HC Deb 14 March 1960 vol 619 cc1075-88

Motion made, and Question proposed, That this House do now adjourn.— [Colonel J. H. Harrison.]

10.18 p.m.

Dr. Horace King (Southampton, Itchen)

I am grateful to the Parliamentary Secretary to the Ministry of Health for taking a third debate at the end of a full day. Those who know and appreciate the work she did in her former Department know that she will do similar excellent work in her present Department. We differ politically, but not personally.

Local executive councils under the Health Service consist roughly of 50 per cent. laymen and 50 per cent. professional representatives. They are doing excellent work. One of their duties is to fill vacancies in the general practitioner service, subject to approval by the central body, the Medical Practices Committee. There is no doubt what the Act intended to happen. In Committee, on 20th June, 1946, my right hon. Friend the Member for Ebbw Vale (Mr. Bevan) said that the executive council, after consulting the local doctors' committee, would select someone to fill such a vacancy and submit the name to the Medical Practices Committee. He said: The only circumstances in which the Medical Practices Committee would be likely to question the local appointment would be where some improper action had taken place. In order that the Committee may have the authority to take such action it is necessary that formally … I underline the word "formally"— they should make the appointment. … Does anyone imagine that a busy central committee is going to worry itself about the whole of these individual local appointments? It is only going to worry if something wrong has happened … but there must be reserve power somewhere."—[OFFICIAL REPORT, Standing Committee C, 20th June, 1946; c. 1642.] My right hon. Friend also said, at col. 1622: In fact, the individual doctor will be selected by the local Executive, and not by the Medical Practices Committee. My right hon. Friend could not imagine that the Medical Practices Committee would interpret the reserve power of which he spoke in the way that it has done. The Committee accepted my right hon. Friend's assurances.

The National Health Service Bill also gave individual doctors the right to appeal against such an appointment. The Committee discussing the Bill was uneasy about this, too. The present Joint Under-Secretary of State for the Home Department said about the right to appeal, at col. 1645: It seems to me that the public may be deprived of services which are urgently required if this takes place. We cannot conceive that the majority of appeals are likely to succeed. Surely, a fairly small proportion of them only will succeed, and, for these reasons, it seems that this procedure will deprive the public of necessary services."— [OFFICIAL REPORT, Standing Committee C. 20th June, 1946; c. 1622, 1646–7.] Again, however, my right hon. Friend the Member for Ebbw Vale assured the Committee that there was no danger and the Committee accepted his assurances.

I want to show that things are not working out as the Minister, and, indeed, the House, at that time intended them to do. If there is a vacancy because a doctor has died or a new housing area has sprung up and needs a doctor, the executive council, after consulting the local doctors and the Medical Practices Committee, advertises the vacancy, then prepares a short list from the applicants, interviews them and chooses the one it considers to be the best doctor for the practice. His name goes up to the Medical Practices Committee. Sometimes, this body asks the executive council to make another short list to interview again. Sometimes, it itself short-lists the second time and interviews the second time. All this takes time.

Finally, both the executive council and the Medical Practices Committee reach agreement, which means that the executive council usually gives in. Even then, however, any doctor who feels aggrieved because he is not the one selected has the right of appeal against his successful colleague. The Minister can decide this appeal himself or set up an appeals committee to judge it. If the appeal is upheld, the appellant gets the post. If not, when all such appeals have been dealt with, the original appointment is confirmed. All this means delay. In the meantime, the locality may urgently need its doctor. The new doctor's list may have dwindled by the time he is appointed. Patients in need will have found themselves another doctor.

Moreover, of all the groups concerned in the appointment of a doctor—the local executive council, the Central Council, the Minister and the appeals committee—it is only the local executive council which has the intimate knowledge which fits it for judging. Indeed, it is only the executive council which has done all the detailed work of shortlisting, interviewing, weighing up the medical and also the personal qualifications—and the Medical Practices Committee admits that the personal qualifications are important—of the candidate. In actual fact, the appeals committee may have seen only one candidate for the job: that is, the appellant himself. What was put into the Act as a reserve power or safeguard has been twisted, as Shakespeare would have said, "clean cam" from its original purpose.

The Minister and the Medical Practices Committee defend themselves in a recent letter which they have sent to local executive councils and both of them show that they have totally ignored what was said in Committee in 1946. The Medical Practices Committee claims that it may have special knowledge of particular applicants. If that is so, it should pass on that knowledge to the executive council when it makes the selection. The letter quotes as the Minister's view: In the matter of selection for a vacancy the Medical Practices Committee has to give meticulous consideration to all applications. It states of an appeal: The Minister considered that the appellant ought to be selected on account of his greater experience and because his personality is not less impressive than the candidate selected by the Executive Council. That may be contrasted with the statement of my right hon. Friend the Member for Ebbw Vale in Committee on 20th June, 1946: The Minister ought not to tell the local Executive Councils what grounds they should consider in making an appointment."— [OFFICIAL REPORT, Standing Committee C. 20th June, 1946; c. 1648.] The price of local government, like that of freedom, is eternal vigilance. Whitehall does not always know best. Executive councils are rightly protesting at what is happening today. I have praised their character, their constitution and their quality. The Health Service is served by thousands of voluntary workers co-operating with professionals in every field, and executive councils are no exception. Moreover, they have now some fifteen years experience of administering their part of the Service. They feel that their part in making an appointment ought to be what the creator of the Act and the House intended that it should be. We still have, however, as late indeed as the Cohen Report, a suggestion that the local council may be susceptible to improper influences.

Both laymen and medical men on local committees resent this. They suggest reasonable reforms, compromises. They suggest that they should make the appointment, subject to only one check, namely, an appeal to the Medical Practices Committee. They suggest that appeals might be restricted at any rate only to those who have got on to a short list.

I would go much further than they do on the matter of appeals. In no other profession has a man the right to delay an urgent public appointment merely because he thinks he is a better man than the man who has been given the job. What a state Britain would be in if we allowed teachers the right of appeal when they are not appointed head masters, or curates because they are not made bishops, or Members of Parliament because they are not made Ministers.

I want to give some illustrations. I shall not name the authorities or the towns, although I have given the names to the Minister. I do not particularise the names, because this is a matter of principle and not of personality. My first example is in a southern town. There was a vacancy for a doctor. It was advertised in mid-August. The short list was drawn up on 8th September. The interviews and selection were on 21st September. If it had been merely a chief education officer or a town clerk, that would have been the end; he would have been appointed. However, the Medical Practices Committee asked why four named doctors had not been interviewed. So there had to be a re-interview on 14th October, and the original doctor was again selected. This time the Medical Practices Committee accepted the recommendation, and the man was appointed on 26th October after a month's unnecessary delay.

In the same southern town another vacancy occurred. The interviews were on 11th October. This time the Medical Practices Committee accepted the recommendation of the executive council. Then one disappointed candidate appealed. Finally, on 26th October, the Minister awarded the place to the appellant, and in the opinion of the local executive council he was wrong in doing so.

I have not time to show why the executive council, with its greater intimate knowledge, was right and knew that it was right. I would only point out that the appellant succeeded only against the candidate selected by the executive council. There may have been better "second choices" on the short list. Indeed, there were if all of them had appealed, or if the decision on appeal had been to send the names back to the executive council so that it might have another look. The Appeals Committee said that this man was given the post because he had longer service than the man the executive council had selected. But if length of service automatically qualifies for an appointment there is no need for executive councils to do the selection at all. A comptometer could do the job.

Incidentally, in case the Parliamentary Secretary intends to quote the Medical Practices Committee's latest circular, my information is that in this case the appeals committee had seen only one man, the appellant, the other doctor having been represented at the appeal by a solicitor.

Now, a case from the North. Five men were put on the short list for interview, and one was selected. The Medical Practices Committee insisted on seven others being interviewed. This was done, and again no change was made in the original recommendation. Then one doctor, who was not on either short list, appealed and was given the post.

In a Midlands town there is a complaint of a delay of three months in filling a vacancy, during which time, says the local executive council, it was difficult to hold the practice together, and there was a "a procession of locum stenens." In the case of another Midlands executive council, there was a short list of six and one man was recommended. The Medical Practices Committee insisted on a re-interview for three more doctors. The original choice was confirmed. The vacancy occurred in May, but the post was not filled until late in August.

In the same town, on another occasion, the executive council's recommendation was accepted by the Medical Practices Committee. Then a doctor, not on the short list, appealed. Arrangements were made by the Minister to hear the appeal, and then the appellant withdrew. The vacancy occurred in July; it was not filled until October. In a north Midlands town, the Medical Practices Committee turned down the recommendation of the executive council, held its own interview and, in this case, appointed a local man. So much for the danger of the local executive council being guided by local, improper influences.

In another case, in the South, the executive council recommended a man; the Medical Practices Committee insisted on a second interview itself, and chose someone else. On this occasion, the executive council's nominee or doctor recommended for the job appealed, and won. It took four months to fill that vacancy.

I am certain that when he reads some of these cases, my right hon. Friend the Member for Ebbw Vale will turn in his bed in the farmhouse where we are delighted to know he is steadily building himself up to full health and strength. This is certainly not what he intended. The Medical Practices Committee has its own important work to do. There are broad fields in which, rightly, it controls and directs the executive councils, but it has not the time, nor has it the men with the special ability that the local body possesses for medical selection for a particular practice.

Sir Harold Webbe said—and the then Minister agreed—in Committee: …If I understand the Minister aright, under the Clause, with his Amendment, there is no question of the Medical Practices Committee ever having to decide, as between A and B, which is the better man for the appointment."—[OFFICIAL REPORT, Standing Committee C, 20th June, 1946; c. 1643.] The over-riding of a local authority in the matter of an appointment poisons relations between the local authority and its staff. It shakes the confidence of the body in itself and, unless there is corruption or suspicion of corruption, it is unjustified. On the Adjournment, I cannot argue the need to change the law or the Regulations, although the real solution would probably be to tidy up the Regulations in the way that the executive councils suggest.

I do claim, however, that the Act is not being administered as it was meant to be, and I want to urge the Minister to change current practice. Under the 1954 Regulation 10 (3), he has power either to deal with an appeal himself or to set up an appeals body. I suggest that, in future, he use that power in a way showing more confidence in the judgment and integrity of the executive councils.

He can at least adopt the common-sense attitude that if a man has not got even as far as the short list drawn up by a competent selecting committee it is extremely unlikely that he is the man who should have the job; or, again, if both local executive council and the Central Medical Practices Committee agree, it is not unlikely that they are right. He can also urge the Medical Practices Committee to get rid of this idea of "meticulousness" in the exercise of what was meant to be a reserve power and itself have more confidence in the local executive council.

Now, if there is a vacancy in a partnership, the doctor's recommendation for a new partner is accepted without question. If a single-handed doctor decides to add a partner or take on an assistant, again there is no question. It is only when an executive council, consisting of representative medical men and laymen, conscientiously and ably does the work of selection given to it that "meticulous examination"—I might almost say agonising reappraisal—takes place, and even the combined wisdom of both local executive council and Central Medical Practices Committee can be overthrown on the appeal of someone whom neither thought eligible to be on a short list.

My right hon. Friend thought that this cumbersome machinery for appointment would work … with less and less interference, and it may be that some of it will pass almost into desuetude."—[OFFICIAL REPORT, Standing Committee C, 19th June, 1946; c. 1622.] The opposite has happened. I would urge the Minister to give due consideration to what I have said tonight, and to the claims of the executive councils to be trusted to do the job that Parliament, when it passed the Act, intended that they should do.

10.35 p.m.

Mr. John Howard (Southampton, Test)

The debate has arisen from representations made to the hon. Member for Southampton, Itchen (Dr. King) and myself by the Southampton Executive Council. I wrote to my hon. Friend the Parliamentary Secretary some little while ago setting out the views put before me by the chairman and secretary of that council, and the hon. Member for Itchen has reiterated most of those arguments this evening. I want to make only two points, briefly.

The first relates to the members of the council. I feel that it is most important that we should retain the interest of those people who give their time to this work. It is very important work which makes the whole system operate fairly. If we are to retain their interest and their support, it is clear that the decisions which they have made on the selection of candidates should not appear to be lightly over-ruled.

At the same time, I do not go all the way with the hon. Member for Itchen, because I feel that the right of appeal by an aggrieved candidate must be retained. In one case in Southampton the aggrieved applicant who appealed, and appealed successfully, was a coloured doctor. He had been unsuccessful in a number of applications and no doubt felt—although I am sure that this was not the case— that he had perhaps been unfairly discriminated against. He enjoyed the right of appeal. The unfortunate part about the appeal was the delay. This delay is inevitable and is caused by the present three-tier structure of the executive council, the Medical Practices Committee, and, finally, the inquiry set up by the Minister.

I hope that my hon. Friend will give some indication of whether this procedure can be streamlined so that appeals can be heard promptly. I hope that we can retain the right of appeal by doctors and at the same time retain the interest of the many people who give their time to this very valuable work.

10.37 p.m.

The Parliamentary Secretary to the Ministry of Health (Miss Edith Pitt)

Perhaps I may first be allowed to thank the hon. Member for Southampton, Itchen (Dr. King) for his very kind words to me on my new appointment. I am very glad that the co-operation which I enjoyed from him in my previous appointment is to be continued in this appointment. I should like to congratulate him on bringing into discussion on the Adjournment a matter which I think it would be very useful to have on the record of the House. May I also thank him for most generously notifying me early of the points which he wished to raise in order that I might have an opportunity to look up the answers.

Before discussing the procedure for filling the vacancies advertised by executive councils, it is worth while considering how big a part this procedure plays in the administration of the General Medical Service. Vacancies filled in this way represent only a small minority of the total admissions to medical lists of executive councils. Last year, for example, only 168 doctors were appointed to advertised vacancies by means of the procedure which has been under discussion tonight, whereas over 900 were admitted to the medical list in other ways.

As the hon. Member for Itchen said, there are no difficulties where the doctor becomes an assistant or a partner or, subject to need, where a new practice is started in a new area. But difficulties arise where there are vacancies in a single-doctor practice advertised by an executive council. These are the vacancies which are subjected to the selection procedure which has been criticised by both hon. Members.

Most advertised vacancies result from the death or resignation of a doctor in an established practice, though some are new practices in an area of rising population where the executive council has decided that an additional doctor is required. In 1959, 168 vacancies were filled in this way. The number of applications for each advertised vacancy averaged 24 in 1959, but the keenest competition is still for vacancies, especially those with substantial lists, in the southern parts of England. No fewer than 99 doctors applied for one vacancy in Hove. On the other hand, several of the vacancies advertised in less popular areas had fewer than 10 applicants.

I welcome the opportunity this debate gives of making the point, not unknown to those concerned, that doctors who are eager to set up in practice would do well to consider applying for a vacancy in one of the less popular northern areas rather than to make repeated unsuccessful efforts to obtain a practice in parts of the country where the competition is most severe.

Complaints have been made that the three-tier system gives insufficient weight to the local knowledge of the executive councils and the local medical committees, and that it takes too long. The system gives full scope to the local knowledge possessed by executive councils and local medical committees since in their report to the Medical Practices Committee they are able to set out fully any special local circumstances which ought to be taken into account as well as advising which of the candidates they consider most suitable.

But, as the actual appointment is made by the Medical Practices Committee, it is clear to all that there has been no undue local bias or prejudice in reaching the decision. Moreover, the Medical Practices Committee, before making its selection, reviews all the applications, including those not short-listed. With the many applications received for some vacancies, short lists may exclude a large number of well-qualified candidates. At present, these candidates know that their claims are considered by a second body. But for this there might well be more appeals and a greater need for oral hearings, which could well cancel out any possible saving in time. The average time taken for filling a vacancy—in England and Wales 57 days and in Scotland 60 days —is well within the period of three months' notice which is required for a doctor retiring from the National Health Service.

The hon. Member quoted from a speech made by his right hon. Friend the Member for Ebbw Vale (Mr. Bevan) on 20th June, 1946. If he will look at the context, he will see that the speech referred to procedure for admissions of all types to medical lists, and not merely to the filling of advertised vacancies. In the same speech the right hon. Gentleman said, for example: As. we are anxious to encourage the creation of group practices, obviously it would be desirable that the members of a local group should have a voice in helping to decide who their new colleague should be."— [OFFICIAL REPORT, Standing Committee C, 20th June, 1946; c. 1641.] That is exactly what happens now. Admission to a medical list to enter partnership is not subject to the procedure which has been criticised by the hon. Member. It is left to the doctors in the partnership to select their new colleague, and admission to the medical list is normally granted automatically by the Medical Practices Committee.

The speech also referred to under-doctored areas. Here again, admission to the medical list of a doctor wishing to put up his plate in an under-doctored area is not subject to the criticised procedure.

In 1959 there were 168 advertised vacancies and over 900 admitted to the medical list in other ways, making about 1,075 cases in all where the approval of the Medical Practices Committee was required. In less than 2 per cent. of these cases did the Medical Practices Committee go against the advice of the executive council and the local medical committee.

In the Ministry we are very conscious of the need for speed in filling vacancies, and I can assure both hon. Members that every effort is made to avoid delay both by the Medical Practices Committee and by the Ministry of Health in the event of an appeal, and the figures which I have already quoted show that decisions are usually given well before a resignation is due to take place.

The hon. Member has mentioned a number of cases where the executive council was concerned with delay which occurred in filling vacancies, and he was good enough to send me a note of these before the debate so that I have had an opportunity to look into the details. I do not think I can deal with them all now, but I should like to say something about two recent cases which he mentioned in his own part of the country. He referred to two cases in the South. They are, in fact, in Southampton.

In the first case, the executive council had long notice of a doctor's resignation. Although the Medical Practices Committee decided to hold a second interview, which made the procedure somewhat longer than usual, it decided to appoint the doctor recommended by the council, and this decision was given two-and-a-half months before the vacancy was due to occur.

In the second case, the procedure was lengthened, first by an appeal to the Minister, and later by the withdrawal of the successful appellant. In this case, a new practice was being created in an area of new housing and building which had not got very far. The Medical Practices Committee considered that October, 1960, would be a reasonable starting date. In spite of the lengthening of the procedure, the Minister's decision on the appeal was given a year before the vacancy was due to arise. The successful appellant later withdrew, but a new appointment was subsequently made and the starting date is still six months ahead.

Both the appellant and the candidate selected by the Medical Practices Committee attended before the persons appointed by the Minister to take the oral hearing of the appeal, and both gave evidence, and the selected candidate was legally represented.

The hon. Member for Southampton, Itchen, seemed to suggest that he would like to take away the right of appeal. This appears to me to be a personal view not shared by the Southampton Executive Council or the Executive Councils' Association. It is a suggestion which would require legislation for its implementation. The right of appeal was provided by Parliament in the National Health Service Act, 1946, in Section 34 (6). It would be a serious matter which would require very full justification to suggest that Parliament should be asked to withdraw a right which it thought fit to give in 1946.

In conclusion, may I say that this debate has had the advantage of drawing attention to the very great help which is given by members of the medical profession and other voluntary members of public bodies in the administration of the Health Service—help for which we are all grateful. I am glad the hon. Member for Itchen paid testimony to the valuable work of members of Executive Councils and that my hon. Friend the Member for Southampton, Test (Mr. J. Howard) asked us to be sure to take action which would retain the interest of the members of these councils. I can assure both hon. Members that we are very appreciative of that service. We believe the system works and we certainly wish to retain the interest.

Question put and agreed to.

Adjourned accordingly at thirteen minutes to Eleven o'clock.