HC Deb 06 February 1975 vol 885 cc1713-43

10.14 p.m.

The Under-Secretary of State for Health and Social Services (Mr. Alec Jones)

I beg to move, That this House takes note of the draft EEC Directives on doctors and dentists contained in COM(69) 127 and R/2610/74 and in particular observes that:

  1. (i) the Directives raise important questions of principle which relate to the special circumstances of medical practice in the United Kingdom;
  2. (ii) the effect of the Directives on the movement of doctors into and out of the National Health Service is not clear.

Mr. John Roper (Farnworth)

On a point of order, Mr. Deputy Speaker. Irrespective of the propriety of tabling take-note motions with riders attached, I should like your advice on the difficulty which is caused to hon. Members on both sides of the House when a motion of this sort is tabled on the day of the debate, making it extremely difficult for hon. Members to table amendments.

Mr. Nigel Spearing (Newham, South)

Further to that point of order, Mr. Deputy Speaker. May I support my hon. Friend on this matter. I think that the rights of back benchers who hold different opinions have a place in these matters. You will recall that before the Summer Recess in the last Parliament Mr. Speaker heard a point of order concerning amendments from backbenchers to take-note motions. As a result of representations made by the Scrutiny Committee to Mr. Speaker, he changed the procedure and such motions were not only tabled but were selected by him—and indeed some have even been accepted by the Government. Therefore, it would be contrary to Mr. Speaker's ruling, and indeed to the request made by the Scrutiny Committee, if it were not made possible for back benchers to table amend- ments to motions on the day in question. There are more of these provisions to come before the House next week, and I hope that the Government will pursue past practice.

Mr. Deputy Speaker (Mr. George Thomas)

There are two separate points which have been raised, the first of which is wrongly addressed to me. The timing of a motion on the Order Paper is not my business. My rule is to follow the Order Paper. But on the question of amendments I understand that the hon. Member for Farnworth (Mr. Roper) submitted an amendment but that Mr. Speaker did not select it. I must remind the House that the time spent on points of order comes out of the 1½ hours of debate.

Dr. J. Dickson Mabon (Greenock and Port Glasgow)

Further to that point of order, Mr. Deputy Speaker. May I seek an understanding of the situation? Was the manuscript amendment submitted to the Table out of order on grounds of principle or of substance?

Mr. Deputy Speaker

Mr. Speaker did not select the amendment. Mr. Speaker is not obliged to give his reasons, and if he is not so obliged, certainly I am not.

Mr. Bob Cryer (Keighley)

Further to that point of order, Mr. Deputy Speaker. Could we know what sort of criteria Mr. Speaker uses—

Mr. Deputy Speaker

Order. The hon. Gentleman may raise a point of order, but it is not for hon. Members to question Mr. Speaker's selection of amendments. The House has entrusted Mr. Speaker with that responsibility, which he has exercised.

Mr. Cryer

Further to that point of order. I am not questioning Mr. Speaker's desire to make a selection, nor his right to do so. I seek an understanding as to what protection Mr. Speaker can afford to back benchers so that the proper democratic procedures can be followed. Clearly, if Mr. Speaker is generally to reject all amendments tabled simply as a matter of principle and will not take back bench amendments, that will not permit back benchers to have a proper and full democratic debate on EEC orders. I appreciate that after the referendum we shall be pulling out of the Common Market and that this problem will not then arise, but until that point is reached. I should appreciate your guidance.

Mr. Deputy Speaker

To my knowledge, Mr. Speaker has on two occasions selected amendments on the Order Paper and therefore the question of principle does not arise. I must again remind the House that this discussion is eating into the debate.

Mr. Mike Thomas (Newcastle-upon-Tyne, East)

Further to that point of order, Mr. Deputy Speaker. May I, too, seek your guidance? It seems to me that some hon. Members appear to have the opportunity of tabling amendments before motions reach the Order Paper, whereas others are not in that situation. Would you rule whether my hon. Friend the Member for Newham, South (Mr. Spearing) is or is not part of the usual channels and whether you have any responsibility for those usual channels.

Mr. Deputy Speaker

I have been here too long to know much about the usual channels. What little I do know warns me not to make a ruling of any sort in that direction.

Mr. Alec Jones

At the outset I should like to indicate that the points of order regarding the nature of the motion will certainly be conveyed to my right hon. Friend as soon as the debate is concluded.

One of the basic principles of the Treaty of Rome is that within the European Economic Community there should be freedom of movement for people and freedom to provide services. There are proposals for a series of directives to be issued by the Council of Ministers which will define the necessary arrangements. Tonight we are debating directives concerning doctors and a related proposal for an advisory committee on medical training. These will be considered by the Council in Brussels next week. They raise important issues in relation to medical education in this country. It must be said that their effect upon movement in and out of the National Health Service certainly is not clear. Because of this, I know that some hon. Members are uneasy. Tonight I hope to explain just how far regard has been paid to our special circumstances and what more we think is needed.

It is, of course, already possible in many cases for doctors to move from one country to another to practise their profession. The proposed directives would, as required by the Treaty, remove a number of obstacles to free movement of both employed and self-employed doctors. Tonight we are considering only doctors, but the pattern which is developing for the medical profession will have implications for dentists and, indeed, for a number of other professions. The Government have recognised throughout this wider interest which again emphasises the importance of the issues raised.

The doctors' directives, as now drafted, are the result of considerable detailed discussion by officials of the member States, and many amendments have been made since they were first proposed. As a result, the 1969 document considered by the Scrutiny Committee, and by another place, has undergone many changes. To bring the House up to date, explanatory memoranda were made available on 30th May 1974 and 3rd December 1974. In addition, in October a memorandum was provided on the proposal to set up an advisory committee on medical training.

Since the accession of this country two years ago my Department has joined in these discussions, most of which have taken place at Council working group level. The Department has been particularly concerned to ensure that account was taken of the special circumstances in this country and that proper regard was had to the need to safeguard the interests of the patient and to ensure a very high professional standard of medicine. There have been frequent consultations between my Department and the General Medical Council, the EEC Committee of the BMA, the Committee of Vice-Chancellors and Principals and the Council for Postgraduate Medical Education.

I should now draw the attention of the House to a few of the more important provisions. We felt that it was an essential prerequisite that the standards of medical training were satisfactory and comparable between member countries. We therefore pressed and obtained the agreement of other member countries to the inclusion in the directives of basic quality criteria. Originally the criteria were merely quantitative, setting out years and hours of training required. The new quality criteria are intended to be sufficiently flexible to take account of future development in medical training while safeguarding the final standard.

Here I should like to draw the attention of the House to the part played by the European Standing Committee of doctors in convincing our partners in the Community of the importance of defining the minimum standards of training by reference to quality as well as quantity. Last year Mr. Walpole Lewin, the chairman of the Council of the BMA, was appointed as chairman of the committee and Dr. Derek Stevenson became the secretary general.

To help to ensure comparability of standards, agreement has been reached on the setting up of an advisory committee on medical training. This committee will exchange information on medical courses, discuss the objectives and review developments in medical training. It will have as members three experts and three alternates from each member State. The three members would be nominated by the Government on proposals made by the practising profession, the universities and the competent authority for registration—in all probability the General Medical Council. Their initial concern will be under graduate education, but the provision of alternates will allow for the inclusion of members with expert knowledge of particular subjects—for example, in postgraduate education. There is also provision for the co-option of other expert opinion.

We also think it very important that doctors seeking to establish themselves in another country should know something of the practices of that country and should demonstrate their command of the language before setting up practice—a point which is not always appreciated. At this point, I should like to remind the House of the existing arrangements for doctors from overseas. Many, generally those from Commonwealth countries, can apply for full registration as medical practitioners. Such a fully registered doctor could set up in private practice or apply to set up in general practice in the NHS. However, if he wanted to work in hospital, he might be required to undergo a three or four week attachment during which, amongst other things, his ability to communicate would be assessed. Other overseas doctors, including those from EEC countries, may be granted temporary registration which permits them to take up specific hospital posts. But they cannot enter general practice. These temporarily registered doctors may also be required to take an attachment.

There has for some time been considerable criticism of these arrangements. The House may recall that on 27th November my hon. Friend announced that the GMC was to introduce later this year a new test of linguistic ability and professional competence for all doctors seeking temporary registration. The GMC's powers do not permit it to apply this test to doctors applying for full registration. However, we are expecting the report of the Merrison Committee soon, and this will touch on many aspects relating to the registration of doctors.

The EEC directives would in effect put EEC doctors on a par with the fully registered. I think it fair to say that one of the concepts underlying the present system of full registration was that it was reasonable to assume—some may doubt this—that English would be a language familiar to the Commonwealth doctor. With all respect to the profession, I do not think it reasonable to assume that all EEC doctors have a good working knowledge of English, nor, indeed, that our doctors are fluent in French, Italian, German or other EEC languages, and certainly not Welsh at this juncture. We would have thought that all countries would want to be sure that a doctor, before practising, could communicate with his patient.

There are some limits on how far down this road we can go without appearing to discriminate and creating a further barrier, when the removal of barriers is the essential objective of the Treaty and the directives. At present there is a provision in the directives which permits member States to set up information centres where the EEC doctor can be given advice on health and social security laws and professional ethics.

Following points made by my Department at Brussels, we were able to have this extended. The doctor can now also be advised on how to acquire an adequate knowledge of the language of the country in which he wishes to establish himself. So far as doctors seeking employment in, say, an NHS hospital are concerned, the existing regulations on the freedom of movement of workers within the Community allow language proficiency to be assessed. As regards the self-employed doctor, for NHS general practice there are selection procedures for all established practices where no doubt language proficiency will continue to be taken into account.

Nevertheless, there is at present no provision which would permit us to assess the language ability of a doctor wanting to enter NHS general practice in an under-doctored area or to engage in private practice. It is considered unlikely that many doctors without an adequate knowledge of English would wish to establish themselves or would attract patients if they did—[HON. MEMBERS: "Hear, hear."] I am pleased that on this issue at least, I command the support of my hon. Friends. There are of course here, as elsewhere, pockets of other nationals, and one or two doctors may wish to come to minister to their own nationals.

In general, doctors who establish themselves in another country will no doubt face many difficulties initially and can be expected to make use of any facilities which are provided to help them. However, I am sure that we ought to pursue this further in Brussels and see what more can be achieved to ensure, if we can, that proper language tests could be universally applied.

This seems to us consistent, not only with current trends in this country but also with the EEC system, which permits such tests for the employed doctor. Particularly where sickness is concerned, it seems only logical to try to bring the self-employed within the same bounds. I make no apologies for spending some time on this matter. We think it important. But there are other matters to which I should draw attention. I notice again that because of some of the interruptions time is passing far too rapidly.

The original proposals were firmly against the possibility of part-time post- graduate training. This was understandable because of concern about the possible abuse of such a system. In this country, however, part-time training under proper safeguards is an established part of our system of medical education. It is particularly relevant in the case of married women doctors with domestic commitments. This is vitally important to us because of our large and growing population of women medical students and doctors. Not only would it be a loss to them personally; it would deprive society of a good deal of medical skill.

I am glad to be able to tell the House that when my Department raised this, other member countries recognised the problem. Approved part-time training will be acceptable so long as the standard is in no way impaired. These arrangements will be reviewed within four years of the adoption of the directives.

The mutual recognition of qualifications is based on mutual trust and on the assumption that a doctor carries out broadly comparable functions and is trained to an approximately equivalent standard in each member State of the Community. The intention is that in general a doctor who is suitably qualified and allowed to practise in one member country will be accepted and permitted to practise in other member States.

The General Medical Council—the competent authority in the United Kingdom—would satisfy itself that a doctor wishing to practise here genuinely holds the qualifications which he claims and will then admit him to the register. Normally there would be no reason to interrupt this process. Conceivably, at some time a situation might arise when the competent authority had justifiable reason to doubt whether the medical graduates of a particular teaching establishment had been trained to the required standard. We do not really expect such an event to occur, but if it did arise here the directives provide that the GMC could require of the overseas competent authority confirmation that all the training requirements laid down in the directives had been fulfilled.

It is also proposed that the Council of Ministers should issue a separate statement which will provide that where a member State has serious doubts that the medical qualifications are based on training which does comply with the minimum standards laid down, they shall inform the European Commission. The Commission will examine the matter as quickly as possible and confirm to the member State concerned that the training standards have been complied with—if that is the case. In such a situation the Commission would be expected to avail itself of the services of the advisory committee. In the meantime we expect that the GMC would defer registration.

Mr. Neil Marten (Banbury)

I am sure that the hon. Gentleman would welcome a short rest in his speech. What is the exact status of these documents? It seems to me that the Minister has made very sensible suggestions about these documents. Obviously this matter will be discussed in Brussels. Will the Minister give an assurance, however, that when things have been discussed and the documents finalised, they will come back to this House so that we can look at the legislation as it is and so that the House can move amendments to that legislation, when we see it in its finalised form, before the Council of Ministers agrees to it?

Mr. Jones

The hon. Gentleman will realise that I cannot give that sort of assurance. The assurances I may be able to give on any points raised in the debate will be considered when the meeting is held.

Mr. Douglas Jay (Battersea, North)

Supposing a doctor from one of the other member States wishes to practise here, yet the General Medical Council is of the opinion that he does not satisfy these conditions—and the Commission in Brussels believes that he speaks perfect English, although the GMC thinks he does not—what is the situation? Is he qualified to practise here?

Mr. Jones

We are talking not only of language qualifications, but also of medical qualifications. We expect that, in this situation, the GMC will defer registration until such time as the conditions may be complied with.

Mr. Jay

Indefinitely?

Mr. Jones

I would say that "defer" means such period of time until those conditions can be complied with. That is the answer which I gave earlier.

The directives provide for the situation where a specialist resident in another country is called in to assist in the treatment of a patient where his knowledge and skill would be particularly valuable, and in a frontier region—we do not seem to have many of them in this country, thank goodness—a doctor may wish to cross the border in the course of his normal work. Clearly there needs to be adequate safeguards. The activities of doctors providing services in this way will be subject to the normal disciplinary rules governing the practice of the profession in the country which they are visiting.

Hon. Members may well ask what is likely to be the result of adopting these directives. As I have already said, the effect on movement of doctors into and out of the NHS is not clear. It would be a very brave man who suggested that with the adoption of directives such as this there could be absolute clarity. The directives do not, of course, affect in any way our existing arrangements for registering and employing doctors from non-member States. As regards the EEC there is already movement between member countries, for the GMC can temporarily register an EEC doctor for practice here, and similar arrangements operate abroad.

I make this point because when I suggested that we could not give an absolute guarantee of what would be the likely consequences of implementing this directive, if it were implemented—that is not in my hands—obviously nor can anyone give an absolute guarantee of what is happening to numbers of doctors practising in this country now. This country has for a very long time provided postgraduate training for overseas doctors and has as a result quite substantial flows of doctors into and out of the country. With the directives, movement could gradually increase, though there are of course factors which will tend to limit movement. The language barrier alone will, I am sure, be a problem for some time. Clearly we shall need to keep a close watch on trends in this direction.

I have sought to explain how the United Kingdom objectives in the negotiations were set, given the obligations under the Treaty of Rome. We have already made considerable progress and I have described the ways in which the directives have been modified to take account of our special circumstances. I have suggested what more we should seek. The House will see that steps have been taken to safeguard the public health and maintain proper standards of medicine. The co-operation and efforts of the profession have been of value in helping us to meet these objectives.

One final point I must make. The directives if agreed would not come into effect for some 18 months so that no action will have been taken pre-empting the outcome of any eventual decision reached on the question of whether this country should remain a member of the Community. Whatever the final outcome of that decision these proposed directives for doctors take proper account of medicine in this country.

10.40 p.m.

Mr. Hugh Dykes (Harrow, East)

I am sure that the House would like me to congratulate the Minister on having so well read out the explanatory memorandum. He made it a little longer by adding one or two points, primarily about the language difficulty, and that was welcome. Whatever one's global views about the EEC, this whole procedure is getting increasingly unsatisfactory. This is perhaps the most difficult example so far, and that is why I sympathise with the Minister's difficulties. But that does not get around the point that the House has to face, irrespective of any negotiation about membership. In an hour and a half, under this special and esoteric procedure, we are debating a momentous decision, the first of the potential harmonisation decisions—"decisions" in the general sense—which I personally support.

This is a major step. We have had points of order, right or wrong, which took several minutes, and the Minister spoke for some time on the Government's position. There is little time left for other hon. Members to put forward their views on this important matter. Presumably because all this is being examined in the Procedure Committee some of the minutes of evidence of which we shall in due course have, which will show how unsatisfactory these proceedings are, we must make do and mend for now. That is why I do not press the point too much.

But hon. Members, whether medical experts or not, are in a great difficulty. We have before us a mix of documents. There are the directives, the most out-of-date documents ever presented to the House under this procedure. They are not even based on any English text officially. They are based on the other foreign language text which has been completely overtaken by events. One understands the validity of EEC documents going to and fro in all the agencies of the Community as proposals are worked out—that is acceptable to many hon. Members—but when a basic document like this is presented on such a complicated matter the House is in great difficulty.

That is one part of the mix of documents that we are considering. The other is not even a draft directive, as we have seen; it is what is called a Council decision. I think that I am correct in saying that one of its essential elements is that it does not have to be examined by the European Parliament. What we are considering in one composite motion, which has some, to say the least, unusual riders and which was presented at the eleventh hour by the administration, is something which will not be examined by the European Parliament, whether other hon. Members consider that relevant or not, nor by the United Kingdom delegation. There is also another document which, according to the Minister, will be discussed in the Council of Ministers next week. But, again, we are not sure whether there should be scope for some follow-up by the House. I suggest that tentatively.

Mr. Marten

Since my hon. Friend represents the Conservative Front Bench,—I think that is what he represents—does he agree that this matter, when it is finalised and before it goes actually to be approved by the Council of Ministers, should come back to this House?

Mr. Dykes

I was not suggesting that I was giving a definite answer one way or the other. It is not for me to answer. It is for the Government to give guidance. My hon. Friend must bear in mind that this is now being considered by the Procedure Committee.

In the time available, I want to fill out some points made by the Under-Secretary of State by asking some questions as well as making brief observations, which, however, will not do justice to the importance of the matter. Bearing in mind that the directive document is out of date, I hope that the hon. Gentleman will be able to say more about the up-to-date text. We need more information. If he has time, I hope he will deal quickly with what might be needed and the manner in which we can make amendments. My reading is that any amendments would be routine and textually of a minor nature. For example, when will the further proposals on dentists be worked out in detail and brought before the House? This point has not been gone into sufficiently so far.

All this emanates directly from Articles 52 and 57 of the Treaty of Rome. These govern the future development of professional workers in the Community. Is there not also relevance in the proposals not only to Article 49 as well but to Community Regulation 1612/68 of 15th October 1968, concerning the movement of workers? I am thinking mainly of the general principle in that regulation, but particularly of Article 1, which is largely relevant to the general conditions for, for example, the qualifications of people coming here, based on professional capacity, not least if those qualifications are to be assessed by other than statutory bodies.

I am anxious to see just how the standards set out so far—apparently in the latest draft directive—which have been described as close to those which our medical profession has wanted all along, are to be developed further once the Council of Ministers has promulgated its decision, presumably next week or shortly afterwards. This is important.

I add my tribute to the work done by United Kingdom doctors on this document in all the relevant committees. It was an immensely complex task. As a result of their intervention at the appropriate moment—they showed better timing than many politicians—the advisory committee was created. It was almost exclusively due to their work although in saying so I mean no discourtesy to the many other doctors in the Community involved.

Then there is the question of the anxieties people here would feel about our doctors going to work in the rest of the Community under these proposals, quite aside from the question of salaries. I think the conventional wisdom of the Department would agree that Belgian doctors earn more pro rata than doctors anywhere else in the Community. That is why they are proving difficult about these proposals. They fear an influx of Italian and British doctors, for example. Apart from the salary aspect, the hon. Gentleman should say more about the vital question of doctors in under-doctored and over-doctored areas—again in the context of the sad fact that we have fewer doctors per thousand of population than almost any other of the major Community countries.

We would also wish to know when the Government last had a formal meeting with the United Kingdom doctors on the standing committee of doctors in the Community. Insofar as the details of that meeting can be made known to the House and the public, what points have come up at the eleventh hour before the Council of Ministers' meeting?

All this seems to have taken place originally some years before we joined the Community, but it seems to have gone with a tremendous rush in the last few weeks and we shall wish to be satisfied that the rush is justified in view of the underlying importance of this first major exercise in professional harmonisation.

I refer quickly to Article 48 of the Treaty of Rome referring to public service, to the public sector posts. In the medical context there are some who believe that certain NHS posts come in here. That might be the relevance of the second rider to the Government motion, but we require more explanation of that from the Minister if he can provide it.

I am puzzled, and perhaps others on both sides are, too, at the registration of qualifications. In the debate in the Upper House on 9th December, the Minister referred to the obvious fact that we have no statutory system of registration. There is no statutory system of registration for medical specialists. That is an important part of the overall picture. In the treatment of registration for visiting doctors or of doctors coming from other countries to settle here we have to have more careful examination than was indicated by the Minister.

I personally would appreciate a more definitive date for the promulgation of directives, bearing in mind the 18 months' gap.

I conclude by expressing a broad welcome on behalf of most hon. Members on this side, but not necessarily all. This will undoubtedly pave the way for other major steps in the harmonisation of professional qualifications and standardised procedure for admission and stay in many other professions. Lawyers will be interested to see how things go, bearing in mind how they tend to control these matters. There is a lawyers' impingement on this subject of medical harmonisation. It is not sufficient merely to express a general welcome for this momentous step in this country and the EEC. It is much more important to have more information from the Government.

10.54 p.m.

Mr. Roderick MacFarquhar (Belper)

I listened with great attention to the Minister's speech but I am still trying to ascertain the precise meaning of the riders in this take-note motion. It is true of all legislation that there is great doubt and uncertainty, but I still fail to see the necessity for the riders.

The problems raised by this legislation are two. Either we should worry about a possible Gadarene rush of British doctors to the fleshpots of Brussels or we should worry about a flood of linguistically and medically incompetent doctors from the Continent attracted by our climate and customs, and of course, our high salaries.

I shall discuss first the problem of our doctors flooding to the Continent. Anyone who has had dealings with constituents who decide to emigrate realises that it is traumatic for a family to reach that decision, and that the decision is made only in extreme conditions. It will certainly not be made, except under grave provocation, where there is an enormous linguistic problem. But the most important indication that the likelihood of a flood of our doctors to the Continent is small is the fact that it is already possible for them to go to the linguistically safer areas of the United States, Canada and Australia, as many have, to get the better salaries and facilities enjoyed there. Therefore, we should be more concerned about those who go to English-speaking countries.

As for the possible influx of medically or linguistically incompetent doctors into this country, it seems to me from what my hon. Friend said, and from EEC Regulation 1612 of 1968, that the linguistic problem is relatively small. We can apply tests, and where there are loopholes this country can ensure that the linguistic qualifications are all right.

Our Department of Health and Social Security has done a great deal of work with regard to medical incompetence in the past couple of years. Whereas there might have been a danger in that regard a few years ago, the proposed creation of the advisory committee, coupled with the further safeguards in the directive, indicate that it is highly unlikely.

Furthermore, there is the question of salaries. It is highly unlikely that French doctors, for instance, would accept salary cuts of 20 per cent. to 30 per cent. to come to Britain, quite apart from the Belgian doctors, who, we have already heard, enjoy a still better standard of living.

When we are implicitly making a judgment on foreign doctors, we must take into account the kind of statistics which indicate their competence. On the whole, infant mortality rates in the Common Market countries are about the same as ours. We are certainly not among the top countries. Life expectancy, which we may presume bears some relationship to medical care, if not a total relationship, is also about the same in all the countries. Therefore, we see that any fear that we shall be flooded with medical incompetents is extremely ill-based.

However, those are negative arguments. If the result of the directives is immigration into this country, it is probably to be welcomed as a net benefit. We are far worse off for doctors per head of population than any other EEC country, with the possible exceptions of Ireland and Luxembourg. We are in no position to scorn foreign doctors. Our National Health Service is totally dependent upon them.

In a statement last December the Department gave startling figures. The percentage of doctors in practice in England and Wales born outside Britain or Eire was 11.3 per cent. in 1965. By October 1973 it had risen to 16.5 per cent., and by last October it was 17.4 per cent. In the hospital service the 1965 figure was 29.1 per cent., and in October 1973 it was 34.7 per cent. Furthermore, when making that statement the Chief Medical Officer of the Department of Health stated that in the previous year the number of National Health Service doctors rose by 3 per cent. and that half had been born abroad.

Mr. Arthur Palmer (Bristol, North-East)

For a long time, and particularly in psychiatry, it has been almost impossible to find young British doctors. Does my hon. Friend agree that those who come from overseas, and sometimes from the Commonwealth, often practise a branch of medicine in which language is all important and that they have an imperfect command of English?

Mr. MacFarquhar

I accept my hon. Friend's point. I suggest that the fears that might be aroused by this directive—namely, either a massive outflow of doctors or a massive inflow of the wrong kind of doctors—are ill-founded. If we are so lucky as to get some competent foreign doctors from the Continent the National Health Service will benefit, as it has already benefited from other foreign doctors.

I close with a different point. I return to the way in which the directive has been presented. As I have already suggested, there was no point in the riders which my hon. Friend added. They were vague and anyone would take them for granted in discussing this legislation. They add nothing to our debate. Why were the riders inserted? They have been inserted after consultation with whom? I suggest that the proper course to take in these debates—they will be regular debates and there will be late night sittings—is to put forward the directives unamended and without internal riders. If the Government or Members have reservations they should be mentioned in debate. The Government will then be able to go forward with their negotiating position, taking into account the points of view of Members.

Mr. Marten

Before the hon. Gentleman sits down—

Mr. Deputy Speaker (Sir Myer Galpern)

Order. The hon. Member for Belper (Mr. MacFarquhar) had sat down. Sir Derek Walker-Smith.

11.3 p.m.

Sir Derek Walker-Smith (Hertfordshire, East)

One thing that emerges from the fasciculus of directives which has prompted these agreeable exchanges this evening is something to which I drew attention in an earlier debate before Christmas—namely, the slow pace of Community legislation. That is not necessarily in itself a bad thing, but it is certainly a slow pace judged even by our legislative pace. It also shows the difficulty of adhering to set programmes.

I understand that these directives date from March 1969 and derive from the general programme adopted by the Council of Ministers as long ago as December 1961. That programme was designed to achieve freedom of establishment in the liberal professions by the end of the transitional period which was reached as long ago as 31st December 1969. Under the programme approximately 40 proposals for directives were received by the Council from 1967 onwards. They covered doctors, dentists, pharmacists, veterinary surgeons, midwives, nurses, opticians, architects, engineers, tax consultants and lawyers. I need hardly say that I catalogue them in no order of priority in putting the lawyers at the end of the list.

It is my understanding that none of the 40 or so proposed directives has as yet come into operation. The consequence of that is that the directives which are mandatorily required for the transitional period in Article 54 of the treaty on freedom of establishment and Article 57 on mutual recognition of qualifications were not achieved during the transitional period. Nevertheless, Article 52 of the treaty, which requires in principle the abolition of restrictions on the freedom of establishment, is now operative in nine member States. That was held to be so by the European Court of Justice in the case of Reyners and the Belgian State. For the benefit of our admirable and conscientious Reporters, that is transcribed as Reyners v. Belgian State. In that case it was held to be directly applicable, despite the absence of the necessary directives.

The result of that is that the first directive which we are considering is no longer operative, is redundant, and we are, therefore, saved the necessity of considering it. The freedom of establishment for these professions is already established in our law under the terms of Article 52 of the treaty as applied by the European Communities Act. If the freedom of establishment for professions is to be good in principle there must be a satisfactory common basis of qualification and training.

As to this, the second and third directives with which we are dealing here, and which deal with this aspect, are out of date. They are out of date not only because they were made before the enlargement of the Community to nine Member States but also because they have been overtaken by events. They have been overtaken by the recommendations of the Commission's working party, which was assisted by a four-day public hearing of the representatives of the medical profession in October 1973, which was attended by, among others, representatives of the British Medical Association and the General Medical Council as well as representatives from United Kingdom universities.

The provisions of the third directive as they stand are unsatisfactory, as the Minister has said, because they specify criteria which are quantitative instead of qualitative; that is, they insist on minimum periods of study and training irrespective of the content of the instruction or the results achieved. This point was taken up by the working party, which recommended making the methods as flexible as possible. It said in its report: This increased flexibility might consist in (a) reducing, as much as possible the evocation of quantitative criteria. It would be very advisable in particular that present and future proposals should not include indications on minimum hours of training to be devoted to each subject of the programme. When quantitative criteria are mentioned the total time devoted to training could, for example, be taken into consideration; (b) referring wherever possible to qualitative criteria". That must be so and I understand that the Minister already accepts that point.

There are two points which I raised in the European Parliament when this matter was debated on 23rd April last, on the resolutions of the working party. The first point concerned disciplinary procedures. I refer to such procedures because the basic ingredients of professional life are, first, a proper qualification to enter, second, an accepted and prescribed code of conduct; and, third, a procedure to enforce that code of conduct. I ask now the question I asked in the European Parliament: is it clear that disciplinary procedures, including the procedures for elimination from the register of those not conforming to prescribed standards, will apply to all Community practitioners in the host country? Will those practitioners simply be subject to the indigenous procedures of the host State or will there be special procedures, and, if so, what procedures, and how much further has that got since the days when the directive was promulgated?

My second point arises from a matter to which reference has already been made, and that is to the inhibitions of language. Language and other considerations give rise to difficulties of adaptation, particularly with regard to medicine. They are not insuperable difficulties. Those of us with any knowledge of the health service know how many people from overseas are practising here. I well remember in the rather distant days when I was Minister of Health—even more distant than the days of the right hon. Member for Down, South (Mr. Powell)—that there were many Spanish nurses in the psychiatric hospitals, all doing the job to the best of their ability.

Nevertheless, language is an obvious difficulty in medicine, and it follows that some period of adaptation is desirable even for doctors who have recognised qualifications in their own country and the right of establishment. But will any period of adaptation be legally possible and admissible?

That question was also discussed by the working party which, in paragraph 28 of its report, said this: There was a widespread expression of view in favour of a period of adaptation for migrant doctors so as to secure a sufficient familiarity with the language of the host country and the legal and social context in which they would be practising. The report continues: In the opinion of the legal services of the Commission, this would be discriminatory against migrant doctors and thus incompatible with the provisions of the Treaty. The report suggested that further consideration should be given to this important matter. A little time has gone by since then. I ask whether that consideration has been given, and, if so, to what effect. Has the matter been reexamined in the legal context from the point of view of the relevance of Articles 56(1) and 66 of the treaty, which, taken together, seem to contemplate the possibility of a dispensation from the right of establishment provisions where considerations of public policy or public health so suggest.

Clearly, if freedom of establishment is to succeed in any profession, particularly in the sensitive sector of medicine, adaptation periods may be required before immigrant doctors from the Community are entitled to practise in this country.

Mr. Mike Thomas

rose—

Sir D. Walker-Smith

I am just about to finish, but I will give way.

Mr. Thomas

I am delighted to hear that the right hon. and learned Gentleman is finishing his speech. Does he agree that all these qualifications apply to the thousands of doctors who are already practising in this country, including the Scots?

Sir D. Walker-Smith

I do not know whether the hon. Gentleman is suggesting that the Scots speak a language different from our own. It may sometimes sound different but it is the same language. I fail to follow the point of the intervention, and I am sorry I gave way. Courtesy led me astray. I shall not allow it to do so another time.

There are these further points which require consideration, and on which I hope we shall receive guidance from the Minister.

Several hon. Members

rose—

Mr. Deputy Speaker

I remind hon. and right hon. Members that the debate must be concluded at 11.44 p.m. Hon. Members may draw their own conclusions on the length of the speeches they make.

11.14 p.m.

Mr. Christopher Price (Lewisham, West)

I should first like to congratulate my hon. Friend the Under-Secretary of State on the funniest piece of "Eurobureaucratese" that the House has ever heard.

It is important to remember that the inclusion of self-employed professionals in the Treaty of Rome was a last-minute afterthought. The workers having been freedom of movement, the élite realised that they would be left out.

Sir D. Walker-Smith

It started in 1961.

Mr. Price

The élite "lump" labour of Europe was included to enable it to move across boundaries. I do not give much account to the scare stories about foreign doctors flooding this country or about us losing all our doctors to other countries. There is already a good deal of movement of professionals in Europe. My objection to the provision in the treaty is that it was unnecessary. Europe would have developed quite sufficiently without such legislation.

The explanatory memorandum mentions, under the heading of ministerial responsibility, the Secretary of State for Social Services and the Secretary of State for Education and Science. But it is difficult to find anyone in the Department of Education and Science, which has important responsibilities here, who knows anything about this legislation. These various negotiations have been left very much to the professionals and their sponsoring Ministries.

The greatest danger in this lies in the attempt to make statutory what was in any case a developing movement of professionals. It is in danger of strengthening a number of élite professional monopolies which were in any case going through a period of development, and it will prevent any further sensible development in the health service professions—and, indeed, in the other professions as we come to them.

Countries all over the world are taking completely different attitudes these days to how they deal with their health service professions. China, for example, is going in for what it calls "barefoot doctors". It is using medical auxiliaries, far more widely than we would think of, as doctors. Russia has a far greater percentage of women doctors—in other words, it promotes its nurses to be doctors far more than we do. In this country, it is almost impossible.

Without such legislation, that sort of development can go on. What the legislation is doing for the medical profession is establishing it as an extremely dangerous élite within Europe. Presumably, the same will be the case with the other professions later.

This thing started in 1961 and has been argued over ever since. It started with the absurd business of adding up the hours spent in the lecture room, and so on, and has gradually evolved. It is one of the most nonsensical ideas ever to emerge from the Treaty of Rome. It typifies the complete waste of time which much of the legislation of the EEC represents.

11.20 p.m.

Mr. J. Enoch Powell (Down, South)

One thing that has become clear as a result of the debate is that, before these directives attain their final form and are ready to be approved, they will need to come back in that final form for the consideration of this House. I understand why the Under-Secretary is not in a position to give that assurance, but I hope that after the debate he will ensure that in the quarters where these matters are decided that is firmly recorded.

It was worth while that considerable time should have been spent, even in this brief debate, upon the form of the motion, because almost on each occasion we are in an experimental area. I think that it would be agreed that this form of motion is decidely unsuccessful. Even if the matter were to be done in a more timely fashion than this has been done, a motion should assist hon. Members to prepare themselves to take part in the debate by concentrating upon what, at any rate, the Government consider to be the relevant point.

No one with this motion before him, even after the most diligent reading of the explanatory memoranda, could have added flesh to the bones or given any substance to these entirely vague propositions (i) and (ii). I mean no disrespect to the Minister when I say that, even after his speech, it was not clear whether they recorded matters on which the Government still required amendment of the directives before they would assent to them or whether they drew attention to subjects of interest which would not be affected one way or the other by the final form of the directive. The situation is unsatisfactory, and I hope that notice will be taken of it for the future.

If this were our own legislation being passed in the proper legislative form, no doubt many of these matters would be dealt with by a White Paper preceding or accompanying the presentation of the Bill. Then such matters as the possible effect upon the volume of migration of doctors, the details of plans for improving linguistic standards, and so on, could be set out before the House, studied, and brought into the debate in the proper way.

This evening, granted the brevity of time, it has been impossible to do that. Therefore, when draft directives come before the House, although I would say nothing to discourage the Government—indeed, I wish to encourage them to pinpoint specific matters which in their view require to be resolved for strengthening their hand—they should not repeat this experiment and put upon the Order Paper observations which are so general that they can be of no assistance to hon. Members and can invoke no expression of concrete opinion from the House which would be of value to the Government.

11.22 p.m.

Dr. J. Dickson Mabon (Greenock and Port Glasgow)

I agree with the sentiments expressed by the right hon. Member for Down, South (Mr. Powell). If there had been added to the motion an item (iii) and an item (iv) saying "God is Love" and "Please adjust your dress before leaving" I should still vote for it, because it would be just as helpful as the two declarations (i) and (ii) that we have here qualifying the motion.

We are taking note of a Council directive which will become effective next week or a month or two from now because, if the Council of Ministers decides that this is formalised, there shall be set up for the first time in the history of Europe—even medieval Europe—what is in effect a European General Medical Council.

I need not remind the House of the formation of the General Medical Council 100 years ago—to be precise in 1858—and what it meant to Scottish doctors who were denied the right to practise in London, to London doctors who were denied the right to practise in other parts of England, to Irish doctors who were denied the right to practise in England and Wales, and so on.

We are discussing a document which proposes to set up an advisory committee on medical training and to assist the practice of medicine with its various specialisations. I accept that there are defects in it, including the one relating to disciplinary matters. I concede that to the right hon. and learned Member for Hertfordshire, East (Sir D. Walker-Smith). It is not a perfect document, but it represents a substantial stage forward in harmonising European medical practice.

The idea that language is a barrier to medicine, of all professions, is absurd. All the great, and indeed lesser, physicians—I declare my interest as a practising physician—have moved about from country to country from time immemorial practising in different areas and giving of their best to humanity. Language was a minor barrier. I ask right hon. and hon. Members to reflect on the number of doctors today in this country who come from many territories and whose mother language is not English, despite their connections with the Commonwealth, and to realise what they do in this country, not only in general practice but in hospital practice and in research. This argument about the language barrier is about as mean as the pusillanimous motion which we are discussing.

There are difficulties about these matters, I agree, and we shall have to sort them out. But we have to recognise that, despite the history of past events beginning in 1961, this document is dated 10th October 1974. It represents a great deal of hard work by the entire medical profession in this country, representative members of which took an active part in the standing committee. No Government Department invented the document. It was prepared by the medical profession of the nine countries of Europe, but principally by the British medical profession. Give credit where it is due.

We have sought to create, for the first time, attached to the Commission and the Community, an advisory com- mittee on medical training, and I imagine that advisory committees on other forms of professional training will follow in this form. This has to work. It is not perfect. It will be improved in time. I remind right hon. and hon. Members that in this House 100 years ago the radicals of medicine pioneered the statutory registration of their profession. From the General Medical Council flowed the pattern of regulation of all the other professions thereafter, and it is right that, in the continuing flow of history, we should have this draft directive in European terms.

I welcome it. I realise that there are defects. But we are making a very big step forward tonight, not only for Europe but for medicine.

11.27 p.m.

Mr. Cranley Onslow (Woking)

I have no intention of disagreeing with a word that was said by the hon. Member for Greenock and Port Glasgow (Dr. Mabon). He put the nub of the matter succinctly, and I hope that the Minister took note of it; his comments on the motion, like those of the hon. Member for Belper (Mr. MacFarquhar) and the right hon. Member for Down, South (Mr. Powell) were also very much to the point.

It seems that the Government have such difficulty in getting their supporters into the Division Lobby—or keeping them out of it—on any given occasion that they are having a dummy run for the question on the referendum. They have tabled a motion saying "We have an important matter to discuss, but we cannot tell you what it is about." I hope that they will do better in future when they put important matters of this kind before the House, and not devalue their importance by tabling trivial motions of this kind.

I wish to ask the Minister two questions and to make one suggestion. First, does he agree that more credit should have been given in his brief to those representatives of the BMA who did the spade work? Dr. Rowe and Dr. Grey-Turner put in an enormous amount of work, and I confess that I was a little taken aback by the self-congratulatory note of the officials in the Minister's brief.

Secondly, can the Minister say what is meant by paragraph 5(i) in the supplementary explanatory memorandum? I do not think it means what it says. If it means what it says, I am disturbed by it. I believe that the intention is that there is, or may be, an obligation on member countries not to put barriers in the way of the employment of other nationals in their hospitals. It is not a matter of laying an obligation on them to employ the nationals of other countries, but that is what it says. In future, I hope that we shall have explanatory memoranda which explain.

I come, finally, to my one proposal. This advisory body will be an important body of some standing in Europe and, I dare say, internationally. When it is set up, it will need a home. I hope that it will not gravitate to Brussels. I do not make a special plea that it should come to London instead. I should like to see it go to Edinburgh, and I can think of many good reasons why it should go there, apart from the fact that I am half Scots myself. When the Minister goes to talk over these important matters in Brussels, I hope he will bear my suggestion in mind, together with the other matters raised in the debate.

11.30 p.m.

Mr. Alec Jones

I naturally expected criticism of the procedure and of the type of motion which is before the House. Not being an expert on procedure in this place, I shall do as the right hon. Member for Down, South (Mr. Powell) mentioned and make sure that the points which have been raised by a number of hon. Members about what they regard as the unsatisfactory nature of the motion are referred to the appropriate quarters. I seem to remember, however, that there have on occasion been other motions to approve or to disapprove something, and they have equally met with the disapproval of hon. Members on both sides. But I do not want to develop that aspect now.

It seems to me that what we are talking about is acceptance by all hon. Members who have spoken—and, I believe, by all Members in the House—that there is at present a considerable movement of doctors both into and out of this country. By and large, I suppose that as customers of the doctors we dislike the movement out more than the movement in.

What we have to concern ourselves with this evening, however, is whether the directive which we are discussing has an effect upon that movement in or out which harms the people who are served by the doctors who practise here. At least, we must ensure as far as lies in our power that the directive effectively protects the interests of doctors but, above all, protects the interests of patients in this country.

That has certainly been the aim of the Government and of all who have taken part in the discussions. I join the hon. Member for Woking (Mr. Onslow), in paying my tribute to the doctors who played a part in this. If the hon. Member felt that my tributes were not sufficiently lavish. I apologise to him for that failure. I would, however, say that, not only tonight but on many occasions, we have indicated to the doctors concerned—indeed, to the whole medical profession—our gratitude for the part they have played in this direction.

It is because of their activities and advice and the guidance they have given, aided by members who happened to be in my Department, that the directives have been amended and improved considerably from the first draft document. That was what we set out to do. We set out to take the first draft document, take the expert advice available to us and see whether we could improve the directive in such a way as to guarantee that the interests of would-be patients in this country were protected. That is why we believe that even next week it will be necessary for us to go somewhat further, because I do not necessarily agree with everything that has been said tonight concerning language. I believe that the aspect of language is of some importance in this matter.

Obviously, the major concern of all of us must be with the standards which the directive contains. I think it was the right hon. and learned Member for Hertfordshire. East (Sir D. Walker-Smith) who spoke about a slow pace of movement and suggested that the documents originated in 1969, if indeed he did not go back to 1961.

It is true, as I said in opening, that we are talking of a document which saw the light of day in 1969. At that time, however, the qualifications were based on length of training, and it was the considered advice given by the experts, by the members of the medical profession, that mere length of training was not a sufficient guarantee as to the nature of the qualification which these doctors might possess. We felt that it was absolutely essential to ensure that the qualifications should be based on the quality of the training and not only on the quantity. Initially there was reference only to the duration of training and the suggestion of a period of either six years or 5,500 hours. But now, as a result of the discussions and the aid we have received, the medical qualification will guarantee that the doctor has acquired adequate knowledge of the basic sciences and scientific methods, of the structure, functions and behaviour of healthy and sick people, and of clinical disciplines and practices, and that he must also have had suitable clinical experience in hospitals under appropriate supervision.

Many of us might well have taken that for granted. But those criteria were not in the original directive. It is because the directive has been improved that we are moving the motion this evening.

I was asked how the medical standards would be promulgated. We envisage that the particular qualifications will be set out in a new schedule to the Medical Acts, when these could be varied from time to time by Order in Council. The detailed requirements as to training will be brought to the attention of universities in much the same way as the GMC makes recommendations today.

The hon. Member for Harrow, East (Mr. Dykes) talked of registration. In this respect, I mentioned in my opening speech the Merrison Committee. We are expecting a report from that committee very shortly, and the committee will be dealing not only with the qualifications and discipline matters but with the question of registration, and the whole picture of registration of specialists will then be brought forward.

I was also asked whether the amendments to the Medical Acts would be minor amendments. It will certainly be necessary to amend the Medical Acts, but until the directive is settled I could not anticipate the extent of any such amendments. The Government will have the opportunity of considering also the Merrison Report, as I have mentioned, and it is quite possible that on overseas doctors there will be constructive amendments to be made as a consequence of that report.

I was also asked by the hon. Member for Harrow, East about dentists. Other hon. Members mentioned the fact that this directive was the forerunner of others. But as far as I am concerned, this evening we are talking about doctors. Although the draft directive as originally published in the Official Journal of the European Communities related to the freedom of establishment and the freedom to practise of dental surgeons as well as medical practitioners, the directives deal now only with the medical profession.

Once the directives on doctors have been finally approved, it is expected that work will commence in Brussels on draft directives for other professions. I understand that some preliminary discussions have taken place on the pharmaceutical industry, and that exploratory talks are about to take place concerning the nursing profession.

My hon. Friend the Member for Greenock and Port Glasgow (Dr. Mabon) suggested that language was not a barrier. I am not suggesting that language is a complete barrier. I can well take the point he made that the great physicians of old time never found language a particular barrier. But those great physicians seldom went into many of the under-doctored areas of this country.

Dr. J. Dickson Mabon

Nonsense!

Mr. Jones

Seldom. We could argue about it. However, without being disrespectful to the doctors in my locality, for whom I have the highest regard, I do not recall those world-famous physicians visiting Rhondda on many occasions.

Dr. Mabon

Rhondda is one of the best examples.

Mr. Jones

I am not suggesting that there is any great conflict. My hon. Friend the Member for Greenock and Port Glasgow spoke of the great physicians. He said that such people would have no difficulty over language. However, that is not the only difficulty with regard to doctors. We must have some regard to the patient. I do not suggest that language is an insurmountable barrier, but it would be folly to suggest that it was no handicap. The majority of people expect, and have the right to expect, when they consult a doctor, whether in general practice or at a hospital, to be able to communicate on a reasonable level. The directive sets out the minimum standards to ensure that that kind of difficulty does not arise.

Reference was made to paragraph 5.i. of the supplementary explanatory memorandum. I assure the hon. Gentleman that the proposition he suggested is not valid. According to Article 48 of the treaty, the provisions in it relating to the freedom of movement do not apply to employment in the public service. When a doctor from a member State practises in the medical profession in a public hospital, the post carries the status of a public servant. Within three years at the latest after the adoption of the directives, it will be possible for nationals of the other member States to be so employed. No attempt is made to erect a barrier. This will remove the barrier which has been suggested.

Many points were raised in the debate. Many of them will be referred to at the meeting in Brussels next week. In the meantime, I commend the motion to the House.

Question put and agreed to.

Ordered, That this House takes note of the draft EEC Directives on doctors and dentists contained in COM(69) 127 and R/2610/74 and in particular observes that:

  1. (i) the Directives raise important questions of principle which relate to the special circumstances of medical practice in the United Kingdom;
  2. (ii) the effect of the Directives on the movement of doctors into and out of the National Health Service is not clear.