§ 11.10 p.m.
§ Mr. Bernard Braine (Essex, South-East)
It has been apparent for some time past that there is deep dissatisfaction among hospital doctors, and, although the feeling is particularly strong among junior doctors, and justifiably so, it is shared by young consultants and indeed by many senior consultants who care profoundly about the future of their profession.
The dissatisfaction stems from a variety of causes. First, there is the feeling that insufficient resources are available to ensure that the good conditions which obtain in our best hospitals obtain throughout the whole Hospital Service, and that, unless the nation wills the means, it will get and deserve to get a second rate Health Service. Second, there is the fact that the present structure of medical staffing in our hospitals is woefully inadequate and utterly unrealistic. Indeed, it is held that there is no proper staffing structure at all. Third, there is a lack of any proper and fair relationship between remuneration, work load and training.
662 As for the allocation of resources—and massive sums are mentioned in the Estimate—the Minister will know that it is the general view of the medical profession that the Hospital Service, in common with the National Health Service as a whole, is not getting adequate funds to provide proper health care. With admirable candour and courage, the right hon. Gentleman admitted that when he wrote last August to hospital management committee chairmen urging them to reduce the work load of hospital doctors, especially that bearing down on junior staff, even though… this might lead to some curtailment of service to the patient.I am fully aware of the difficulty of any Minister of Health in securing an adequate share of available resources. I suppose that it would be out of order for me to go into this in detail, but perhaps I might be permitted to make one brief observation. As long as we are limited to a completely State-financed National Health Service, there will always be too little room for manoeuvre. It should be the duty of any Government to investigate alternative sources of finance and publish their findings.
§ Mr. Deputy Speaker (Sir Eric Fletcher)
I do not think that that would be in order. All that is in order on this debate is to deal with the Supplementary Estimate.
§ Mr. Braine
I bow to your guidance on these matters, Mr. Deputy Speaker, but, with respect, it is the inadequacy of the resources available—and, in particular, the Estimate which we are discussing—which lies at the root of the dissatisfaction to which I wish to draw the Minister's attention. As I hope to show, with your approval, it is impossible to draw any distinction between the staffing structure, responsibility, work load and actual remuneration.
I was not intending to say any more on the general subject of finance, except that, unless this nettle is grasped firmly, it seems inevitable that the quality of the Service will fall, the present discontent of health workers will reach boiling point, and emigration will quicken.
It is relevant in that connection to say that, as a reflection of the conditions about which I am talking, emigration of 663 junior hospital doctors is on the increase. In 1958, only three doctors took the examination enabling them to practise in America. A year ago, more than 400 entered. Last September, more than 600 entered. I know that a proportion of those were not British-born doctors, but I am sure that the Minister agrees that the trend is quite serious and ought not to be disregarded.
I do not think that it is of much use the Minister pointing to the increased output of our medical schools in the next few years, welcome though that is, if in fact a large number of our graduates are going to leave these shores. I do not wish to labour this point, except to say that surely our aim must be to improve conditions in the Hospital Service so that we not only keep our young doctors here, but encourage those who have gone abroad to return. I mention this solely to underline the importance and urgency of everything else that I shall attempt to say about the discontents of our junior hospital doctors.
I turn now to the inadequacy of the present hospital staffing structure, which stems, I submit, from the failure to match the Supplementary Estimate to the real needs of hospital service.
It is clear that there are insufficient senior consultants to meet the needs of the service. Proof of this is to be found in the fact that many senior registrars, and even registrars, are doing the same work, and have the same responsibilities, as consultants, although they are only paid according to their grade. The crux of my argument is simply that this failure to equate status, conditions of service, and remuneration to actual work and to actual responsibility goes all the way down to senior house officer level.
To be fair—and I dare say the Minister will point this out—conditions vary from region to region, and from hospital to hospital, but in many hospitals a registrar is exercising a consultant's responsibilities while working a senior house officer's hours, without this being reflected in his remuneration. Nominally a consultant is responsible in every case if anything goes wrong, and I want—
§ Mr. Deputy Speaker
Order. I am sorry to keep interrupting the hon. Member, but Mr. Speaker has made it quite 664 clear on more than one occasion that the debate on these Supplementary Estimates is limited to the reasons why the increase is sought, and does not enable hon. Members to canvass the general questions of policy for which the original grant was made. The debate must be limited to the reasons for the increase.
§ Mr. Braine
During the course of the afternoon the debate has gone fairly wide, provided that the remarks have been related to the Vote. With the greatest respect, Mr. Deputy Speaker, it is the unrealistic nature of the advances made to hospitals in respect of pay which is directly related to the conditions which. I am describing.
Money itself is of no importance unless one sees to what use it is being put. Surely examination of this is the purpose of Parliament? This is the purpose of the back bencher. This is one of the very few opportunities that we get to question the Estimates brought before us. I submit that in this case there is the closest possible relationship between the Estimate and the conditions in hospitals, which are a scandal. The national interest is concerned. This is aSupplementary Estimate of the amount including a sum on account required in the year ending 31st March 1967 for the provision of hospital services…We are dealing with £651 million.
§ Mr. Deputy Speaker
Order. On the contrary, we are not. We are merely dealing with an increase of £23 million on the original Vote.
§ Mr. Braine
I accept that, Mr. Deputy Speaker, but in relation to the problem which faces us in the Hospital Service, and which I am endeavouring to describe, this latter sum is derisory, and I am taking the opportunity of asking the Minister to explain how the money is being spent, what it is proposed to do, and whether the Supplementary Estimate covers some of the things which I shall suggest in a moment are absolutely necessary.
I am most anxious to abide by your Ruling, Mr. Deputy Speaker, but I submit that it is necessary, in order to establish my case, to show how bad these conditions are, what needs to be done, and whether the money that we are considering here bears any relationship to 665 the realities. Nominally speaking, a consultant is responsible in every situation where a less senior hospital officer is acting, and something goes wrong. The fact that things go wrong very rarely is a wonderful tribute to the skill and devotion of junior saff. This only emphasises the value of the work they are doing. The nation is getting skill and devotion of a high order on the cheap. That is the whole burden of my observations.
There is another aspect of the situation which I feel sure—knowing him—must be causing the Minister considerable anxiety. Because of the pressure of work many consultants cannot fulfil their obligations to take a share in teaching, training and research, all of which should be part of their normal duties. On the other hand, when they do take an active part in teaching, training and research of necessity more of their clinical duties are left to junior staff. It is said that there are three types of medical man—the first, those rare beings who by their sheer genius make some unique contribution to the art and science of medicine, so that their names become part of history; the second, those who serve their patients to the utmost of their skill and, in addition, pass on that skill to the next generation, and the third, those who certainly look after their patients but simply have no time to make any contribution to the future of their profession. Unhappily, due to pressure in the Hospital Service, the majority of consultants are forced into the third category, and in their hearts deeply resent it.
I want to say a word about the house officer, who has been having a particularly difficult time. I suppose that most housemen have always been badly paid. Formerly they were regarded as apprentices, still under training, who had personal obligations and were preparing for a worth-while career which would give them status and satisfaction and high earnings. Today all this has changed—
§ Mr. Deputy Speaker
Order. I am sorry. We cannot embark on a debate on the general working of the National Health Service, or the medical service. This debate is confined to the reason for which the Supplementary Estimate is 666 required; otherwise we shall find ourselves debating the whole working of the National Health Service.
§ Mr. Braine
One of the reasons why we are having the increase in the rates of pay referred to in the Estimates is the tardy implementation of the award in respect of hospital doctors' pay, which has just come into operation. I am talking here about the most junior of hospital staff who, under the Estimate, are receiving some increase in remuneration. I am talking directly about people affected by the Estimate. Everybody knows—the Minister knows; his heart is in the right place on this—that these junior staff were particularly badly hit by the pay freeze. It was most unjust that they did not get the award announced in the House by the Prime Minister last May before the freeze. I hope that the Minister recognises that these young doctors should have had a better deal.
I now turn to the relationship of pay to work load and post-graduate training. In any rational system, remuneration is closely related to the quality and the quantity of the work done, and to the responsibilities which are carried. Hospital doctors complain that their profession is the one exception to this sensible practice. They allege that nobody really knows what is going on, and they regard hospital returns on which Ministerial statistics and judgments are based are such that Supplementary Estimates are often wrong and misleading.
I hope that the House will begin to see the justification for my preliminary remarks that official returns simply do not reflect the intolerable burdens which are carried by many junior staff working a hundred, or even more, hours a week. I am told that the resident staff in some hospitals, or on call, cannot leave the hospital for weeks on end. I do not believe that even the Minister knows the extent to which this burden is affecting the doctors or the quality of the treatment of their patients. I know of a case where a doctor has been on continuous duty for up to 48 hours.
Hon. Members may have seen a report in The Times for 28th December last. I will make brief reference to it, but the House should know about it. This report 667 quotes a senior registrar in the north of England who described the situationas 'appalling', adding that it would worsen 'as the work load is increasing and the number of doctors decreasing' ".A surgeon at a midlands hospital statedthat after long hours on duty with little or no sleep, 'one's judgment is bound to be affected, to the detriment of the patient' ".The report quotes a surgeon in the Birmingham Accident Hospital as saying,'It is a disgrace. Patients do not get good treatment.' Since going to the hospital he was 'tireder than I've ever been before' ".The report adds,He said he was lucky to get more than two or three hours' sleep a night when on a 48-hour duty. These duties came round two or three times every three weeks.At Edinburgh Royal Infirmary a surgeon saidthey had a 48-hour duty once a week, and two every third week".At Newcastle General Hospital, a doctor said:the junior doctors were sometimes on duty for 110 to 120 hours a week. He said that some nights they got 'quite a lot of sleep', but during others only two to three hours".The report stated,One senior registrar feared that the supply of Indian doctors, on whom British hospitals depended to a large extent, would dry up in the next few years as it was the policy of their Government to keep them at home. Other overseas doctors, he said, were being attracted to America, like so many British doctors".Another surgeon wasleaving for Canada because of the working conditions here, rather than because of the money".If only half of those stories are true—and why should we doubt them—it shows an absolutely scandalous state of affairs. The law very rightly protects airline pilots and coach drivers who have the responsibility for the lives of passengers, from working excessive hours. The law protects lorry drivers, but not hospital doctors who apparently can work until they drop. It is in the interests of the patients, as well as of the doctors to stop this frightening state of affairs in our hospitals.
The Review Body rightly recommended last April that there should be a substantial increase for general practitioners to the minimum necessary to maintain general practice. But, in doing this, it 668 simply highlighted the fact that inadequate recognition had been given to the hospital doctors. In the British Medical Journal for 29th October last year, there was reference to… the rigorous processes of training and of competitive selection which have to be undergone by those who choose a career in hospital medicine; to the relatively late age at which a hospital doctor attains security and full earning power as a consultant; and to the responsibility borne by consultants for undergraduate and post-graduate training".I know that the Minister is negotiating this matter with representatives of the profession. Yet there remains a real doubt in the minds of many junior hospital doctors that the Minister himself is aware of the basic causes of their discontent. It is for this reason that the Junior Hospital Doctors Association urged that an independently conducted work study should be undertaken in a particular hospital region by a reputable firm of management consultants.
My information is that one regional hospital board strongly favoured this suggestion on the grounds that it would provide much-needed information and would help towards a better understanding of the problems of hospital staff. I should like to know whether it is true that the Ministry vetoed this suggestion on the ground that they were intending to undertake the task themselves. Come what may, we are faced with a shortage of hospital doctors and, with the best will in the world, the situation cannot be eased for some time to come. This means that if justice is to be done to those who carry the present burden, the Minister should be prepared to make certain minimum concessions. I should like to know whether there is provision in this Estimate that we are discussing to cover the concessions that I am suggesting should now be made.
First, the contracts of junior hospital doctors should state clearly the minimum amount of time on duty. It is clear from what I have said that in many cases this is impracticable. In that case, I am saying that some extra incentive should be provided. Does this Estimate, which must cover the whole of the year, take that sort of provision into account?
Secondly, short of a radical revision of the staffing structure, when a hospital doctor is carrying the responsibilities of a senior grade and there is manifestly a 669 shortage of senior men in a particular hospital group, he should be remunerated accordingly. Is there some provision in the Estimate to cover this, should the Minister decide to take some action on this matter fairly soon?
There are some other matters which could be put right without a great deal of difficulty if the will to do so exists—such as the payment of proper mileage and telephone allowances, and the provision of more generous study leave. I will not go into any detail on these points, because these and other matters are the subject of negotiation. But I want to know whether this Estimate covers any of these.
Bearing in mind what the Minister has already done in respect of the new contract for general practitioners—speaking for myself, and I imagine for the whole House, I welcome what he did—I am sure that he will agree that considerable relief could be given to hospital doctors by utilising more ancillary aids. Registrars have told me that they spend half a day purely on clerical work which takes much longer than necessary because of the relative inexperience of the secretarial staff provided. The reason is that hospital management committee budgets will not stretch to provide the kind of salaries which will attract and hold—that is the important thing, which will hold—the right kind of staff.
None of these smaller matters must be allowed to obscure the basic problem—that of providing as soon as possible a really satisfactory career structure. I do not know whether the Estimate makes any kind of provision for this. I refer to the sort of career structure which provides doctors who have had two years experience in the house officer grade with security of tenure and financial reward comparable to that obtaining in general practice, one which provides a realistic ratio between consultants and assistants, and one that provides effective and continuing post-graduate training for all doctors.
I have referred to the negotiations which the Minister is engaged in, and, no doubt, some of these matters are being discussed now. He may wish to be guarded about them. I do not blame him if he is. On the other hand, I think he could do much to allay the current 670 anxiety of junior hospital doctors if he would give a clear answer to a number of questions.
First, do the negotiations cover all the points that I have raised? When does the Minister hope to conclude his talks, or is it his intention to implement individual decisions as they are reached? Next, on what basis can remuneration and conditions of service be based when, as far as I am aware, the existing work load, which we all know exists, has not yet been measured scientifically by anyone? Is it not ironic that the Minister has agreed to work studies to be carried out in respect of nursing, secretarial and domestic staff but has so far failed to put in hand a similar study of medical staff, who are, after all, the key to the whole problem? Or is it the case that he has put a study in hand? Or is he planning to do so? We should be told. In any case, will the findings be available before the current negotiations are concluded? Or why not allow an independent study to be made, as suggested by the Junior Hospital Doctors Association?
If it is unrealistic—I want to be fair to the Minister—to expect such a survey to be completed in time, will the Minister say whether it is his intention in the current negotiations to reach an interim settlement which deals with some of the more pressing problems but gives real promise of better things to come, with an undertaking that negotiations will be reopened when the true facts about staffing are known?
I have raised these matters not in any spirit critical of the Minister's own approach to these problems. I have always held—I hope I always shall—that health is a field in which there is no room for violent polemics. It is one of the few areas of human activities that we discuss in the House where science and humanity essentially go hand in hand and where the strong are daily called upon to help the weak—
§ Mr. Braine
Mr. Deputy Speaker, it is kind of you to point that out. I am clearly reaching my conclusion. As I am anxious to obtain from the Minister the fullest and most detailed answer and am 671 anxious to secure from him the maximum co-operation, surely I am permitted to put these matters to him?
§ Mr. Deputy Speaker
No, because the Minister will not be entitled, any more than the hon. Gentleman is, to proceed beyond the limits to which this debate is permitted to go.
§ Mr. Braine
However narrow the rules of order are, Mr. Deputy Speaker, surely it is in order on a matter of this kind for me to go on to say, as I intended, that I wish the Minister all success in the negotiations which he is carrying out. That is all I was seeking to say. Here we are concerned with an Estimate covering millions of pounds, touching upon the health and welfare of sick people and those who tend them. Is it out of order to wish the Minister success in the negotiations and, in the process, to ask him whether he can answer the various points that I have made on this subject?
All I would add is that the right hon. Gentleman will be judged by us and by the medical profession by his deeds, not by his good intentions, and for that reason we look forward eagerly to hearing how he views the situation, which I should have thought was one of growing concern to anyone in the House and outside it who cares about the National Health Service and the morale of those who work in it.
§ 11.40 p.m.
§ Mr. Philip Goodhart (Beckenham)
This Supplementary Estimate deals with the whole of the increase in pay for the medical staff in hospitals which has been agreed so far. However, because of the lateness of the hour I do not propose to tread the paths so ably explored by my hon. Friend the Member for Essex, South-East (Mr. Braine) in initiating this short discussion. Nor do I wish to go over the sad story of the long, delayed negotiations which were involved, for the House is well aware of that story.
A minor part of the Review Body's recommendations was that we should abolish the old system whereby a doctor who was compelled to live in a hospital had a substantial part of his salary withheld to meet his board and lodging expenses. This system has today been 672 abolished, but to take its place, perhaps not surprisingly, the charge for meals has been increased very substantially. This means that a doctor who takes all his meals in hospital will be paying fractionally more at the end of the year than he does under the system which died today. Indeed, a married doctor would be substantially worse off because married doctors who maintain accommodation for their families outside their hospitals have been able, until today, to claim full tax relief on the board and lodging scheme. This can no longer apply, since the charge relates only to meals and they cannot get any tax relief at all. Thus, the married doctor is considerably worse off under the new system.
I have received a letter from a young registrar in my constituency—I am happy to say that he lives in Goodhart Way—who writes:I personally am not required to live in hospital, but for the hospital's convenience have slept in on those nights … when I have been on call for emergencies".Under an agreement made between the Ministry and the medical profession, nonresident doctors on call for emergencies have been provided with free meals outside reasonable working hours. Now this free meals system has been abolished. My constituent continues:… I shall have to pay for every meal at new and increased prices. The extra cost will amount to about £80 per annum, so you can see that I have already lost £80 of the £150 net rise that I have just received".This is a niggling new imposition which frays the nerves of those doctors who must work exceptionally long hours, about which my hon. Friend the Member for Essex, South-East spoke. They often do 110 or 120 hours a week. Now they have suddenly found that this new additional charge is being imposed on them. On the one hand they are given a rise of £150 and on the other this extra charge is imposed. It is that little straw that sends people not so much climbing up the wall but climbing on to the boats which leave this country and the hospital service. My constituent adds:My family and I really do not want to emigrate, but are you surprised that I am at present investigating the prospects of a post in a Dutch hospital for a salary of £8,000 per annum, with a house provided nearby (at an appropriate rent)?673 He goes on:The Government has done its best in recent months to persuade me to emigrate, and at last I intend to take the hint and do so. The only further step they could take is to offer to pay my passage".This doctor has not yet emigrated, but, as we all know, hundreds of doctors emigrate from this country each year. The estimated net emigration of doctors in 1966 was over 300. On 5th December last, I was told by the Minister of Health that the total medical staff in our hospitals of the grade of registrar or below was 10,234, and of these 4,661, or 45 per cent., were born outside this country. Is it desirable that our Hospital Service should be dependent, and become increasingly dependent, on immigrant doctors? This trend will certainly continue if the Ministry maintains its policy of niggling over comparatively small matters such as this. As my constituent says, the Government have done their best in recent months to persuade him to emigrate.
§ 11.46 p.m.
§ Dr. M. P. Winstanley (Cheadle)
I endorse the general argument put by the hon. Members for Essex, South-East (Mr. Braine) and for Beckenham (Mr. Goodhart), and I wish to focus attention on three specific points arising out of what they have said. In doing so, Mr. Deputy Speaker, I shall, I assure you, have in he forefront of my mind the Supplementary Estimates which we are here considering and the question as to whether they will prove adequate for the mammoth tasks which the Minister faces.
On the general question of staff shortages in hospitals and the plight of house surgeons, house physicians and resident staff generally, one must agree that we have come quite a long way. At the time when I qualified in medicine, a fair time ago but not all that long, the pay of a house surgeon or house physician in the Manchester Royal Infirmary—I have no reason to think that other places were more generous—was 9s. 2d. a week. But, of course, as the hon. Member for Essex, South-East emphasised, we were then working in a different career structure, and, rightly or wrong—wrongly, as it has proved—we felt that we could survive the roundabouts in view of the swings we might benefit from later on. We must look at things in an entirely different way now.
674 There is no need to talk about the size of the shortage of doctors or the problems which certain hospitals face on that account, but the important point—I am sure the Minister knows this—is that the shortage is an extremely delicate matter in that it is liable at any time or at any place to snowball rapidly. If a hospital is adequately staffed, it tends to remain adequately staffed. Once it begins to be under-staffed, it rapidly becomes much more under-staffed.
If a hospital advertises at present rates of pay for, say, seven resident hospital staff, house surgeons or house physicians, it may not have a single applicant because a man tempted to apply will realise that he may well be the only one, in which case he can find himself doing the work of seven. On the other hand, a hospital advertising for one house physician will probably have several applications. This has been my experience, and I have no doubt that the Minister will confirm it.
There is, therefore, a situation of some danger in certain special areas of the country—the north-west of England, the North-East, the West Riding of Yorkshire, South Wales and other parts—where there is an overall shortage, and within those areas there will be specific districts, at a distance from those in which there are teaching hospitals, in which the problem is accentuated. A rather serious disparity is created by the teaching hospital being able to attract staff by reason of other inducements which it has to offer. The outlying hospital, on the other hand, has no such inducements to offer.
That necessarily means that the Minister must now consider ways of inducing people to work in those hospitals as a matter of relative urgency and these inducements may very well have to take monetary form. So far as emigration is concerned, it is certainly not only a matter of money. There are other matters that make doctors emigrate, such as facilities and conditions of work generally.
It is well established that certain doctors who have left this country to work overseas have done so at a net reduction in overall remuneration. I know some who work overseas for less money than they received here, but they are working in infinitely better circumstances. That 675 is a money matter in the sense that to provide better circumstances the Minister must provide money to increase staff or provide the additional facilities that may be needed.
I cannot give an estimate of the numbers of doctors emigrating, nor, I suspect, could the Minister or one of his predecessors the right hon. Member for Wolverhampton, South-West (Mr. Powell). I was at a meeting with the right hon. Member for Wolverhampton, South-West, when he attempted to calculate how many doctors were emigrating every year. It appears to be a very difficult exercise. He did it by taking the total number on the register at a certain date, deducting the number who had died or retired—he knew the latter figure because he had to pay them pensions—and adding those who had qualified and gone on the register each year. As a result of that complicated arithmetical calculation he was able to give a precise figure of the maximum number that could have emigrated! That is rather like trying to find out how many people had gone to a football match by counting all those who have not gone.
The hon. Member for Beckenham tried to give an estimate, and I would not quarrel with it. I think that the Minister will agree that the figure is worrying, whatever it is, and that it shows a tendency which must be reversed.
§ Mr. Braine
Does the hon. Member attach much importance to the estimate which Dr. Seal has made that in 1965 the number of doctors that emigrated was equivalent to one-third of those produced by our medical schools in that year?
§ Dr. Winstanley
I am grateful to the hon. Member. I am aware that Dr. Seal has made a number of estimates over a long period, and has done very valuable work in pointing to the problem. But I do not necessarily accept his estimate any more than I do any of the others. I think that the Minister and the rest of us accept that there is a worrying figure. Let us not waste time saying exactly what it is.
There is also a worrying figure in the other direction, and again it is a monetary matter. Many of the doctors who come here from countries such as India and 676 Pakistan, or have come here in the past, to take up resident hospital posts have done so to do post-graduate work and study for higher qualifications.
Two things have happened. First, those countries are developing their own resources and organisations, so that the doctors are perhaps tempted to remain in India and take their own higher qualifications. Secondly, they find that owing to the general shortages in hospitals their time for study, which, after all, they have come here for, has become progressively eroded in certain hospitals. Therefore, the object of their visit is defeated in a sense, and as information about the situation spreads they will tend to come here less and less.
I feel that those observations are important, and the Minister will be seized of them. It is essential that he should have at his disposal the necessary resources with which to take the emergency steps necessary if the tendencies of which I have spoken are not to snowball. It is no good waiting for another opportunity to come to the House for more money. By then it will be too late. These things can escalate rapidly. I have seen the problem grow in my area; a hospital is slightly short of staff and then almost overnight it becomes desperately short. I would like to be assured that the right hon. Gentleman feels that he has at his disposal the resources to apply in the necessary places if it should prove necessary to make such applications.
Two days ago, the right hon. Gentleman announced the measures being taken to combat drug addiction. I welcomed those measures, the extremely mature consideration given to a number of very difficult aspects and the serious thought obviously given to the problem. The Minister had clearly taken into consideration a whole number of complicated but very important factors. He announced certain measures which, it seemed to many of us, would cost money.
In response to questions put to him by the right hon. Members for Ashford (Mr. Deedes) and Leeds, North-East (Sir K. Joseph), the right hon. Gentleman assured us that these projects would not suffer for lack of money. Yet we could not get a specific assurance that more money would be made available for them.
I cannot imagine that these new special centres in hospitals for treating drug 677 addiction can be mounted effectively without more money being made available and I would like to hear from the right hon. Gentleman tonight that the extra money which will prove to be necessary for these projects, which we all welcome, is included in the Supplementary Estimates.
§ 11.56 p.m.
§ Miss Mervyn Pike (Melton)
I am grateful for the opportunity to add my observations to this short debate, which I am sure we all welcome and which will be welcomed outside as well. Everyone on both sides of the House shares the anxiety that is felt for the future of our hospital service. I want to start where the hon. Member for Cheadle (Dr. Winstanley) left off.
On Monday—and this is the question uppermost in our minds—we had the opportunity to ask the right hon. Gentleman al out the money that is to be made available within the Hospital Service for the new centres for curing drug addiction and we do not think that we got a satisfactory answer from him. He said that the money would be forthcoming and this we believe. We believe that his intention is that a real effort should be made in this respect. We do not doubt that it is his intention to do everything possible to ensure that these clinics are set up and the treatment facilities made available.
Nevertheless, we must express our anxiety, with these Suplementary Estimates before us, that there will be cuts in other parts of the Hospital Service to find the money for the drug addiction centres. This adds to our anxieties about the state of the hospital service generally. Hon. Members have referred to shortages in the service and about the general level of emigration taking place. This is relevant to the amount we are discussing on these Votes.
The brain drain to some extent reflects a bad investment, if one can put it that way. So many of those going abroad are not going because they really want to or because they are dissatisfied with their life here, but because they are dissatisfied with the future prospects in their careers. At the same time, they are going when there has been, as it were, the maximum investment in their training and when they have given the minimum return on that investment. They themselves are 678 getting a very bad bargain because they have not finished their training.
There is great anxiety that any further shortages which occur in the National Health Service will lead to further acceleration of the process of emigration and damage to the N.H.S. as a whole. To some extent, the Minister's own statements have probably accelerated this process, but perhaps he will take this opportunity to clear this up. He is in print as giving the impression—not exactly saying—that he thinks that perhaps steps should be taken to stop this.
§ Miss Pike
I hope that the right hon. Gentleman will clear this up. If he means that he is to make it more difficult for these doctors to emigrate, they will go now while the going is good. If he means, as I hope he does, that he will try to get more money for the Health Service and so improve conditions that this desire to emigrate lapses, then we will all welcome that; but I cannot see from these Estimates how he will manage that.
The questions to which I want to address my remarks fall into three categories. First, how does the right hon. Gentleman intend to spend the money covered by the Supplementary Estimates? Secondly, does he consider that the Estimates are adequate in view of the present situation in the Hospital Service? Thirdly and most important, is this money being spent wisely and are we getting the fullest value for our money from the Health Service?
The emigration figures are relevant in this connection, because we get the vicious circle that the greater the shortage of doctors the greater the difficulty and the less good the work done by doctors who are overworked and overburdened, and the less adequate the service, the less good the value we get. One of our main anxieties in this respect is the excessive work load put particularly upon young junior hospital doctors and the dependence on immigrants to which this is leading. We are very grateful for the services which these immigrant doctors give, but their supply is not within our own control and may well diminish in future, because they, too, are being attracted overseas, and in their own 679 countries there is a movement to build up services and keep these doctors at home.
Good though these doctors are, their presence puts an added strain on our own services. There are language difficulties, which are often serious, and in many respects more training is needed. They certainly come to us for our training facilities and in many cases they require extra training facilities to help them to give their best in their own hospital services.
But the maximum strain in the service is being exerted on young men at the most vulnerable times in their careers, these young hospital doctors who are just finishing their training with all that that means. Most of us can still remember—although it is probably putting our minds some time back—what strain it was to go on year after year taking examinations and going to university and working hard and reaching maturity. It is a tremendous nervous, emotional and mental strain. People are marrying at a younger age than used to be the case, and this brings the added difficulties which the family man has. All this comes at their most vulnerable time in their career and, because of it, they are more liable to break down with the excessive burden of overwork.
Here, too, this can be said to be a bad use of resources when there is this ridiculously heavy strain on young men at this vulnerable time in their careers. It often means that they are not able to absorb the training which they ought to have and not able fully to use the available facilities, and because of that many of them are not able to give of their best.
We want to hear how the Minister believes that he will be able to meet this difficulty in future and to hear that he does not mean to lock up doctors in this country, but to make conditions so good that they will want to say. Will the Minister nail the rumour that the pre-registration requirements will be stepped up from one to two years, to some extent compulsorily lengthening the time whereby he can keep his hands on these people? Fundamentally the shortage is due to three main factors.
The first is mainly financial. We keep saying that it is not wholly financial, but the financial factor looms very large 680 in the crisis that we are now facing. What progress has been made with the B.M.A. charter for hospital doctors? What progress is the Minister making in the talks, which he says started early this year? There is great dissatisfaction at the remuneration levels, and most people, looking at the structure of the service, believe that there is still insufficient flexibility. Is the Minister sure that in these Estimates he has enough room to manoeuvre?
The hon. Gentleman the Member for Cheadle (Dr. Winstanley) pin-pointed the fact that we need more flexibility in the service structure if we are to achieve the necessary overall picture. There should be added inducements for difficult conditions. The hon. Gentleman talked about cases in the West Riding. It should be possible to attract people to these areas which are facing conditions of near crisis. The hon. Member for Beckenham (Mr. Goodhart) spoke of the residential charges on the men in the hospital services. Let us not forget that these doctors are living in the hospitals to suit their employers rather than themselves. In looking at this matter, the Minister should bear that in mind.
Is he sure that this extra money will be sufficient? Probably more important than money in the long run are training facilities, and this is where we want to know if the Minister believes that the Estimates provide adequate resources, not only to give hospital doctors the time they need, but to give them proper training facilities. Because I do not want to delay the House I will not read all of the cuttings that I have, emphasising the need for training. Every item, whether in the British Medical Journal, The Lancet, the Press, or letters from hospital chairmen, emphasises that there are inadequate training facilities for young hospital doctors.
We want to know more about what the Minister will do to attract women back to the service. To some extent young women doctors who have gone out of the service early can be attracted back given the proper facilities. Training is more important than pay here. The work load is possibly one of the most important considerations.
Are we sure that the organisation of work is properly looked after? It is a 681 platitude to say that the general practitioner is not organised on the most efficient basis, but it is less commonly realised that the same criticism can be made of the work done by the hospital doctor.
An article in The Lancet of 26th August says that the shortage of hospital doctors was at its most acute because of the survival of the myth that nearly all medical work not undertaken by consultants must be carried out by "transients". In almost every hospital junior staff spend much of their day on work which could be undertaken by others. The article goes on:It would surely be sensible to examine their day's work closely in order to discover by how much, and by whom, they could be relieved of their tasks as clerks and messengers.The work load of casualty services is perhaps a part of the hospital service that requires special attention. At present doctors in the casualty services have to deal with many cases which are not "accidents", and emergencies. In these services junior hospital doctors, very often confused by long queues of cases, of which some are trivial, often have to make rapid decisions and difficult diagnosis at great speed. In order to help the young inexperienced doctor, it has been suggested, by Sir Harry Platt, that there should be consultant supervision in casualty units at all times. Here again we come up against shortages, but surely the Minister must give us some reassurance on these points.
It is the career structure that is possibly at the root of so much of the difficulty at the present time. Remuneration is very relevant to the Estimate. I must admit that I am getting slightly nervous, Mr. Deputy Speaker, because I see you frowning at me, but I assure you that I am anxious to keep within the rules of order. Like my hon. Friend, however, I find it difficult to divorce the career structure from remuneration and the Estimates, because they are all so closely bound up.
The problem of hospital doctors is not simply lack of money and overwork. Part of the problem is also the lack of opportunities for promotion for junior hospital doctors. The hon. Member for Cheadle said that in his early days—I was going to say before the Second World War, but I am sure that he was not practicing then. I am 682 sure that he was not even born before then.
Before the Second World War, far fewer resident doctors were needed and it was possible then to relate the number of senior resident doctors required to keep the hospital going with the number of consultant vacancies which they would be expected to fill. The residents were hard worked, badly paid and badly housed. But the juniors were not staying for long and the seniors were prepared to put up with it in the hope of becoming consultants within a reasonable time.
Today, a modern hospital cannot be run with such a minimal number of staff. Hospitals have, therefore, been compelled to take on senior residents for whom they know there is no future at all. The situation is aggravated by the enormous inflation of research staff who receive preference in the allotment of consultant jobs. At present, there is no reason why an ambitious young medical student should contemplate a career in the hospital service where opportunities are so limited. Unless there is a revision of the career structure in the non-teaching hospitals, increased pay will not attract more doctors.
More consultant posts are certainly needed. There is plenty of work that they could do. Much emergency work and surgery which is at present being done by registrars could well be done by consultants, as, indeed, it was before the war. This would relieve the pressure on registrars, give them more hope for the future and also improve the standard of treatment.
Another much-needed reform is the integration of general practitioners—
§ Mr. Deputy Speaker
Order. The hon. Lady is now travelling a long way beyond the scope of the Supplementary Estimates.
§ Miss Pike
I apologise, Mr. Deputy Speaker. I do not want to stray out of order, but I want to deploy the case that the career structure is very important. I will stop if you think that I am going too far, but I was about to make the point that we cannot get away from the world outside in this respect.
The integration of the general practitioner into the hospital service is—
§ Mr. Deputy Speaker
It would be wrong to let the hon. Lady, because she is speaking from the Front Bench, proceed further than other hon. Members have gone.
§ Miss Pike
I certainly bow to your Ruling, Mr. Deputy Speaker, and I will not seek to go further. I believe, however, that the Minister has taken the point, which he knows only too well.
Career structure, conditions of work, remuneration and opportunities throughout the whole service are uppermost in our minds in asking the Minister how he will spend the money that is provided in part of these Estimates, how he will make sure that he gets the best value for it and how he will ensure that in extending one part of the service he is not making cuts in other parts.
We want to hear clearly from the Minister the position that will be brought about by the added money that is to be spent on clinics for drug addicts. This is uppermost in our minds. We are facing a crisis in the hospital service. We believe that more money should be brought into the hospital service and that these Estimates should be bigger.
We only wish that as part of these Estimates the Minister could start a survey to see how he could bring more money into the service as a whole. We only wish that as part of these estimates we could recommend certain courses of study to find ways in which we could get out of the financial straitjacket which is causing so much damage to the service at present.
But uppermost in our minds is the problem of finding extra money without making any cuts in the service, for if the Minister makes any further cuts in the service affecting young hospital doctors the crisis in the service is going to be very real indeed.
§ 12.16 a.m.
§ The Minister of Health (Mr. Kenneth Robinson)
I am very glad to respond to this opportunity, afforded to us by the hon. Member for Essex, South-East (Mr. Bernard Braine) and others, to discuss the conditions of junior hospital doctors, or at any rate, to discuss this Supplementary Estimate as it relates to junior hospital doctors. The rather narrow limits of this Supplementary Estimate have, of course, led certain hon. Members into some difficulties.
684 The hon. Lady the Member for Melton (Miss Mervyn Pike) rather highlighted these difficulties by asking me three questions. She asked me "how are you going to spend the money?" The answer, which is in the Estimate, is on Selective Employment Tax and on increased rates of pay in respect of pay awards agreed to date.
The hon. Lady asked me "is the money adequate?" My answer is that it is perfectly adequate to meet the purposes for which it is being voted. She asked me if I am going to get good value for the money? I am quite sure that I shall get very good value for the money paid to these hospital doctors.
It follows that these Supplementary Estimates will not cover the cost of addiction centres at hospitals, which have not yet been set up. I have nothing to add to what I said the other night about that. All hospitals get more money every year; the rate of increase is greater than ever it was under hon. and right hon. Gentlemen opposite, and those hospitals called upon to provide these facilities will get the resources needed to provide them.
Before I come to the main debate, on the conditions of junior hospital doctors, perhaps I can deal with the particular matter the hon. Gentleman the Member for Beckenham (Mr. Goodhart) raised in relation to board and lodging charges for junior doctors. It is difficult to deal with a particular case, that of the doctor whose letter he read out, but I would be glad to look into it if the hon. Member will send it along to me.
The Review Body, in making this award which is a very substantial increase for junior grades, said that in future there should be no payment for board and lodging together as in the past, and that for those doctors who should be compulsorily resident in hospital there should be no lodging charge but that they should be required to pay for their meals as they are taken.
An agreed scale of charges for meals has been agreed by the B.M.A. on behalf of the profession, and I am sure it is not true to say, as was alleged in the letter, that the new meals charge for the compulsorily resident will be more than the combined charge abolished by the Review Body. I am told that it cannot be more, but as I have said, I would be 685 very glad to look into the particular case.
Doctors have always had to work hard in their early years in the hospital service, at a time when they are acquiring their professional skills. I think, therefore, that it is all the more important that they should feel content with their general conditions of service, ranging from living accommodation to facilities for post-graduate training.
Now in discussing the recent discontent among junior doctors, very vividly described by the hon. Member for Essex, South-East, it is well to bear in mind that recent years have seen great advances in medicine, increasing public demand for medical care, and considerable social change. It would be fair to say that conditions which were accepted as a matter of course by the previous generation, for example, by the hon. Member for Cheadle (Dr. Winstanley) when he was a young hospital doctor, are no longer acceptable to the present generation. I make no complaint about that. But the grievances of hospital doctors have not blown up overnight. For the most part, they go back a long time; certainly throughout the 13 years during which right hon. and hon. Gentlemen opposite were in charge of the National Health Service.
I should like, first, to say a word about the work load, which I agree is one of the most important factors. It may of itself determine whether a doctor is satisfied with his employment. I agree that no one can give of his best when he is fatigued by excessive hours of work, and every year the volume of work in our hospitals increases. It can be measured to some extent by the figures in respect of hospital patients, such as discharges and deaths. But the figures do not fully reflect the increasing burden falling on doctors and other professional staff due to the growing complexity of medical care.
New techniques of great benefit to patients very often require much more intensive work on each patient by the medical staff. The growing burden of complex and responsible work falls upon doctors of all grades, not only on the juniors.
The extent of the increase in medical staffing in the hospitals since the beginning of the National Health Service is perhaps not even now sufficiently widely 686 known. All grades of staff increased by about 65 per cent. between 1949 and 1965 in terms of whole-time equivalents. In the intermediate and junior grades—that is, registrars and below—the increase was about 88 per cent. There were over 7,000 more doctors working in our hospitals in 1965 than there were in 1949.
Despite the very considerable expansion, we still need many more doctors than we have. In recent years, the medical schools have not produced as many doctors as were needed, and the hon. Member for Essex, South-East knows why as well as anyone in the House. I do not want to labour the point about the Willink Report tonight.
The average output of British-based graduates from medical schools in Britain was 1,600 in the years from 1961 to 1965. It is now rising, and the intake of British-based pre-clinical students has increased from 1,788 in 1960–61 to 2,363 in the autumn of 1966. That increase will be reflected in an increased output of doctors over the next five years, and that should help our hospital staffs to cope with the ever-increasing volume of patient care.
At the end of last summer, I wrote to the chairmen of hospital authorities, as the hon. Gentleman mentioned, asking them to review the hours and organisation of work undertaken by junior medical staff, the facilities for recreation and study, and the provision of residential accommodation in their hospitals, and to report to me on the action taken to make improvements on each count. The response to that request has been encouraging. It is clear from the reports that I have received that boards and committees have set about this task with determination and ingenuity.
Almost all committees acted on my suggestion and appointed one or two members to take a special interest in the welfare of junior doctors. Many committees have arranged special meetings with the junior medical staff, and in some groups other steps have been taken to improve communications between the younger doctors and the administration. Junior doctors have been co-opted on to medical committees or have been encouraged to organise junior staff committees. I am sure that all these measures will help promote an understanding of the sort of problems that we have to tackle.
687 Most authorities have reviewed or are reviewing hours of duty and organisation of work with special reference to standby duties. Steps are being taken where possible to reduce excessive hours and to increase time off for recreation and study by reorganisation of duties, by improvement of arrangements for filling vacancies and covering absences, increased employment of general practitioners on standby duties, and by increases in medical establishments. To some committees the basic problem is a shortage of medical manpower which will not be solved by the creation of additional posts which cannot be filled, and this relates to the point made by the hon. Member for Cheadle. These authorities say that there seems to be no way of achieving a material reduction in hours of duty for their junior medical staff at the present.
It is very clear that the major cause of excessive hours is the need to provide round-the-clock services for accident and emergency departments, but most hospitals find this an unavoidable obligation. A few have found it possible to close small accident departments by making alternative arrangements to receive casualties elsewhere, and a limited amount of rationalisation in casualty services has been achieved as between hospitals situated fairly close together. This last was, of course, what was meant by the phrase, quoted by the hon. Gentleman, "some curtailment of services" in my letter to chairmen. In fact the curtailment has been minimal.
There has been a good deal of development recently of medical libraries and other facilities for post-graduate study. Further expansion, including the provision of several new centres of postgraduate medical education, is planned. I am glad to say that there is increasing provision for study leave, day-release courses, and other forms of help for those studying for higher examinations, and I entirely agree with the hon. Gentleman that these facilities must be open to all junior doctors, whether British born or from the Commonwealth.
In recent months the profession has been discussing these problems, and it sent me the memorandum upon them which it published in the medical journals. In answer to a Question in the 688 House on 14th December I said that I intended to start negotiations on the hospital doctors' document on 19th December. The negotiations did indeed start on that day, while, incidentally, the memorandum was still under discussion within the profession, and I really do not know what the hon. Member for Beckenham meant when he talked about a long delay in negotiations. I was discussing the document before it was finalised.
Arrangements have been made for a full series of meetings to discuss in detail the many aspects of the hospital service which are raised in the memorandum. The negotiations concern all grades of hospital, medical, and dental staff, and not only the problems associated with junior grades in particular. They will cover a wide range of problems, but not major matters of remuneration. As the House knows, these are for the Review Body, and the Review Body awarded substantial increases in pay, particularly for junior doctors, in the Seventh Report which was accepted by the Government.
If we are now getting the services of junior hospital doctors "on the cheap," to quote the hon. Member for Essex, South-East, I do not know how he would have described their remuneration when he was Parliamentary Secretary at the Ministry a few years ago, because these increases have been very substantial indeed.
§ Mr. Braine
I was referring to junior staff taking on the responsibilities of senior staff and not getting the remuneration for it. The sole purpose was to probe the right hon. Gentleman's intentions with regard to the staffing structure. Is the Minister going to deal with that?
§ Mr. Robinson
I am, but the hon. Gentleman knows full well that those conditions did not suddenly appear on the horizon when the Government changed in October 1964.
§ Mr. Robinson
The increases to which I have referred are now in payment following the six-month deferment which was necessitated by the prices and incomes standstill.
It has been for the professions themselves to decide who should represent 689 them in the negotiations, but the importance which they attach to ensuring that the interests of the junior doctors are kept well to the fore is shown by the fact that four out of the negotiating team of nine were themselves junior doctors.
I am fully aware of the feelings of frustration which have been expressed by so many of the juniors, and which have been quoted during this debate. I am hopeful that when the current feelings of uncertainty about career prospects in the hospital service have been removed, many of the relatively minor matters which seem to cause a great deal of vociferous complaint will then be seen in perspective.
The major problem of career prospects is not one that can be solved overnight. But these discussions do provide a real opportunity to review with the profession the junior hospital doctors and staffing structure. This is of vital importance and I am not without hope that major modifications in the career structure may be agreed that will go a very long way towards alleviating the current difficulties.
A somewhat different series of problems raised in these discussions are those aflecting the work load and the hours off-duty of junior hospital staff. Some improvements have already been made here. My Department had already obtained preliminary information about the work of junior doctors and is planning a further study. Some improvements will inevitably affect the relationships between different categories of hospital staff, because we must bear in mind that it is not only junior staff who may be overworked but some consultant staff as well; or no one will be very much helped if changes made result merely in moving the burden of work from some staff to other staff who are already equally overburdened.
Equally, we must provide that any changes must be co-ordinated so as to make sense within the framework of the hospital service as a whole.
§ Dr. Winstanley
Can the Minister mention any proposals that he has for removing the burden from one hospital to another; in other words, the arrangements he has described about what to do within a hospital do not cover the problem of transferring hospital staff as between one hospital which is fully staffed 690 and another which is very much understaffed. Has he any suggestions for dealing with that problem?
§ Mr. Robinson
This was one of the situations which gave rise to my suggestion about a rationalisation of casualty services. A certain amount has been done, but I hope that more can be done. In the long run, however, the solution is to improve conditions within these hospitals where staffing is very difficult in order to improve recruitment prospects.
The hon. Member for Essex, South-East, asked how long negotiations would last. If he is interested in the answer—and it appears that he is not; perhaps the House will be—they will last as long as is needed to achieve a satisfactory outcome. I have made it quite clear—and this was another question of his, the answer to which he is apparently not interested in—that any agreed improvements which can be implemented in the course of the negotiations will be implemented without necessarily waiting for the conclusion of the whole lot of negotiations.
Another important factor in the life of a junior doctor is his requirement for study leave to prepare himself to sit for higher qualifications which are normally necessary for a career in this service. The current negotiations deal with the special problems that this poses both from the service point of view and from that of the junior doctor. Our aim is to provide in future more flexible schemes which can readily be adapted both to the developing needs of hospital medicine and the varying requirements of the individual doctor. I believe that the House will recognise, in the light of what I have said, that the problems of junior hospital doctors are now being critically and urgently reviewed by the Government, in full consultation with the medical profession.
§ Mr. Braine
Will the Minister say something about the question of a survey of the work load in hospitals? Is his Ministry engaged on any kind of work of that nature?
§ Mr. Robinson
This was one matter I was dealing with when the hon. Member was deep in conversation with his hon. Friend behind him.