§ 10.30 a.m.
§ The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)
I beg to move,That the Chairman do now report to the House that the Committee recommend that the National Health Service (Vocational Training) Bill [Lords] ought to be read a Second time.The Bill which I commend today to the Committee is a simple but significant measure aimed at improving standards in primary care. Its purpose, which is strongly backed by the academic and professional bodies—including the British Medical Association—is to tighten the entry requirements for becoming a general practitioner principal in the National Health Service by introducing a period of compulsory post-registration 820 "vocational training". The Bill marks a development not only in the National Health Service, but in the recognition of general practice as a specialty in its own right.
There is no need for me to remind the Committee that the Bill comes before us at a time of severe restraint in public expenditure. However, as the Government's recent consultative document on Priorities for Health and Social Services in England pointed out, while it is essential at any time to work out our priorities carefully, at such time of severe restraint it is all the more imperative that we should choose the right priorities. The same document stressed the rôle of primary care in helping to relieve pressure on hospital and residential services and 821 described as a "key element" in the strategyto maintain and where necessary increase the level of training and to improve the ways in which skilled manpower is used".This Bill reflects both these priorities: the importance of primary care and the increased emphasis on training.
Vocational training for general practitioners has existed for some years now on a voluntary basis, and its development has been encouraged by successive Governments. Many doctors already embark on organised schemes, comprising two years in appropriate hospital posts and one year as a trainee in general practice. Others, after a period in hospital, decide that they wish to take up general practice as a career, and also take a trainee year in general practice. In 1970, there were 211 trainees in England; in 1975, about 660—a most encouraging increase. Wales and Scotland have seen a similar development. The Government, strongly backed by the medical profession and other interested bodies, believe that the time has now come to increase the momentum already generated by making vocational training for new general practitioner principals compulsory from a future date to be agreed with the profession. I shall return to the question of timing later.
I should perhaps make clear now those to whom it is proposed the new compulsory arrangements will not apply. They will not apply to general practitioners already providing the full range of general medical services when the new arrangements start. They will not apply to doctors entering general practice as locums or assistants. There will be other groups as well who for some reason should not come under these arrangements but these will include the general run of family doctors providing the normal range of services.
We shall also need to consider very carefully the position of those doctors not in general practice when the new arrangements start but whose experience may warrant particular consideration; for example, those who have previously been general practitioner principals or have had considerable hospital experience. This is something that we shall 822 be looking at closely in consultation with the medical profession.
The regulations will, of course, also need to take account of the wider European scene and the agreement on free movement of doctors. With that in mind we have already discussed our plans with our colleagues in the EEC, in the forum of the Committee of Senior Officials in Public Health. Already it is clear that our EEC partners warmly welcome the proposals in the Bill and the contribution that it will make to the development of general practice as a specialty within the Community. Some EEC countries already require a measure of vocational training before their general practitioners can work within their social insurance schemes.
I turn now to the mechanics of the legislation, and to explain these I should first remind the Committee of the current procedures by which a doctor—who must already be a fully registered medical practitioner—sots up as a general practitioner principal in the NHS. First, he must apply to a family practitioner committee, administering these arrangements on behalf of an area health authority, for inclusion in its list of doctors undertaking to provide general medical services in its area. The family practitioner committee refers the application to the Medical Practices Committee for a decision. The Medical Practices Committee may refuse the application, but only on the grounds that there is already an adequate number of medical practitioners undertaking to provide general medical services in the area or part of an area concerned. Thus, the family practitioner committees, which receive the applications and make subsequent arrangements with those doctors whose applications have been accepted, have no power to accept or refuse applications, and the powers of refusal of the Medical Practices Committee are confined by law to the grounds of adequate provision in the area.
What the Bill does is to extend the powers of the Medical Practices Committee to refuse applications so that after the appointed day it can, and indeed it must, refuse applications from doctors who have not been vocationally 823 trained and who are not entitled to exemption. The exemptions will, of course, cover doctors providing general medical services on the appointed day and subsequently moving to another family practitioner committee area.
Because the Bill extends to Scotland, I should mention here that arrangements there are similar except that they are operated by the health boards, not family practitioner committees, and that there is a separate Scottish Medical Practices Committee; the Bill makes suitable corresponding provision.
I come now to the very important question of timing. The Bill provides for the new powers of the Medical Practices Committee to operate after an appointed day—that is a day appointed in regulations—and there are a number of factors to be taken into account before a decision is made on what that date shall be. We cannot commence these new arrangements tomorrow. The full period of training will be three years, and clearly in the regulations we must give doctors at least three years' warning so that they can plan their careers to comply with these statutory requirements. The medical profession has proposed 1980 as the target date for the full three years' training requirement and this will be in our minds when consulting on the regulations.
The Committee will wish to know something of the kind of training that it is proposed to prescribe under the powers in the Bill. Let me preface my remarks by saying that in laying down details in the regulations we shall want to consult very closely with the medical profession and the educational bodies on these matters. But we expect the general pattern to follow the pattern of training at present undertaken voluntarily by many young doctors; namely, a period in hospital, normally in senior house officer posts, and a period attached to an established general practitioner who has been approved by the general practice sub-committee of the regional committee for postgraduate medical education. This pattern of voluntary training is greatly influenced by the requirements for the vocational training allowance, at present payable to principals during their early years in practice. These include three years in hospital posts—including the pre-registration house officer year— 824 and one year as a trainee in general practice. During the hospital period the doctor occupies a post in a number of specialties. He may spend either six or 12 months in each of several specialties, so as to get the broad base of experience so valuable to a general practitioner. There are some posts which provide for rotation through a number of departments for short periods. In order to qualify for the allowance, he must include at least six months in two or more specialties from a specific list which includes general medicine, chest medicine, traumatic surgery or accident or emergency work, obstetrics and gynaecology, paediatrics, psychiatry, geriatrics, otorhynolaryngology, dermatology, ophthalmology and anaesthesia. It may be that when we consult the profession it will wish to amend these criteria in the light of experience before adopting them as the basis of compulsory arrangements, but I hope that that gives the Committee the general picture.
§ Mr. Kenneth Lomas (Huddersfield, West)
I appreciate that my hon. Friend is to have consultations with the EEC, but what consultation has been taking place with junior doctors, consultants, other people inside the health service and the trade unions on this matter? Perhaps my hon. Friend would like to elucidate that. He may have had two hours' sleep. I have had only one hour. He may be better for it.
§ Mr. Deakins
I wonder whether I could crave my hon. Friend's indulgence. I shall come to the question of consultations in a moment. There is quite a lot that I can say about consultations, and I want to give the Committee all the relevant information about the processes through which we have gone in consulting people and organisations. Perhaps I might be permitted to return to what I was saying.
Whilst working in hospital, the potential general practitioner does the same kind of work as his colleagues who are planning a hospital career—he is in effect a hospital junior in the specialty. However, in addition he may throughout his training attend special lectures and courses arranged by the local clinical tutor in consultation with the regional postgraduate dean and the general practice sub-committee. During the year in 825 general practice, the trainee gains practical experience of the work of the primary health care team, the links with local authority services and the whole pattern of the organisation and delivery of primary health care. He will have an individual training programme designed for him by his trainer, and may participate in visits and consultations with the trainer or undertake them on his own.
At all times he will work closely with his trainer and other members of the team in order to gain a deeper understanding of the medical and social problems involved in the medical care of a patient and his or her family. He may be seconded for short periods to other practices, and recently some short experimental attachments to social services departments have been arranged. I hope those will become more widespread.
However, we do not wish to make the regulations so inflexible that all doctors must follow the same training pattern. For that reason, we have provided for an alternative route—the certificate of equivalent experience. A postgraduate medical dean and regional adviser in general practice may wish to experiment with different specialties, for example. Also, doctors coming from overseas need to have their experience individually assessed.
There is also the question of doctors who can train only part time. Clearly, the regulations will need to provide for part-time training, and the Bill requires them to be framed so as to allow the prescribed experience to be acquired without undertaking whole-time employment. As far as administrative arrangements are concerned, part-time junior hospital posts already exist, but we shall be emphasising to health authorities the importance of planning for the needs of these potential general practitioners. Similarly, part-time training in general practice also occurs and we see no problem in extending this. We shall, of course, keep the operation under review.
A doctor who has completed the prescribed training or has had equivalent experience will need a certificate to support his application to the family practitioner committee, and professional committees will be responsible for issuing these. The detailed arrangements will of course be subject to full consultation.
826 There is also the question of appeals. Clearly, it should be possible to appeal against a refusal on the part of such a committee to issue a certificate of prescribed or equivalent experience. Committees having such appeals will be professional bodies set up after full consultation with the medical profession. There will, of course, be no appeal against a refusal by the Medical Practices Committee to admit a doctor to a family practitioner committee list on the ground that he has not had the necessary experience, whether prescribed or equivalent, and is not entitled to exemption.
The Committee will appreciate that flexibility is essential to operate a system such as I have outlined and to allow also for future developments and variations. That is why we feel that the details of the training are more appropriate to regulations, where changes can be more readily made, than to the Bill itself—so the Bill before the Committee is a short one. In fact there are only five clauses, and I shall describe them briefly.
Clause 1 is the basic provision of the Bill. It contains the new powers of the Medical Practices Committee and the Scottish Medical Practices Committee to which I have already referred. Clause 2 contains the regulation-making powers, including the powers to prescribe details of the training to be required. There are also powers for medical experience judged to be equivalent to that prescribed to be accepted as meeting the requirement, to prescribe exemptions from the requirement and to make what administrative arrangements may be necessary. The remaining three clauses consist of minor amendments to other legislation arising out of the Bill, definitions of terms, authority for expenditure incurred by the proposals and the usual formal provisions for citation and extent. The Bill does not extend to Northern Ireland, but I understand that there is a proposal to introduce a similar requirement there by means of an Order in Council.
The reply to my hon. Friend the Member for Huddersfield, West (Mr. Lomas) is that we have had consultation in advance of presenting the Bill, and we shall have extensive consultations following the passage of the Bill into law.
§ Mr. Deakins
I make that point for the benefit of my hon. Friend. We have had preliminary views from the General Medical Services Committee, which is the appropriate body representative of all interests in the profession, the Royal College of General Practitioners and the Council for Postgraduate Medical Education. I should say, for the benefit of the laymen like myself on the Committee, that the General Medical Services Committee is an autonomous committee of the British Medical Association, recognised as representing the interests of general practitioners.
Further consultations will include representatives of the health authorities who usually invite a multi-disciplinary team to advise the Department. Our further consultations will be on a number of matters, such as administrative arrangements, training arrangements and categories, with the bodies that I have mentioned, but I do not rule out consultation with other interested bodies. Those that I have mentioned are the main ones to be consulted automatically on a Bill of this nature which affects the medical profession.
§ Mr. Deakins
They have not been consulted, and until now it has not been our intention that they should necessarily be consulted on a Bill which concerns solely general practice. General practitioners do not employ members of NUPE and NALGO, who work mainly in the hospital service. The Bill will have no impact on the hospital service, because two-thirds or three-quarters of general practitioners already do two years in general hospitals, and this is merely to extend that slightly.
The Bill will mean that people who go to their family doctor will go to someone who if he qualifies after the Bill is passed, will have been compulsorily trained. The Bill is an important step, a result of which should be a significant and ongoing improvement in the standards of primary care in this country. I am 828 sure that the Committee and the House will welcome the measure.
§ 10.49 a.m.
§ Dr. Gerard Vaughan (Reading, South)
I thank the Minister for his clear-cut and helpful description of the Bill and for presenting it in the way that he did. I also welcome your presence, Sir Donald, as Chairman. I think that under your experienced guidance this Committee will not only be entertaining, but entertainingly brief.
In welcoming the Bill—from a party point of view it is non-controversial—I would say that the extent of the agreement already felt about it is unusual. All the medical organisations are agreed about it, and my experience is that when a large number of medical people agree about something, it will be very good or very bad indeed.
In a way this is a historic Bill, because when it becomes law gone will be the days of the Cronin era when one could go out, put up a plate and see whether any customers came along. I welcome the change. It fits in with the general wish to raise the status of general practitioners, and it will give them a much more specialist rôle in our medical services.
The Minister said that it was a simple and significant Bill. It may be significant, but I am not sure that it is so simple. One worry about it is that so much is left to regulations that we are literally presenting the Minister with a blank cheque, or blank prescription, the details of which he will fill in later. I hope that things are not being left open to regulations because the Government do not know what they intend to do. We have had one or two examples of legislation covering up uncertainty about the action that the Government intend to take. We need more certainty, and to be reassured.
The Minister says that vocational training will be for three years and that he has no intention of extending it but the recent BMA conference thought that it should be five years. I believe that three years is long enough. I should like a list of those who were consulted about the Bill because when that was discussed in the other place the noble Lord said that the consultations were so extensive that he was not able to list all those 829 involved because that would be too complicated.
We should like to know more about the exemptions. I find it sinister when the Minister says that he has three groups in mind. Which three groups? I understand that people doing maternity services only will be exempted, as will those doing family planning. We should like to know what others will be exempted.
The Minister was disarmingly vague about the implications of the Bill for the EEC. I ask him to look at the debate in the other place. The noble Lord said:…our lawyers advise that the medical Directives, when read with the Treaty of Rome, may be interpreted as meaning that doctors from other EEC countries cannot be subject to mandatory vocational training—[Official Report, House of Lords, 17th June, 1976; Vol. 371, c. 1396.]The noble Lord went on to say, that BMA's legal view was that the position was not clear and that it must be clarified in the immediate future. The Minister did not make it clear today. Have we a right to make it mandatory for people from other parts of Europe. to undertake vocational training If not can we leave open the possibility of changing the Bill to include changes in EEC regulations?
We should like to know how people doctors, and I should like the Minister to confirm that it is the Government's intention that they can break off their training to have a baby and then return.
We should like to know how people will be selected. There will be grants amounting to £580 a year.
§ Mr. Deakins
When the hon. Member asks "How will people be selected?" I am not sure what he means, because this will apply to everyone who wishes to become a general practitioner.
§ Dr. Vaughan
That is exactly what I wished to ask. Will anybody who wishes to become a general practitioner automatically be able to apply for a grant and go in, or will the Medical Practice Committee select people? No one has any idea what effect this will have on recruitment. I asked my students the other day what they would do, In previous years, 50 per cent. would have wanted to go into the hospital 830 service. Now, 50 per cent. want to go into general practice, other than those who wish to emigrate. It may be that a training scheme of this kind will reduce, rather than increase recruiting. I see that £1 million is allocated, but already people are saying that that will not be enough. I should like to know exactly how much the Minister thinks the scheme will cost.
Those are the main points that I wanted to make. We welcome the Bill, and we support the principle, but I must make it clear that there are a number of detailed points about which we want to be satisfied before we give the measure our full support.
§ 10.56 a.m.
§ Mr. Colin Shepherd (Hereford)
I should like, as a layman and a potential, but I hope not too regular, consumer of medical services, to say that I welcome this attempt to improve the standards that will be available to us in the National Health Service.
There are a number of points that I should like to mention. They are nontechnical, but I share the concern of my hon. Friend for Reading, South (Dr. Vaughan) that this is enabling legislation and is subject to variation by statutory instrument under the negative procedure.
I agree that there is no question of consultation with the trade unions, but, on the medical side, would it be possible for a schedule to be added indicating the make-up and constitution of the bodies that will have to be consulted before the regulations can be firmed up and setting out the means by which their views will be taken into account?
The Explanatory and Financial Memorandum says that there will not be any increase in public service manpower. The temptation within an administrative empire like the National Health Service is to create departments and departmental responsibility for training. There are already in area health authorities with teaching hospitals departments that cover training, and I cannot help thinking that the increased training facilities will lead to increased staff. I should like to hear what the Minister says about that, and especially how it is considered possible to increase the training commitment drastically without increasing the number of employees covering the administration 831 of training. That affects the money cost, which has been put at an annual level of £1 million. As my hon. Friend said, it has been suggested that that is not enough. Paragraph 7 of the Explanatory and Financial Memorandum says that small administrative costs may arise as a result of these proposals, but the answer is to get a closer estimate of the expenditure involved.
Those are two points to which I should like the Minister to give consideration because they are important in terms of principle and expenditure at a time of severe public expenditure restraint.
§ 11.0 a.m.
§ Mr. George Thompson (Galloway)
Last night at about 2.30 a.m. I made a little self-denying ordinance for myself. I had prepared a five-minute speech for that debate and I thought that in order to assist the House I would forbear to make that speech. Little did I know that that debate would eventually end at 9.50 a.m. this morning and that I could have made my five minute speech. I have decided not to exercise that self-denying ordinance in this Committee. I am grateful that the fact that the blinds are drawn in this Committee will mean that nobody will be able to see my 11 o'clock shadow.
I am grateful to the Minister for referring to the separate arrangements in Scotland. All the consultations that I have had in Scotland point to the fact that the Scottish medical profession welcomes the Bill because it provides for compulsory vocational training for general practitioners and can also be said to meet the needs of patients. Therefore, it will he welcome from all sides.
I wish to pay a small tribute to the voluntary training scheme which has existed for a number of years. In my locality we have benefited for many years from the fact that a local general practitioner has acted as trainer in that scheme. Therefore, we have had the benefit of the services of young medical men. Admittedly they have taken their first steps in general practice in our area, but I am sure that that has not been to thy disadvantage of patients. Indeed, they may well have benefited from the advantage of those young doctors and the freshness of their new knowledge and skill. It appears that the move towards 832 compulsory training makes excellent sense.
At this stage in Scotland we are concerned mostly about whether finance will be provided for the necessary facilities required for training. A certain number of these trainees will be required to do their training in deprived areas in West Central Scotland. It worries us that well-motivated and trained doctors go into deprived areas and can—I do not necessarily say that this happens often—become overwhelmed by the conditions which they see around them and in which they work, and thus become disillusioned. There is a tendency in those areas for general practitioners to have rather more patients than do doctors in rural areas, but to have possibly less equipment with which to deal with the situation.
There is a need for improvements in the National Health Service in those areas not only for the sake of the trainee but for the sake of the trainer. Our medical schools give the ideals and the skills, and it is up to the community—and in this case ourselves—to provide the necessary facilities for the trainee to make the best of his training. We must help to encourage some of the young men and women to take up medical practice in deprived areas and, indeed, to look upon this work as a challenge, a medical crusade. We hope that many people will undertake that work, but I believe that we should give them especially generous help in those areas.
I wish to ask the Minister whether, even in the nation's present economic straits, there will be sufficient finance to provide better equipment and facilities, such as health centres, and so on, which will be required to give those young doctors a good send off in their careers as general practitioners.
With those remarks, I welcome the Bill wholeheartedly on behalf of Scotland.
§ 11.4 a.m.
§ Dr. Reginald Bennett (Fareham)
I wish to join my hon. Friend the Member for Reading, South (Dr. Vaughan), who sits in the place of honour in front of me on the Opposition Front Bench, in extending our felicitous greetings to you, Sir Donald, on chairing our Committee. It is a great privilege for hon. Members 833 to see you presiding over our deliberations. We appreciate that very much indeed.
This Bill seems to me, at first blush, to be a wholly beneficial arrangement, having behind it excellent intentions. As I understand it, it does not prolong the training period in regard to general practitioners who are subordinate partners as they are generally understood, but applies only to those who wish to embark as principals in practice. That is my interpretation of the word "principal". It is therefore desirable that people should not be able to come into general practice straight from qualification, even though that may be the moment at which they know most in medicine. They should not be able to come in straight from qualification or from abroad and set up as principals in general practice without having established themselves, to the satisfaction of the community, as having acquired enough experience. If that is the case, I am certain that this is a beneficial measure and deserves our support. I have certainly heard no word of doubt about this matter so far from any part of the Committee.
It is curious that a dozen or so years ago I was asked to attend a dinner given by the Society of Apothecaries. It was a livery dinner, but I hasten to say that there was nothing hepatic about it. I was asked to speak on a topic that alarmed the members of that society; namely, the impending negotiations for Britain's entry into the EEC. Their fear was that should we join there would be a completely uncontrolled flow of doctors in all directions within the Community. I attempted to reassure the assembled company that we were not likely to allow into this country people with inadequate training or qualification to practise here.
Will the Minister underline the fact that the relationship with the other EEC countries will mean that we shall insist on fully mutual arrangements within the EEC? Will he seek to ensure that the EEC countries adopt these undoubtedly admirable principles of ensuring that the skills exist among those who seek to practise and who, so to speak, have the power of life or death?
I have only one misgiving about the Bill, and I hope that the Minister will 834 be able to dispel it. I refer to the kind of derogatory journalism that often attaches to these measures, to the effect that these are further examples of restrictive practices within an established profession, and that that is a thoroughly bad thing. It must be left to the Government's abilities to expound the virtues of this Bill and to demonstrate that it is not a way of shutting the door to aspirants to the medical profesion, but rather a method of seeing that those who practise practise well.
I support the Bill and wish it a speedy passage.
§ 11.9 a.m.
§ Mrs. Lynda Chalker (Wallasey)
I wish, first, to apologise to the Committee for not having been present at the beginning. I was down the corridor in a Committee considering a statutory instrument.
I did not hear the speech of my hon. Friend the Member for Reading, South (Dr. Vaughan), but it would appear that we do not in any way wish to oppose this Bill—for the simple reason that there is not very much meat in it. The Bill appears only to pave the way for the regulations that must follow giving the details of how vocational training should be carried out. Therefore, we await with interest to see the extent of the regulations that no doubt will come before us, probably later this year, and we shall look to see whether all the matters that are beginning to be raised on these issues are incorporated in them.
In seeking the wide acceptance of the idea of vocational training, I believe that these matters should not be entered into willy-nilly without canvassing the views of doctors about the extent of vocational training. We should see that information is exchanged on a wider basis than hitherto has been possible.
I was surprised to learn that a number of general practitioners have always felt it right to participate in one or two sessions in a hospital from time to time, but that they have undertaken that activity of their own free will. The difference between the voluntary vocational training that they are currently carrying out and what is now to be required through the Bill by the regulations is extreme. There is a good deal of work 835 to be done before we arrive at the regulation stage. I hope that some way will be found through the BMA and the Medical Women's Federation to assure the medical profession as to the right way of proceeding and taking into consideration those reservations that exist on the compulsory vocational training that we now require.
I wish to refer briefly to the 1972 Women Doctors Retainer Scheme and to ask the Minister whether the Government have any intention of extending that facility. I regard that scheme as a great step forward for women doctors, and the matter was referred to in Committee in another place on 28th June at column 641. The scheme provided for increased facilities to be offered to women doctors who wished to undertake part-time training posts. When the other place considered amendments to the Bill, their Lordships were most concerned that women doctors who are now required to undertake an additional three years in total vocational training should have the opportunity to undertake part-time work when perhaps the coming of a family might intervene in the total training period, which now extends up to eight or nine years.
The noble Lady, Baroness Young, tabled an amendment in the other place, which was accepted by the Government and which seeks to put at rest the minds of women doctors who go into practice but on a more part-time basis than their male colleagues. I ask the Minister to consult with the Medical Women's Federation in the coming months to ensure that the final regulations will not be subject to argument, because we cannot amend them. In other words, our homework must be wisely completed in this respect.
I wish to refer to the question of vocational training for general practitioners compared with post graduate training for some of the general practitioners who will be exempted from the three-year period—in other words, those who have been in practice for a considerable time. We are aware that apart from one or two sessions a week, many general practitioners hardly have the contact with the hospital service that we would wish them to have. I do not know whether the Minister is thinking of any way in which these exempted general practitioners can 836 be encouraged to do voluntarily at least a part of what is now being done by those general practitioners who have contracted to do a few sessions a week. That is particularly important, because there are departments of medicine which do not have enough junior staff.
I hope that the Committee will forgive me for saying this, but I have had the experience of an accident and emergency unit closing suddenly in my constituency. One wonders why it is that the general day-to-day work cannot be taken over by the kind of facility of which some GPs avail themselves already, by offering to give some sessions to a hospital for specific reasons. The older GPs can bring their experience to bear and they in turn can gain from contact with junior doctors who have been more recently trained and from contact with consultants, and thus keep going some aspects of our health service that is under the severest pressure that it has ever experienced. I hope that the Minister will turn his mind to that.
The EEC regulations must be clarified. It is my understanding that in the interval between the Bill being considered in another place and today the matter has not yet been fully clarified, but I shall be happy to be corrected if I am wrong, As long as EEC-trained doctors cannot be mandated to undergo vocational training in this country they will not be able to be principals here, however good their English standards or anything else. If we are to have free movement of labour between this country and the other EEC countries, that would create two levels of doctors, without the real reason for having two different levels. It may not be on a training basis. The vocational training in their own country may be just as good as ours. It may be that special regulations will be required if the EEC Directives will allow that. That is where the matter is totally unclear.
§ Dr. Vaughan
It could be the other way round. A doctor from the EEC could come here, put up a plate and set up a one-man practice, and there would be no way of stopping him.
§ Mrs. Chalker
My hon. Friend is correct. He could so do. The point is that before he can put up a plate presumably the Medical Practices Committee will have something to say about his ability to. 837 practise. Not long ago it was found that a motor mechanic in Scotland had spent six months advertising himself as a doctor and treating patients before it was discovered that he had no qualifications whatsoever. If that can happen north and south of the Border, the problems that could occur across the English Channel might be even greater. This matter is obviously in urgent need of clarification from the Minister.
We feel rather strongly that the Bill is a blanket cheque, and that until the consultations about the regulations are openly held, which I hope they will be, with all the interested parties listed in another place during the debate there we shall not really see how vocational training will work out in practice.
We give the Bill a welcome because anything that improves the primary care standards in our health service and removes the pressure from our hospitals and residential homes must, as the White Paper on Priorities for Health and Social Services said, be welcome. If it is to be done, there is no point in spoiling the ship for a ha'porth of tar. I look forward to being involved in the consultations that will come prior to the drawing up of the regulations. They are the heart of vocational training. I want to see the blood flowing freely through vocational training, and that will happen only if the preparation is thorough.
§ 11.19 a.m.
§ Mr. Deakins
We have had a very interesting discussion. On behalf of the Government, I am glad that there has been a wide welcome for the provisions in the Bill and the principles involved. The hon. Member for Reading, South (Dr. Vaughan) asked a number of questions, and I shall do my best to answer them all.
I start with our intentions for the training period. The hon. Gentleman made the point that the BMA might want to lengthen this to five years. That is news to me. I accept what he says. The current target is three years because the medical profession has been pressing us strongly to bring this into effect as soon as practicable. That means that we shall be allowing for the fact that we have to give doctors a chance to decide what their specialties are to be, and what 838 arrangements are to be made in the future. There are a number of administrative arrangements to be made, and this scheme could not possibly be brought into effect before 1980. I do not believe that the medical profession will turn round in the course of consultations and say that three years is not adequate and that it wants five years. That seems unlikely.
On the question of resources and costs, to which the hon. Gentleman referred, in view of the potential resource costs, we should prefer, and the profession would prefer, if one is to judge from our consultations with it, that the training period should be for three years, and not for more. We have had consultations with three or four bodies. If the hon. Gentleman wishes I should be happy to provide him with a list of all the bodies that we consulted about the Bill. It goes rather wider than the major bodies that I have indicated.
The hon. Gentleman asked about exemptions, and this is an important matter. We have not yet agreed a list of exemptions with the medical profession, but we expect that it will include the following. First, those who have been in general practise some time in the past, although not actually practising on the appointed day. I should enter a caveat there. If someone had been in general practice in the 1920s and 1930s and had not practised for the past 20 years, the appropriate professional body would have to see whether he had the appropriate qualifications for service. Secondly, doctors in practice on the appointed day subsequent to moving to another family practitioner area. Thirdly, doctors contracting to provide maternity medical services only, and doctors contracting to provide family planning service only in the National Health Service.
There are two other groups that it will not be necessary to exempt, because the provisions of the Bill will automatically not apply to them. These are doctors already in general practice on the appointed day, and doctors entering general practice as locums or assistants. The former will not be making applications to the Medical Practices Committee after the appointed day in respect of their current practice. The latter do not contract with a family practitioner committee to provide services but are employed by general practitioners who 839 are on a family practitioner committee's list.
It may be that other groups will be exempted; for example, general practitioners who were at one time on the family practitioner committee list. As I said earlier, we may want to place some time limit which should elapse before they can re-apply automatically.
We shall also consider the position of other doctors who have been assistants or hospital doctors and who wish to move into general practice. It may be appropriate for them to be exempted, or it may be appropriate for them to apply for a certificate of equivalent experience, which has to be taken into account.
§ Mr. Deakins
Vocational training requirements apply only to the National Health Service. Many doctors in the Armed Forces already undertake vocational training in preparation for their return to civilian life. Their experience in the Armed Forces will be considered either under the certificate of prescribed experience or under the certificate of equivalent experience, whichever is the more appropriate.
I now turn to the thorny question of EEC medical practice which the hon. Members for Wallasey (Mrs. Chalker) and Fareham (Dr. Bennett) mentioned. We see mandatory vocational training as a necessary consequence of the emergence of general practice as a specialty in its own right, and there is certainly strong support for this approach among our Community partners, some of whom intend to move in the direction that we are taking, and some of whom have already done so. We should like to apply this requirement to all new principals after the appointed day. For that reason we wrote to Brussels recently, to the Directorate there, explaining our plans so that there could be full and informed discussions, and the discussions that we have had so far have been highly encouraging. I cannot say, for the benefit of the hon. Gentleman or the Committee, that they have yet been finalised. If problems are raised about applying this regulation to EEC doctors we shall look into it further, but we are con- 840 fident that we shall have the sympathy of our EEC partners, many of whom will be or already are in the same position.
We are not trail-blazers in this respect. If one looks at other EEC countries, one sees that most are agreed on the need to improve the postgraduate training periods for medical practitioners. Denmark already has a mandatory 18-months course, which is to be increased to three years from December of this year. The French are hoping to make a modest start by introducing a one-year course initially, aiming for a two-year course later. These arrangements, like those for Britain, apply only to the State-supervised health services. I cannot go further on the EEC point at the moment. We shall work very hard in Brussels to do our best to ensure that in terms of medical directives these arrangements do apply. I am not in a position to give an undertaking to the Committee when that will apply, but it is our intention that it should be subject to what happens in Brussels.
The hon. Gentleman asked about recruitment. Perhaps it will help if I deal with the more general problem which I am sure is in the minds of some hon. Members—it is in mine—and that is the effect on the number of general practitioners. Until the regulations are effective, any fully registered doctor can continue to enter general practice as a principal without further training after his pre-registration year. However, there has been an increasing tendency for doctors first to undertake voluntarily some form of vocational training. At the beginning of this year the number of trainees in Great Britain was about 900. About 1,300 new general practitioners are needed annually to replace deaths and retirements and to sustain the 1 per cent. growth of recent years. We do not expect the transition to the new compulsory position adversely to affect general practice or the numbers of doctors needed.
The hon. Gentleman and the hon. Lady were concerned about women doctors, and this was one of the major points with which the House of Lords were concerned. I have read through the debates with great interest. The argument used in the other place was that by lengthening the training period to perhaps five years or six years, and three 841 years extra—which means that we are talking about nine years—this would hinder the chances of women becoming general practitioner principals.
Certainly the period that we are discussing will considerably lengthen the time spent in training for general practice, but that has not discouraged those women who have already voluntarily become trainee general practitioners. About 28 per cent. of all trainee general practitioners in 1974 were women. Female principals made up only 12 per cent. of the total in the same year. There is a larger block of women coming in as we increase the intake of women into our medical schools, and I do not think that it would be right to require less training for women merely because they are women. No one argues that. We are trying to improve the standards of primary care, and we cannot do that unless we raise standards all round.
We shall meet the need to provide part-time training for doctors who are unable to work full time because of domestic commitments. That applies mainly, but not exclusively, to women—in accordance with a provision introduced by means of a Lords amendment—and we must ensure that that need is properly catered for. There is express provision in the Bill to safeguard that aspect. I give the Committee an assurance that we shall do our best in ongoing discussions on the detailed administrative arrangements to make sure that that provision is followed up.
I now turn to another of the points made by the hon. Member for Reading, South about costs. The Explanatory and Financial Memorandum refers to extra costs of £1 million. It may help the Committee if I explain how that figure was arrived at. The bulk of expenditure on vocational training at the moment, under the current voluntary system, is the cost of trainees in general practice. In hospitals they do jobs and are part of the hospital service. They do not just hang around and watch other people working.
While in general practice, each trainee receives a salary from the trainer, who in turn is reimbursed by the family practitioner committee. That salary is related to that of the last hospital post that 842 he held. The trainer, who is usually a general practitioner, also receives a fee for carrying out the training, which is at present £1,300 per annum.
Voluntary vocational training has been increasing steadily. The cost in the Bill is therefore the difference between where we might have been without statutory provision—bcause of the expansion in voluntary training arrangements—and where we expect to be with it. The total cost of mandatory vocational training is likely to be about £8½ million. The £1 million mentioned in the Bill is merely the extra cost. We think by the time the Bill becomes law we will be spending up to £7½ million on the voluntary arrangements. Therefore, we are basically concerned about the extra cost.
The hon. Gentleman asked about the selection of people for general practice. The Medical Practices Committee will not select future GPs. For example, some doctors will apply to their regional postgraduate deans to go on organised training programmes. Others will apply for hospital posts in the usual way and subsequently themselves seek a general practitioner trainer to look after them in the training year.
I now turn to the points raised by the hon. Member for Hereford (Mr. Shepherd). He asked about the make-up and constitutions of the bodies that will advise us under the terms of the regulations. He asked why they could not be embodied in a schedule. Perhaps I should say something about prescribed bodies. Those bodies will obviously be professional bodies and will include representatives of the medical profession from both the clinical and educational areas. We are expecting to make use of the existing bodies rather than to have to set up new bodies specifically for that purpose. Those that we have in mind are the Council for Postgraduate Medical Education, the regional postgraduate committees and the Joint Committee on Postgraduate Training for General Practice. The point that we are still considering with the profession—this is one of our difficulties—is which functions should be assigned on a regional basis and which should be on a central basis.
Let me deal with the appeals procedure, which is at the back of the hon. Gentleman's mind. The Bill gives power to 843 establish committees to hear appeals against refusals of certificates of prescribed experience or certificates of equivalent experience. These will be professional bodies set up after full consultation with the medical profession. Their composition will be determined by regulations, partly because we must still decide on the bodies that will issue these certificates, and partly to allow for change and development in the light of experience. We are embarking on something new here.
The hon. Member for Hereford also asked about public service manpower and increased training commitments under the Bill. We already have administrative arrangements for the organisation of vocational training on a voluntary basis. As many doctors—900 a year at present—are already doing this, we do not expect any increase in administrative staff to cope with the change from a voluntary to a statutory system. We hope that the existing administrative arrangements, especially in area health authorities and hospitals, will be able to cope with the problem—if, indeed, it will be a problem.
The hon. Member for Galloway (Mr. Thompson) asked about the deprived areas and finance for improvements in Scotland, and he welcomed the Bill. A general practitioner who seeks to become a trainer has first to satisfy the general practices sub-committee of the regional postgraduate committee that he can provide the necessary training facilities. Obviously, while we want to see an improvement in primary care, the kinds of improvements that the hon. Gentleman mentioned are not incorporated in the Bill as there are already sufficient approved trainers throughout the country to match the likely number of trainees.
Finally, let me deal with the points raised by the hon. Member for Wallasey. I think that I have already dealt with some of her points about women doctors. The hon. Lady asked about women doctors under the existing training scheme and quoted a point that was raised in the debate in the House of Lords. Following a conference which the previous Secretary of State for Social Services held at Sunningdale last year, the Department is reviewing the arrangements for women doctors in consultation with the medical profession. In these days of no sex discrimination I should perhaps refer to 844 "doctors with domestic commitments". There may, of course, be some men in the same position.
Obviously, we shall want to take account of the new measure. I assure the hon. Lady that I have taken note of her points. The Medical Women's Federation is represented on the General Medical Services Committee. However, if there should be specific problems which women would rather bring forward through their own organisation, we shall not say that we shall not consult it. If it wishes to put points to us, we shall be willing to discuss them with that body.
The hon. Lady's final point dealt with the encouragement of general practitioners in general practice who are at present exempt under the terms of the Bill from a compulsory period of vocational training. She asked how we might encourage them to have closer contact with hospitals and be brought up to date. That is a wider problem. There must be thousands of general practitioners who are already in general practice. Their number will diminish over the years. However, in the next couple of decades there will be many general practitioners who are already in general practice, received vocational training. There are extensive arrangements for the ongoing education of existing general practitioners.
I now turn to service questions. The new hospital practitioner grade is intended to encourage doctors to pursue a career based both in general practice and hospitals. Progress has been made in establishing these posts, but I am afraid that it is rather slow. We shall have to do our best to improve matters.
I hope that I have dealt with all the points that were raised in the debate. I am grateful to the members of the Committee for their comments. I hope that in the further consultations we shall produce both regulations and administrative arrangements that will satisfy both hon. Members and the medical profession.
§ Question put and agreed to.
§ That the Chairman do now report to the House that the Committee recommend that the National Health Service (Vocational Training) Bill [Lords] ought to be read a Second time.
§ Mr. Deakins
May I, Sir Donald, on behalf of the Committee thank you for 845 the good-humoured way in which you have presided over our deliberations. It is pleasant for us to see you in charge. We are perhaps sorry that we have not given you a whole morning's work, but I am most grateful that we managed to finish in just over an hour.
|THE FOLLOWING MEMBERS ATTENDED THE COMMITTEE:|
|Kaberry, Sir Donald (Chairman)||Hatton, Mr.|
|Bennett, Dr. Reginald||Hunt, Mr. David|
|Chalker, Mrs.||Lester, Mr. Jim|
|Crouch, Mr.||Lomas, Mr.|
|Crowther, Mr. Stan||Shepherd, Mr.|
|Cunningham, Mr. George||Thompson, Mr.|
|Deakins, Mr.||Vaughan, Dr.|
§ Committee rose at twenty-two minutes to Twelve o'clock.