I would emphasise, on this question of fees, that the rules cannot come into force until they are confirmed by order of the Privy Council.
The amount of fees in practice will largely be determined by two factors—the number of people admitted to the initial register, and the economy with which the Council and the boards operate the schemes.
Questions have been asked about the inclusion or exclusion of professions. We thought it right to include only those professions which are the subject of the Cope Reports, but that does not preclude additions, because the Bill provides under Clause 9 for additions up to a total of twelve boards. I think it is reasonable that this question should be considered initially by the Council, the body specifically constituted and quail- 944 fied for so doing. But again I would stress that a change could be effected only by an order made by the Privy Council.
As to whether any of the bodies already named wishes to opt out, my right hon. and learned Friend explained about the speech therapists and said that they had asked to see him. Since they have featured largely in this debate, I should perhaps add a few more words particularly to deal with the point raised by my hon. Friend the Member for Tynemouth who said that the speech therapists had specifically told the Minister that they did not want to be included in the Bill. I think that point was echoed by the hon. Member for Bolton, West (Mr. Holt).
I am advised that the facts are that the College of Speech Therapists has been concerned in all past negotiations. In 1956 it indicated that the scheme in its then form was unacceptable to the College but not that it was opposed to statutory registration in principle. At the conference to which I have referred, held in July, 1958, the speech therapists said that there was no support for the scheme in its then form amongst the profession, but this was not to be taken as an announcement of their wish to withdraw from the scheme. Since then they have indicated much uneasiness about the scheme on a number of occasions but they have not said specifically that they wish to withdraw. In any event, the Bill differs in some respects from the scheme, as I have pointed out, due to the introduction of the Privy Council, and it seems right that the speech therapists should see it and make up their minds whether they wish to be included.
§ Dame Irene Ward
I apologise for interrupting my hon. Friend, but I should like to point out that it was made perfectly plain to me on the telephone by Dr. Morley—and I can only repeat what she said—that the Ministry had been informed quite recently that they did not wish to be included in the Bill and that they had had no acknowledgement of their representations. I can only say what she said to me. I cannot say whether, in fact, the communication has been received or not, but I think this ought to be put on the record.
§ Miss Pitt
That is the information I have, from what is available in the 945 Ministry, and I am sure that both my hon. Friend and I can both agree that we hope that the speech therapists will have second thoughts before they decide deliberately to exclude themselves from the provisions of a Bill which will give them status and authority in the work to which they have to make a contribution, and that is very important.
The initial register provides that people qualified for employment in the National Health Service under the 1954 Regulations, which as I have mentioned, were made by the then Minister, shall automatically be entitled to admission to the initial register now, but the boards may also admit people holding qualifications approved by them or having a qualification and practical experience. This is a matter for the discretion of the boards, but there is a right of appeal to the Council on admission to the initial register only. This is a reasonable arrangement, as the Bill does not prohibit unregistered persons from engaging in private practice. What it does do is to give protection to State-registered persons, both the professional persons themselves and the public who make use of their services. It will not prevent anyone earning a living in private practice, though, in fact, as my right hon. and learned Friend said in opening the debate, except for chiropodists and physiotherapists, none of these professions engage in private practice to any great extent.
My right hon. Friend the Member for Thirsk and Malton, and the hon. Member for Bristol, South (Mr. Wilkins), were concerned particularly about chiropodists and the position of those who were not qualified, or were perhaps not in-chided in the 1954 Regulations. The position is that the precise standards to be laid down for the admission of existing chiropodists to the register will depend on the judgment of the board, under Clause 3 (2, c), but it may be that more chiropodists will be admitted to the register than are now qualified under the 1954 Regulations. When the Bill is law and the register is being drawn up, the intention is that revised regulations should be made to allow for any State-registered chiropodists to be employed in the National Health Service. This I think answers the point which so concerned my hon. Friend.
946 To deal with another point which my hon. Friend the Member for Putney raised, I was asked about the use of the word "registered", as distinct from "State registered". It will be an offence for the persons concerned to use the words "State registered". The Clause does not specifically prohibit the use of the title "registered", but using this title in such circumstances as to imply that the practitioner was State registered would be an offence, and I hope that in that direction we have given sufficient protection to the public.
I was asked about the disciplinary procedure by my noble Friend the Member for Hertford (Lord Balniel), my hon. and learned Friend the Member for Surrey, East and my hon. Friend the Member for Maldon (Mr B. Harrison). The Bill follows the procedure adopted for doctors, dentists, and opticians. The investigating committee has to consider only whether there is a prima facie case, like a magistrates' court. Since this committee is concerned only with this and not with deciding whether disciplinary action is needed or not, its procedure is not prescribed in the Bill, but standing orders may be made under paragraph 16 of the First Schedule. The investigating committee would be small in number, and there should be no difficulty in constituting both it and the disciplinary committee under the provisions of paragraph 1 (2, a) of the Second Schedule.
The hon. Member for St. Pancras, North also asked me one other question on disciplinary powers. Could the investigating committee members be outside the board? The answer is "No," because it is specifically provided in the Bill that they must be members of the board concerned. My hon. and learned Friend the Member for Surrey, East asked me whether the powers of the disciplinary committee—this is my own phrase—could be used in such a way as to give degrees of punishment. He thought that it might be rather severe for a man to be struck off. My right hon. and learned Friend has asked me to say that he is prepared to consider this, but the usual provision—and this is certainly so in the medical Acts—is to allow for restoration to the register. However, we are grateful for the suggestion, and it will be considered.
947 I was asked by the hon. Member for St. Pancras, North what had happened to the almoners, and how had they disappeared. I asked this question myself when I started work on the Bill. I am told that, in the course of the long discussions leading up to the preparation of the Bill, the views of the almoners were generally accepted—that they belong to the field of social work, and had no real connection with auxiliaries or the supplementary professions, to give them their new title. They have dropped out of the scene. Remedial gymnasts have always wanted to be treated separately, and this was agreed in the course of the negotiations. Therefore, we are still back at eight professions, having lost one and gained another.
Trying to sum up, I think the Bill is in line with other registration Acts. It is on the same principle as the registration Measures we have passed here, particularly the Opticians Act, 1958, with only such modifications as we have had to introduce owing to special circumstances. It is complex—a word that I prefer to "cumbersome", which was used by the right hon. Lady—because it covers eight professions, and it is necessary to provide co-ordinating machinery, which means that it has led to a two-tier, or rather a three-tier arrangement, if we include the Privy Council. We have been conscious of the need to establish a proper balance between the supplementary professions and the medical profession. It means, for example, that the Privy Council has a rather larger part to play and does not merely have to approve certain sets of rules and exercise default powers, but must also have final approval in connection with training courses and qualifications.
I believe that in this Bill we have achieved the balance which we have been working for, and that the Bill will provide status and give responsibility to these professional bodies. It recognises also the importance of the relationship of these bodies with medicine, and therefore provides for the inclusion of medical 948 views in every phase of their professional organisation. The hon. Member for Bolton, West, as well as the right hon. Lady, both said that the Bill had been presented and debated on Second Reading at short notice, with very little time for hon. Members to consider it. There was no ulterior motive in that. My right hon. and learned Friend and I do not control the Parliamentary time-table, but we assure hon. Members that we wish the Bill to be fully discussed. It is our hope that we shall have contributions in Committee from those hon. Members who have taken part in the debate today. What we must not lose sight of—and I think we have succeeded in this—is our responsibility to the people who are receiving the services that we are talking about—the members of the public. We want to make sure that those who will benefit from these professions will receive the best possible services. I think that the Bill will help to ensure that, and for that reason I commend it to the House.
§ Mr. Holt
For the future benefit of the House, can the hon. Lady clear up one point? From the statement in her last remarks, is she suggesting that the Minister, knowing that he was to present a Bill to this House and take it through Second Reading, has not been consulted through the usual channels of communication, or are the channels between the Minister and the usual channels which organise the business of this House so blocked that he has not been consulted in any way whether he would like to have the Bill taken this week or next week?
§ Question put and agreed to.
§ Bill accordingly read a Second time.
§ Bill committed to a Standing Committee pursuant to Standing Order No. 38 (Committal of Bills).