JUNIOR HOSPITAL DOCTORS

HC Deb 21 January 1972 vol 829 cc926-38

4.9 p.m.

Mr. Laurie Pavitt (Willesden, West)

Junior hospital doctors are overworked and underpaid, their hours are too long and they do not get sufficient recompense. This is not a new situation and the question I address to the House is, why has this exploitation gone on for so long?

There are three reasons for this. There has been complacency by hospital authorities, indifference and smug satisfaction with their own success on the part of specialists and consultants, and, until recently, a fatalistic acceptance of the power and promotion structure and the consequences for junior hospital doctors if they protested their cause too vigorously.

I am pleased to record that there has been a breakthrough on the latter problem in recent years. I salute the courage of junior hospital doctors who, under the organisation which they have set up, the Junior Hospital Doctors' Association, have pleaded their own cause knowing that it may well interfere with their individual career prospects. I pay tribute to Dr. Katherine Bradley, the chairman. If the voice is that of the hon. Member for Willesden, West, the brain is that of the junior hospital doctors in the case I am presenting.

Another new and welcome phenomenon is that for the first time the junior doctors have been able to organise in such a way as to retain the allegiance of those who were once junior doctors and have now been promoted to consultants. There is now an "old boys' association" of junior doctors, in marked contrast to the position some ten years ago when once a doctor became a consultant he was only too pleased to haul up the ladder after him.

There have been two recent studies on this subject, one by the Department and one by the British Medical Association. The weak response of the Secretary of State to the Questions that were put to him in the House on 21st December and which was recorded in column 1279–80 of the OFFICIAL REPORT has led me to seek this debate. In his reply the Secretary of State said that he had asked hospital authorities to do all they can and he asked hospital authorities to make a return and he hoped to receive during the coming year and to make use of it for guidance."—[OFFICIAL REPORT, 21st Dec., 1971; Vol. 828, c. 1279–80.] We are talking about doctors who very often have life and death decisions in their hands and who are doing on average an 88¼-hour week, either on call or actually working. There is no need to wait much longer for further information, because the J.H.D.A. will be presenting to the public early in February a survey of all pre-regisration housemen, the hospital doctors who work the longest hours, and when that report is published I am delighted to think that it will be completely comprehensive of that grade.

I ask the Minister some specific questions. Why are not extra duty payments related to a normal working week? Why do we have the present system? What is the minimum amount of off-duty time? How much cash would a pre-registration houseman get for working 10 hours overtime? Is the Department now considering a normal week of 40 hours' duty, including time for meals, as a possible basis for a new deal? These questions could all be answered very briefly, and the answers would do a lot to clarify the objections which the junior hospital doctors are mounting against the present system and favourable answers could give them some hope of success.

Will the Minister also bear in mind the urgent need for research on fatigue and the fall in efficiency of doctors who work excessively long hours? There is a precedent for this. A number of studies have been made on airline pilots and their reactions when in a state of fatigue. Why cannot a similar research project be mounted by the Department for doctors? It is recognised that efficiency drops long before it is realised by the person suffering the fatigue.

Should not there be regular breaks for a person who is on duty for a long period of time? If I may put in a personal note, I think it is worth pointing out that my daughter, who is a nurse, did a 14-hour stint last Sunday in a case of cardiac arrest, and surely a junior hospital doctor who works for 14 hours at a stretch should have provision for a break from duty. If it is good enough to make regulations governing such matters for shift workers in factories, why cannot the Department make similar provision that a doctor on long hours should have regular rest periods?

The more junior the doctor, the longer hours he is likely to work and the more his judgment is likely to be affected. This means that the doctors with least experience are working the longest hours. Every Member in the House must sympathise with a houseman who has an agonising decision to take where an acute abdomen case arises. Does he call his boss out of bed at 11 o'clock at night to deal with the case, or does he wait until the morning? If he does decide to call in his superior and his guess is wrong, then he is in for trouble.

Alternatively, if he does not call out the consultant and the patient dies in the night, what a responsibility for a young man just beginning his hospital career!

It is nearly 10 years since I campaigned in this House for the young married doctor resident in his job to be able to lead a normal married life, as do members of other professions. When we speak of "junior" hospital doctors we must remember that we are dealing with men between the ages of 25 and 40. In the case of time-expired registrars, we are talking of men over 40. I am appalled by the complacency and lack of drive to provide married quarters. When rebuilding of a teaching hospital in London was to take place in 1963, I was promised in this Chamber a certain number of married quarters for resident doctors. But when I investigated the situation a few months ago I found that in many cases these had been given, not to resident junior doctors, but to consultants to use for their own accommodation needs. It must be borne in mind that three out of four doctors resident in hospitals are married.

May I remind the Minister of his study group report of 1970. One of the conclusions then reached was as follows: The hospital authorities we visited are well aware of the problem and are tackling it energeticaly and practically within the limits of the available resources. We consider that all hospital authorities should be encouraged to give high priority to the provision of more and better residential quarters. But what has been done about the situation? This kind of exhortation and the idea that one can change the situation in hospitals by this kind of wishy-washy approach is inadequate. The junior hospital doctors are right to mount as vigorous a campaign as possible to try to alter the situation.

There is also a shocking amount of red tape and bureaucracy in existence. I give just one example of the sort of attitude which is encountered. A resident doctor who occupied single quarters in a hospital recently became ill. His wife moved in for two nights to nurse him during the illness and to save the hospital staff the chores involved. At the end of the month the doctor received a bill for two night's bed and breakfast for his wife This kind of treatment of professional men is indefensible. What is needed is a complete demolition job on the present negotiating hierarchy for junior hospital doctors. At the moment the system rests with the toppest of top people in the C.C.H.M.S., so much so that even consultants have had to organise regional consultants' committees to redress the balance as compared with the top people here in London. As for the junior hospital doctors their voice has to be heard through the B.M.A., which is very much an establishment organisation.

The Minister might turn his attention to the complete muddle in the National Health Service as regards the responsibility of the B.M.A. to the C.C.H.M.S. and the Royal Colleges. The constitution is quite fantastic. A person may be a member of one but not the other, but, if he is not a member of the B.M.A., he cannot go back again to the General Council. Mr. Vic Feather would find it almost impossible to sort out this kind of relationship if it were ever applied to industry.

The J.H.D.A. now has a membership of 5,000. It is difficult to understand why the Minister will not recognise this body for negotiating purposes. In the last few years it has proved its responsibility and the fact that it voices the views of those in the grades of pre-registration houseman, houseman, registrar and senior registrar. If the voice of the J.H.D.A. is not recognised by the Government, my voice and those of many other hon. Members on both sides of the House will be prepared to speak up in Parliament so long as the present injustices exist in terms of hours, pay, conditions and the exploitation of men and women who represent such a very valuable asset to the nation, the junior hospital doctors, without whom the National Health Service will not continue to exist.

4.21 p.m.

The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)

It is a pleasure to hear the voice of the hon. Member for Willesden, West (Mr. Pavitt) a second time today, as eloquent in his second speech as he was in his first. I am very glad that he has provided us with an opportunity to look rather more fully than was possible in the Question Time to which he referred at the hours and pay of junior hospital doctors, a group of people whose indispensable, vital contribution to the country's medical services I cannot over-estimate.

Both the Government and the profession have recognised the problem of long hours worked by many junior hospital doctors. At the outset, I wish to express my admiration for the exemplary way in which these young men and women carry out their duties. Like the hon. Gentleman, I speak with some personal knowledge since my own brother-in-law's wife, as a young woman recently married, is exactly in this position. I am intimately aware of the pressures which arise in the case of this category of people.

Before turning to the question of hours, upon which the hon. Gentleman dwelt at some length, I wish to comment upon pay. Clearly, it is related. The House will be aware that the remuneration of doctors and dentists in the Health Service for the period beginning 1st April this year is currently being reviewed by the independent Review Body on Doctors' and Dentists' Remuneration under its new chairman, the Earl of Halsbury. Both the Health Departments and the professions will be giving evidence to the Review Body during the next few months. I cannot, of course, forecast what will be the Review Body's next recommendations for junior hospital doctors, but there have been substantial improvements in the pay of junior doctors in recent years.

In 1966, when, as a result of the Kindersley Review Body's Seventh Report, an average pay increase of about 13½ per cent. was awarded to all doctors and dentists, the junior hospital doctors received relatively larger increases in recognition of their heavy work-load and long hours of duty, to which the hon. Gentleman directed special attention in respect of the junior grades. As a result of this, first-year house officers, for example, were awarded an increase of 35 per cent. while consultants received just under 10 per cent.

In 1969, the Kindersley Review Body's Tenth Report recommended an average increase of approximately 8.5 per cent. for all grades but again a greater increase for the most junior grade—house officers were awarded a 12.5 per cent. increase as opposed to 8.3 per cent. for consultants.

From 1st April, 1970, as a result of the decisions of successive Governments on the recommendations of the Kindersley Review Body's Twelfth Report, all doctors in the training grades were awarded a 30 per cent. increase, compared with about 21.5 per cent. for consultants. On this occasion the minimum of the house officer salary scale was raised from £1,250 to £1,626 per annum; and the minimum of the registrar scale from £1,790 to £2,328 per annum. The present salary maxima for junior doctors range from £1,884 for house officers to £3,588 per annum for senior registrars.

It is clear that there has been a striking improvement in pay in favour of junior hospital doctors over recent years, and this is perhaps best illustrated by the fact that, as a result of the 1966 and subsequent awards, the maximum of the house officer's salary scale rose from £940 per annum to £1,884, an increase of just over 100 per cent., while the consultant scale rose from £4,445 to £6,840 per annum, an increase of about 50 per cent.

Mr. Pavitt

Do not forget "A" merit awards.

Mr. Alison

Not all junior doctors get them, but then not all consultants get them.

In addition to basic pay, junior hospital doctors have been eligible since 1st April, 1970, for extra duty allowances, and this brings me to the question of the hours worked by junior doctors.

The nature of medicine, with the need for continuous care of patients, and the shortage of medical staff combine to involve many junior hospital doctors in long hours on-duty and on-call. One Government after another have recognised that junior doctors need adequate periods of time off duty for rest, recreation and study, and that prolonged periods of long hours on duty can lower a practitioner's standard of performance. I make no bones about that. The hon. Gentleman reasonably drew attention to that. I was interested to hear the experience of his daughter in this context-14 hours on duty.

Although junior doctors do not work fixed hours, the Health Departments, in consultation with the profession, in 1967 laid down recommended minimum periods of time off duty for junior doctors, in addition, of course, to the recommended entitlements of up to 30 days leave a year with pay and expenses for study purposes; and, of course, to annual leave allowances, in addition, ranging from four weeks for house officers, senior house officers and registrars to six weeks for senior registrars.

Provided always that the needs of patients permit, all junior hospital doctors are entitled to assured minimum periods of time off duty, including freedom from on-call liability. The recommended minima are one afternoon a week, alternate nights—normally from Monday to Thursday—and alternate weekends, or the equivalent of these periods taken at other times. I stress that these periods are the minimum entitlement to free time, and it should not be inferred that doctors are generally expected to be on duty at all other times.

If a practitioner fails to receive his minimum time off, an extra duty allowance, as the hon. Gentleman inferred, is payable. In practice, this means that he does not qualify for the allowance until he has been on duty and "on call", either at home or in the hospital, for about 102 hours a week. The payment of extra duty allowances is not, therefore, a normal overtime payment, but is, rather, compensation for failing to receive the recommended minimum time off.

Two documents have appeared recently on the subject of the hours worked by junior hospital doctors. One is a report on the organisation of the work of junior hospital doctors entitled "All in a Working Day". As indicated by my right hon. Friend the Secretary of State for Social Services in the House on 21st December—the hon. Gentleman referred to this matter—although the report contains much useful information which is being studied, we feel that it would be unwise to regard it as a fully representative guide to the present general situation on hours of work on two main counts.

First, although the report was not published until last month, the field work was completed as long ago as 1968, and the information is therefore a little out of date. Secondly, the report was based on the work of only 85 junior doctors in nine acute general hospitals in the three departments of general medicine, general surgery and accident and emergency. No studies were carried out in teaching hospitals, psychiatric or chronic sick hospitals or small hospitals.

The Hospital Junior Staff Group Council of the B.M.A. has issued a memorandum on extra duty allowances which reaches the conclusion that the system of extra duty allowances as at present organised is working fairly well. It does, however, recommend changes in the basis of the system which the Department will be discussing with the profession through the normal negotiating machinery which exists for discussing matters affecting conditions of service.

It is clear from these recently published documents and from other sources that too many junior doctors are still failing to receive the recommended minimum time off-duty, despite efforts by hospital authorities to reduce the hours worked by hospital doctors while still guaranteeing the essential continuity of patient care. It is encouraging to read that the Hospital Junior Staff Group Council is of the opinion that reorganisation of medical work at local level could lead to a reduction in the hours worked by junior doctors. This is a view shared by my Department. It is pre-eminently a question of management at local level.

We think that a good deal can be achieved, for example, by the revision of duty rosters, the extension of cross-cover within and between hospital departments and, perhaps, by more participation by consultants in "on call" rotas in small specialties. But local conditions, and patients' essential needs, vary so much that the responsibility for ensuring that junior doctors get adequate rest must lie with local management and, in particular, with the consultant, whose function it is to organise the work of his department. "Cogwheel" systems of medical management can, of course, do much to promote the co-operation at all levels which may he necessary to reduce the burden falling upon individual doctors, particularly the hard-pressed pre-registration house officer to whom the hon. Gentleman accurately referred as being particularly exposed.

As my right hon. Friend indicated in the House at Question time on 21st December, we are now receiving from hospital authorities detailed information about the incidence of extra duty payments by grade, specialty and hospital and we hope this will help in considering further guidance on ways of reducing the hours worked by junior doctors in our hospitals.

The hon. Gentleman spoke about the problems of residential accommodation. Here again I speak with personal knowledge, through my family connection, of the real strains imposed particularly upon young married doctors. It is an essential part of the newly qualified doctor's training that he—or she—should live in the hospital during the first year. After that, the residence requirement varies according to grade and specialty. This, I am afraid, is an unavoidable part of the junior doctors' way of life which is very often bound to be irksome, particularly for wives—or the husband if the wife is a doctor—and their families. However, hospital authorities are recognising the need to provide more good residential accommodation with better amenities for single doctors and married quarters.

Last year my Department commended to hospital authorities the report of a study group—representative of both the Department and the profession—which gave some helpful advice on the sort of amenities that should be provided for doctors and their families in hospital houses and flats, and we have asked hospital authorities to continue to do all they can, having regard to other demands on their resources, to meet these needs.

Junior doctors are eligible under their terms of service for assistance with their removal expenses when they transfer from one hospital to another during the course of their training, often at short intervals, and we have recently agreed with the professions' representatives to extend these arrangements in future to assist junior doctors with the expense of moving to take up first appointments in the consultant grade.

I will consider in the cold print of HANSARD the particular case which the hon. Gentleman mentioned and will perhaps communicate with him about it.

Very much bound up with the question of pay and hours is the aspect of promotion and career prospects. Of course, the more doctors there are in training posts to share the work that has to be done, the more there are to compete for the available consultant posts. Last year, therefore, a number of steps were taken towards improving the career prospects of junior hospital doctors.

Agreement was reached with the representatives of the professions that the consultant grade must be expanded in relation to the training grades. The target set for the consultant grade is expansion at 4 per cent., as compared with a 2½ per cent. rate for the training grades, over the next 10 years. In practice this implies an increase rising to 500 extra consultant posts annually over the next five years, compared with only approximately 270 new posts made in the past year.

In order to sustain this pattern of growth it was seen that a greater degree of forward planning of medical staffing was required. Discussions with the professions and with employing authorities resulted in agreement to establish new central machinery to advise my Department on these matters. The profession, Including junior hospital doctors, is strongly represented on this body.

The proposal to increase the number of career posts available is a key element in the improvement of the career structure and should lead over time to a substantial lowering in average age of appointment to the consultant grade. An improved balance between the numbers of career posts and the numbers of doctors in the training grades will thus help to remove the frustrations generated by a bottleneck at the point of entry to the consultant grade.

The hon. Member mentioned the J.H.D.A. and the willingness or otherwise of my Department to negotiate with it, and he also mentioned the Central Committee for Hospital and Medical Services. My Department has conducted negotiations exclusively with the latter in respect of hospital doctors and dentists. This group has constituted a bargaining unit and the C.C.H.M.S. in effect has been the sole bargaining agent.

My Department's view is that neither the passing of the Industrial Relations Act nor the registration of the B.M.A., of themselves, affect the present negotiating arrangements. The Department has no proposals for change, since it has always been the practice in the National Health Service for representation of staff interests to be settled by the staff interests themselves. This convention would require the Department to advise anyone requesting recognition to consult the C.C.H.M.S.

Continuation of the present arrangements is therefore subject to any arrangements which may be agreed among the staff interests or any changes in consequence of any application by anyone under the relevant provisions of the Industrial Relations Act.

I am grateful—as, I am sure, are the House and a wider public—for the opportunity of discussing this problem. I hope that I have been able to show the Government's concern over the hours of work of some junior hospital doctors, and outline some of the measures taken to improve their conditions of service, their training, and their career prospects.

I am confident that, for the able young doctor, the prospects of an interesting and rewarding career in an expanding Health Service are and remain first class.

Question put and agreed to.

Adjourned accordingly at twenty-one minutes to Five o'clock.