§ 11.8 p.m.
§ Dr. J. Dickson Mabon (Greenock)
Tonight I want to raise a matter of considerable urgency and importance, namely, the proposed erasure from the Medical Register of over 5,000 of my medical colleagues. This erasure is not because of any of the usual charges of immoral behaviour or for some other reason with which we associate this serious action by the General Medical Council, but simply on the ground that the members concerned have not paid their annual retention fee.
It must strike hon. Members who may be unaware of the dispute as strange that professional men should refuse to pay £5 a year to keep their names on a professional register entitling them to the privilege of the protection and administration of the General Medical Council. The answer is simple. These 5,000 or so doctors feel, as a matter of principle, that there is something seriously wrong with the present-day General Medical Council, not so much in the people as in its structure, functions and financial setup. This has been coming for a long time. The Minister might say that these doctors have been threatening to withhold and have withheld their annual retention fee for almost three years. I accept that, but they have done so only to prove their utter determination to try to make their objection clearly to the general public as well as to their professional colleagues.
572 I for one—and perhaps other doctors in the House have done so—have paid my fee because I would not wish to get into direct dispute with the council but, rather, would wish to argue in some other forum, such as this one, how the council should be reformed, and also that its reform is urgent and necessary. I shall not put up with the argument from the hon. Gentleman—and many other doctors who have paid their fees will not stomach it either—that these doctors are letting down their professional colleagues by failing to pay. That is rather a cheap argument. Many doctors who have paid their fees are as anxious as the protesters to see the changes that have been talked about.
Our entry into the Common Market will throw a new burden on the General Medical Council, namely, the registration of specialists, and there is a great deal of dissatisfaction in the profession about what the council does already in relation to registration work, for example in pre-registration and in dealing with foreign doctors. I shall not develop that. Suffice it to say that already there is dissatisfaction over this present matter, and yet the council is to be charged with an additional and important burden.
The Minister may claim that it is only a few militants in the medical profession who are causing all this trouble. The junior hospital doctors have earned a name for themselves in militancy, and quite rightly, for they have improved the lot of junior doctors in hospitals far beyond the wildest expectations of many of us, and good luck to them.
But let us accept that they are a pretty belligerent lot. The Minister might say that he prefers to deal with a more sedate organisation. He can hardly call the Medical Practitioners Union/ASTMS a sedate organisation. It is 100 per cent. behind the campaign to have the General Medical Council's structure, functions and finances reviewed. The Minister might take refuge with the BMA, and there is no doubt that the council of that association—and I stress that—has taken what the Minister might call a very responsible attitude, but that council has in effect been repudiated by its own representatives.
573 At its annual meeting in July of this year the representatives of the BMA said:This meeting "—and this is the doctors' parliament as far as the BMA is concerned—views with dismay the acceptance by the Council of the BMA"—that is its own council—of an increase in the GMC retention fee before the GMC is reconstituted and its functions and finances are agreed.I invite the House to listen to this for responsibility and sedateness:The meeting views with disfavour any attempt by the GMC to exercise its discretionary punitive powers for non-payment of the annual retention fee prior to the implementation of the working party's report".That is a reference to the working party set up in great haste by the GMC and the BMA, and excluding other doctors who might be in other or no organisations. It is a working party constituted by the GMC and one of the professional organisations, albeit the largest. This method is all very questionable. Even if we accept the bona fides of all concerned, the first finding of this working party, namely, the review of finances, is not entirely acceptable and satisfactory to doctors. The Government must face up to their responsibilities and start at the beginning on the problem of the GMC.
For more than 100 years the General Medical Council enjoyed immense respect not only from doctors but also from the general public. That is not so today. The GMC is in danger of being lightly disregarded or held in dubious respect by doctors if affairs carry on as at present.
When Lord Cohen, that most distinguished Chairman of the GMC, was faced with the problem of what to do with these recalcitrant doctors, I am told—perhaps the Minister would confirm this—he wrote to the present Secretary of State and in effect said, "I am faced with a rebellion by 5,000 doctors. What shall I do? If we strike them off the register, will they be able to practise in the National Health Service, and if they cannot, will this be an immense public burden, or is is something up with which you can put?"
I am told—this is astonishing—that the Secretary of State replied, in effect, that it was all right to erase them, to strike them off, that in some strange way the 574 NHS would not be embarrassed by having 5,000 practitioners knocked out. Indeed the possibility that there may be actions in the courts when someone loses his livelihood, to seek an injunction on the grounds of natural justice, that he has been denied the means to earn his living, without a hearing, seems not to have crossed the Government's or the GMC's mind.
This is a ridiculous situation and it is the Government who are allowing events to drift. I do not blame members of the GMC or Lord Cohen or any members of the profesional associations. They do not have power to check the drift. The only effective way in which it can be done is by the Secretary of State. I would remind him that there is a clear and established call from every articulate voice in the profession saying that something is wrong and that something must be done. That something is not the implementation of Brynmor Jones, the report which is now the basis of a draft Bill by the Government. That has long been overtaken by events. The Bill might as well be taken away. What we want is an expert, independent and public inquiry into the future structure, functions and finance of the GMC.
It is not a fair argument to say that this will take a long time. Anyone who has considered this matter knows that a tremendous amount of material is available. A hard-working committee, if it were appointed to start next month, could report by the end of June or July. There is no reason why a Government with such a report could not produce a Bill by this time next year, so that we could see a reform of the GMC which was not just a patchwork affair, such as Brynmor-Jones was suggesting—they were limited within the context of their time—but a radical and much-needed reform.
I hope that the Minister will not consult his brief or tell us about that Bill which is hanging about in the corridors, or in the usual channels, waiting to be delivered here. I hope that he will say, "I agree that there is a crisis and an embarrassment to the general public, and I will set up an independent inquiry."
Doctors are coming up with the old cry of, "No taxation without representation." They are saying "The once-for-all fee that we paid when we entered the profession has now been replaced by an 575 annual fee, yet we do not have a majority vote in deciding how it is dispensed." Is this not a fundamental breach of constitutional rights? Is the GMC the servant of the profession or the servant of the public? The Government should make up their mind, so should the profession and so should we all. Then we can see how the finance of the GMC can be worked out.
There is too much confusion and ambiguity surrounding this for the Minister to rest content or to let matters drift as they are. I appeal to him to take away the message to the Secretary of State that we do not want palliatives or this ramshackle Bill. We want a real inquiry and we want a real change.
§ 11.20 p.m.
§ Dr. M. S. Miller (Glasgow, Kelvingrove)
The complacency with which the Government seem to be facing this situation of such seriousness causes me great alarm. As my hon. Friend the Member for Greenock (Dr. Dickson Mabon) said, there are more than 5,000 members of the medical profession who, because of an arbitrary and dictatorial command of the General Medical Council, will be prevented from practising, prevented from earning their livelihood and thus endangering the National Health Service.
These doctors are not wild men who are attempting some form of subversion. They feel that a principle is involved and I totally agree with them. The Under-Secretary of State is no doubt aware that the GMC was formed in 1858. He is also, no doubt, aware of the functions of the GMC. Can he say that it is fulfilling those functions for which it was established? If he can, I should like him to explain why one of the main functions, which is to supervise and improve medical education, accounted last year for only £4,500 out of the GMC's income of nearly £350,000. It is one of the most important aspects of the Council's functions.
This is not the time to go into all the GMC's faults. The doctors believe—and no one can gainsay it—that it is not a representative body. In many respects it is archaic in its functions but often it is completely undemocratic in the performance of those functions. Of 47 members, 576 only 11 are elected. Surely at this stage in order that the public are not endangered—and there is a grave chance of that happening because of the GMC's action—it is not beyond the power of the Government to stay the hand of the GMC until its functions and structure have been completely revised.
§ 11.23 p.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Michael Alison)
What I can most usefully do tonight, in the light of what the hon. Members have said about the dispute, is to try to fill in a little of the background before going on to the appropriate steps for the Government to take or to consider. The dispute is about the framework for the regulation of the medical profession. I should like to look at that under three headings, namely the finances of the General Medical Council, its composition and its functions.
First, there are the general purposes of regulating the profession. The GMC was established in 1858 and the preamble to the Act which set it up states:It is expedient that persons requiring medical aid should be enabled to distinguish qualified from unqualified practitioners.As the GMC points out in its general leaflet, the whole of the council's functions flow from that original objective. Thus, the council keeps a register of qualified doctors. The hon. Member for Greenock (Dr. Dickson Mabon) has been on it since January, 1954. I do not know about the hon. Member for Glasgow. Kelvingrove (Dr. Miller)—
§ Mr. Alison
It has, therefore, a general supervisory function in relation to medical education as well as the registration function, and also, as hon. Members have said, it takes disciplinary action against doctors if it appears by reason of their misconduct that they are unfit to remain on the register.
I am sure that it will be generally agreed that, whatever differences there may be about the means of securing these aims, or about the standards to be applied, both the general aim and the three particular functions will never cease 577 to be relevant in the public interest in relation to the medical profession.
So far as I am aware, there was not prior to 1969 any substantial degree of disquiet among the medical profession about the council. In that year, a Medical Act was passed into law which empowered the council to make regulations to charge an annual fee for the retention of a practitioner's name on the medical register in addition to the initial registration fees already required of new entrants to the register. The BMA was consulted about this proposal prior to the 1969 Act and indicated its acceptance of it.
No body with the continuing and heavy duties of the GMC can afford in modern conditions to be financed solely by once-and-for-all subscriptions. Only at the cost of the unfairness of saddling young newly qualified doctors—this possibility was considered at one time—with fees of quite considerable size on registration could the GMC continue to function on a once-and-for-all basis.
Accordingly, a £2 annual retention fee became payable from May, 1970. The financial position of the GMC made it necessary to increase this fee to £5 from May, 1972. Even before the £2 fee was introduced, developments occurred, alas, to widen the GMC problem.
Before I leave the question of finance, I should mention that accountants appointed after discussion between the GMC and the BMA reported in July this year that,the administrative staff is in no way indifferent to the ordinary considerations of prudence and economy. We have found no evidence of any waste or misuse of funds".I return now to February, 1970, during which month a special meeting of the representative body of the BMA took place. That meeting decided to make payment of the annual retention fee conditional upon a change in the composition of the GMC so that it contained a majority of members elected by the profession. The BMA advised doctors to pay the annual fee voluntarily for 1970–71, on the assumption that, during this time, action to alter the Council's composition would be taken.
I understand that it was the view of the Government of that day—I make no criticism here, because it is the view 578 of this Government also—that the medical profession should be given every opportunity to sort out the problem of the GMC on its own. Accordingly, the Department's chief medical officer presided over a conference at which it was agreed to set up what we now know as the Brynmor Jones Working Party, which had on it three representatives of the BMA as well as representatives of the universities and the Royal Colleges.
The question of the GMC's functions was deliberately excluded from the remit of the working party on the ground that the question of composition was more urgent. The working party reported in 1971, and its main recommendation was that the number of elected members of the council should exceed by one the number appointed to the Council by the Royal Colleges and the universities. In other words, it was a switch over to an elective majority.
§ Mr. Alison
This and the other recommendations of the working party were accepted by the Government, and since then—if I may say this without transgressing order—legislation has been prepared to give effect to them. Subject to the continued agreement of the profession that it wishes legislation to come forward, the Government are prepared to seek a convenient opportunity to introduce it. In view of the current pressure on the legislative programme I am afraid that I can go no further than this tonight.
I have dealt with the finances of the GMC and its composition and I turn now to the council's functions. It was agreed by the various parties that this should be left over while the other matters were being considered. In July, 1971 the BMA set up a working party of its own to consider those aspects of the GMC's functions which it wished to discuss with the council. On the basis of that working party's report, joint discussions between the BMA and the GMC were started in the spring of 1972 under the chairmanship of Sir Ronald Tunbridge. The hon. Member for Greenock has referred to these discussions.
It was at about this time that the annual retention fee payable was increased to £5 and just afterwards that the GMC concluded that it must take action against those doctors who, against 579 the advice of the BMA, had failed to pay their fees since 1970. This conclusion was confirmed very recently at a meeting of the council on 9th November.
Again I digress briefly to deal with the point that the Government should have taken steps, or should now do so, to dissuade the GMC from taking action against doctors failing to pay the fee. The GMC is, as hon. Members know, an independent body and for that reason any Government would hesitate, after making statutory provision for it, to intervene in the way in which it does its job, particularly when it is doing its job in the fulfilment of the powers given to it and the requirements laid upon it.
§ Mr. Alison
More generally, the Government could not be unaware that the majority of doctors have paid their annual retention fee. It would be unfair to them if a minority were allowed to go on indefinitely without paying.
§ Dr. Shirley Summerskill (Halifax)
On the one hand the Minister says that the Government should not intervene but on the other he tries to justify the intervention that the Secretary of State has made. Is it not a fact that the right hon. Gentleman suggested to Lord Cohen that he should go ahead with erasing doctors?
§ Mr. Alison
Intervention of this formal kind is quite a different proposition from the sort of communications—[Interruption.] The Brynmor Jones working party was set up very much through the collaborative interest taken by my Chief Medical Officer in the discussions going on between the BMA and the GMC. This is not intervention, this is communication.
Discussions between the BMA and the GMC about the functions of the council got under way at the time when the medical profession was faced with an increased retention fee and all the consequences of non-payment. These developments were considered at the annual reppresentative meeting of the BMA in July of this year. While members were still advised to pay the fee for 1972–73 a motion was passed viewing with disfavour any move by the GMC to erase doctors from the register prior to the implementation of whatever emerged from the dis- 580 cussions under the chairmanship of Sir Ronald Tunbridge. The meeting also considered that the Government should be asked to set up an independent inquiry if the discussions under the chairmanship of Sir Ronald did not result in agreement with the GMC within six months. It is important to get that on the record.
Important progress has been made. The working party has reached two main conclusions and reported. The first is that there is a continuing need for a statutory body such as the GMC, reconstituted in accordance with the Brynmor Jones proposals. The second conclusion is that although substantial differences of opinion have emerged in the working party these should nevertheless be capable of reconciliation if the discussions are resolutely pursued, which is what is to happen.
Let me summarise the position. The profession over the last two years has brought the finances of the GMC under scrutiny and decided that they are on a proper footing. It has considered the position of the GMC and agreed upon changes leading to an elective majority.
§ Mr. Alison
Now it has indicated that agreement is possible on functions. The Tunbridge Report was accepted on 1st November by the BMA which proposed to the GMC that joint discussions on outstanding issues should begin immediately. On 9th November the GMC accepted both the report and the BMA's proposals.
It is right to stress two things about the discussions which have been taking place between the two bodies. First, I refer to the very wide range of matters on the agenda to indicate the universal view almost which both parties to the discussions are adopting—a very broad and responsible view. The topics covered by the working party include the following: the need for registration as well as its cost; how the present method of supervising the pre-registration year could be improved; the registration of overseas doctors, includingthe unsatisfactory nature of the present system of temporary registration";the need for a body to supervise specialist registration; important aspects of the 581 GMC's procedures in relation to professional discipline. I could give other examples. The agenda is very wide.
Secondly, the members of the joint working party have stated that professional bodies such as the GMC must have regard to the public interest and have a duty to safeguard that interest as well as serving the interests of their profession. Moreover, the members of the working party, in their report to the BMA and the GMC, remind us that since the GMC exercises statutory powers and its major functions are controlled by legislation, the Government will be concerned, and the House should be concerned, with any changes which may be proposed and will, when considering them, very properly have to take account of the public interest. Thus, the professional bodies recognise the wider public interest.
There is room for difference of view, and careful judgment, as to whether, as some have urged, the public interest would in this instance be best served by submitting all or some of the matters to some form of independent inquiry. Others take the view that most if not all the matters are primarily professional and that only perhaps at the stage when legislation is proposed should the issues be taken to a higher tribunal—perhaps the House of Commons.
One can recognise that a genuine difference of approach is possible in these circumstances—that if we might for a moment disregard the more noisy sec- 582 tors of the clamour for an independent inquiry there must be something to be said for the submission of some of the matters to independent assessment at some stage. At the same time, it is very necessary to recognise the value of intra-professional discussions in resolving some of the kinds of issue that the joint working party currently has on its agenda. The Government for their part have to balance the conflicting approaches.
I said earlier that the Government's aim has been that the medical profession should find its own solution to the problem of the GMC; and that remains our policy, subject to ensuring that any solution is consistent with the public interest. During the last few weeks, however, while the BMA and the GMC have been trying to reach a solution, there have been calls from other quarters for a Government inquiry and a good deal of loose talk about erasure and its consequences. In the light of these developments, my right hon. Friend has concluded that he ought to give the whole profession time for final thoughts. I have in mind in particular that the BMA Council is to meet on 22nd November to consider its response to the decisions taken by the GMC last week—
§ The Question having been proposed after Ten o'clock, and the debate having continued for half an hour, Mr. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at twenty-two minutes to Twelve o'clock.