HC Deb 29 October 1976 vol 918 cc854-65

As amended (in the Standing Committee), considered.

Motion made, and Question proposed, That the Bill be now read the Third time.

11.8 a.m.

Dr. Gerald Vaughan (Reading, South)

We would like to discuss some of the intentions of this Bill, albeit briefly, because it has the support of all the medical bodies. I know from conversations which I have had with them that they are extremely anxious to have the changes which the Bill will bring about.

The Bill is a natural development of the present voluntary arrangements which many general practitioners undertake in their own time or in the training programmes which are available. They do this voluntarily because they see the need for this kind of training.

The Bill will make a major change in the history of general practice. The days when any doctor could put up his plate as a senior practitioner and wait for customers to arrive will be over.

We are happy to support the aims of the Bill. There is no significant difference of view between the two major parties. As a general comment, while we agree about the purpose of the Bill, we do not agree entirely with the method which has been adopted by the Government. We think that far too much has been left to be decided by future consultations. That means to be decided by regulations to be laid by the Minister. In effect, we are being asked to give the Minister a blank cheque or a blank prescription and he will fill in the details of the medicine later. We think that, however good the cause, this is not the right way to set about it.

In June, the Government said that they were having consultations with a large number of bodies. In fact, in another place they said that there were so many bodies with whom they were having talks that they could not list them all at that time. We have been told this again since, but we have never been told whom these bodies represented. When questioned about women, for example, it quickly became clear that none of the major women's organisations at that time had been consulted. One question to which we would like an answer today is: has the Minister now consulted the women's organisations? If so, which organisations, and what did they have to say about the Bill?

We should like to know a great deal more about the position as regards Europe. Shall we be able in this country to make this vocational training mandatory for all general practitioners? Or are we, as some people are telling us, in a position in which a doctor can still come from another part of Europe from the Common Market and practise here as and when he pleases because he has come in from outside the country? We have been told that this may be the position. I think that the Minister should tell us exactly where we stand.

There is, also, the question of appeals In another place the Government said that there would be "a body", a single body, but that they did not at that stage know which body. In the debate in the Second Reading Committee, the Minister said that there would be "several bodies". He used the plural and he said that they would be professional bodies set up after consultation with the medical profession.

Can the Minister tell us now what kind of bodies these will be, who will serve on them and to whom they will be responsible? For example, will a person have a right of appeal beyond whatever this body is to the Secretary of State? Will they be subject to the rules of the Council of Tribunals? Will they be subject to inquiry by the Health Commissioner, the Ombudsman? We would see these as important safeguards for a doctor who does not feel that he has been properly and fairly treated.

Finally, there is the question of the cost. The Minister has told us that the total cost of all this would be £8½ million. He justified that by saying that it would be only £1 million more than the expected cost of the vocational training voluntary schemes which are now in operation, but that was a projection of the costs today on into 1980. It was based on the assumption that the same increases in the number of people applying would continue. In fact, there is not a true argument. We should have liked to know the actual cost today and what will be the increasing cost when the Bill is passed—as we all hope it will be.

With those very few words, I should like to say again that there is no material measure of difference between the two major parties on this matter. If the Minister will answer those questions, we shall be very pleased to give the Bill our full support.

11.12 a.m.

Mrs. Lynda Chalker (Wallasey)

I welcome this opportunity to take part in the debate on Third Reading of the Bill, having watched its progress in another place and through this House with interest. As my hon. Friend the Member for Reading, South (Dr. Vaughan) has just said, there are still a large number of unanswered questions. It is interesting to trace that at each debate we have asked the same questions and at each debate the Minister has been forced to go away to have another look. We hope that he has managed to find some answers during the Summer Recess.

I am concerned about three areas in this legislation. First, we have, in the present arrangements for vocational training, a requirement that there is a minimum of two six-month periods spent in a hospital within certain specialties. However, I have been unable to find from any source a mention of the problems of mental illness and mental handicap in those specialties which are listed for those two six-month pre-registration hospital periods.

The House will be aware of the increase in mental illness in Britain over the last decade. It is absolutely vital, with some 600,000 people receiving psychiatric help every year, that in vocational training more attention is paid to this particular specialty in medicine. Every survey that we look at indicates this same need.

I am quite surprised that in the current arrangements, on which the Bill has been formulated, there is no specific reference to this specialty. I sincerely hope that the Minister will put this right in the places on the blank cheque on which he is going to write the coming regulations under the Bill when it becomes an Act.

I now come to two or three other points. One is the question of the flexibility of the vocational training. I note that the noble Lord, Lord Wells-Pestell, said in another place on 28th June this year: We do not wish to make the regulations so inflexible that all doctors must follow the same training pattern. We think there is some merit in leaving some of the training for the trainer himself to develop in the various regions."—[Official Report, House of Lords, 28th June 1976; Vol. 372, c. 655.] I should like to develop the question of regions more widely because it seems that as yet these matters are not resolved. We still have a chance before the regulations come forward for the Minister to look at the flexibility of training which might be afforded in the three years by some occupational medical experience, some industrial medical experience and, indeed, some experience of specialised areas that do not usually come up in the normal Health Service pattern across the whole country.

In that last phrase I refer, of course, to things such as tropical diseases, which are very specialised, yet which, with the increase of travel. are becoming more of a worry for the medical profession year by year. Therefore, reference to this sort of speciality in any vocational training programme should certainly have more attention paid to it than has been the case hitherto, if we are to use primary care in the correct manner.

During our Second Reading Committee, I referred to the interchangeability for doctors in the Armed Forces, how they might, on retirement from the Forces, perhaps, be able to swell the ranks of our general practitioners. That will be possible after the passing of the Bill only if they fulfil the requirements of the regulations to come. I do not know whether the Minister has yet been able to iron out some of the problems that might arise for doctors who have trained and then spent the whole of their medical practising life in the Forces. As the push for earlier retirement from the Forces comes for some of these people, there will be a very large problem unless we sort it out with this piece of legislation.

My next point concerns the question of the European Community. The Minister was to take up with the Commission in Brussels the question whether making vocational training for three years mandatory for British practitioners would also be able to be applied to European practitioners who might seek to come to this country as general practitioners. We urgently need further information on this matter, particularly in view of the differing standards—although very high standards—and differing practices in each of the countries of the Nine and, indeed, of other countries that may well come into the EEC within the next decade.

Finally, I refer to the situation of women doctors and their part-time training which may be necessary in view of the length of the total training period now. In the Second Reading debate and in the debate in Committee in another place, there were many references to this matter, and finally, on Report in another place, the Bill was satisfactorily amended.

However, the Minister undertook, during our Second Reading Committee, to find out what comments there may be from the Equal Opportunities Commission. and from the Women's Medical Federation, as a specific body rather than through the one voice of one of the other bodies which he was consulting. We hope that they are now satisfied with the amendment that has been made to the Bill, but this again is something that the Minister will need to consider in the preparation of regulations. It would be helpful for the House to know that this was being done.

I think that everybody welcomes the step forward that is being taken in this Bill, but we shall welcome it even more if there is a greater interchange of medical experience with industry, in occupational medicine, and in some of the specialties about which at one time we did not have to bother, but which now concern the practice of medicine at the primary care stage. We should seek to avert the need for further medical care by up-to-date and urgent action on the problems that face the general practitioner in his surgery.

11.20 a.m.

The Under-Secretary of State for Health and Social Security (Mr. Eric Deakins)

I apologise to the hon. Member for Reading, South (Dr. Vaughan) for not having been here when he rose to speak.

The Bill, which has now virtually completed its passage through Parliament, is an important though fairly small measure compared with many of the Bills facing us. I am pleased to note the general welcome that has been given to the Bill by both sides of the House today and during our important and detailed Second Reading Committee upstairs.

We in this country are proud—and I think rightly so—of our primary care services, and this measure will enable us to improve standards still further by formalising a trend that has been taking place for some time. Already many doctors spend a period in hospital posts and as a trainee in general practice before establishing themselves permanently in general practice. Some participate in organised schemes, comprising two years in appropriate hospital posts and one year as a trainee in general practice.

There are now about 700 doctors in England undertaking a trainee year, compare with 100 doing so 10 years ago. That is very good progress. Wales and Scotland have seen similar developments. The Royal College of General Practitioners, the General Medical Services Committee and the Council for Postgraduate Medical Education have all asked that this voluntary scheme be made into a statutory one. That has always been the aim of successive Governments, and it is clearly an issue on which both sides of the House are united.

Dr. Vaughan

How many doctors are expected to undertake the mandatory training when the Bill has gone through?

Mr. Deakins

I was coming to that. The number that I gave on Second Reading was up to 1,300. We estimate that there will be a small element of growth over the period. We shall be introducing the trainee arrangements up to 1980, if that is the starting date agreed with the medical profession. We have expanded medical schools, and some of the intake from them will come forward additional to the number that we have now.

I also said on Second Reading that we were training about 900 doctors, again on a voluntary basis. We hope that that will move to the full 1,300 in the course of time, because when the scheme becomes compulsory those who have not thought it worth while to undertake this form of training on a voluntary basis will have to do so from 1980 onwards.

Let me now deal with the question of costs. The hon. Member for Reading, South reminded the House that implementation of the scheme will cost money, and in these days of tight public expenditure that is a matter of concern. By far the largest sum arises from payments to trainers and trainees. We estimate that the additional cost of requiring all doctors to be trained, as compared to the cost of continuing extension of the voluntary arrangements, will be about £1 million a year. There will also be—I know this is a matter about which hon. Members are worried from time to time—some small administrative costs, although I connot detail exactly what those might be because the exact amount will depend on detailed arrangements. I give the assurance that it will not be a significant amount.

Trainees go on educational courses, and the costs that arise here are handled within the normal programme for funding postgraduate education for GPs. In general, the expenditure to which I am referring fits in with the key element of our strategy, which is to increase the level of training in the National Health Service and to give high priority to developments in primary health care which, as the House knows, is one of the main themes of our consultation document which was issued earlier this year and which I think has been warmly welcomed in many respects.

Dr. Vaughan

What is the current cost of the voluntary scheme?

Mr. Deakins

I cannot give the exact figure, but it will be the cost of the 900 doctors now engaged in the voluntary training programme. If my arithmetic is correct, that is about two-thirds of the number that we finally expect. If the total cost when we get 1,300 trainees is £8½ million, two-thirds of that gives one an approximate idea of the current cost. The expansion of voluntary training has to be taken into account in estimating additional costs. While we might have a cost of £5 million to £6 million now, in any event it will rise to £7½ million by the time the scheme comes into effect, because more and more people going into general practice are undergoing voluntary training arrangements. Therefore, in any case costs would have gone up.

I come now to the general theme of consultation, about which I was asked. The hon. Gentleman expressed some concern about this, and I have written to him. We have had a number of consultations about the principles and mechanisms that will underlie the regulations that will be made under what has been described as a Bill giving the Government a blank check. I do not believe that that is an accurate description.

There will be exemptions—and we made this clear on Second Reading—for example, for GPs already providing the full range of general medical services when the new regulations start. For the potential GP, the regulations will have to set out clearly what he will be required to do, yet at the same time they must allow the profession scope for experiment with different patterns of training, because this is, after all, an evolving field.

The provisions for certificates of prescribed experience and of equivalent experience will meet those objectives. The arrangements will cater for the doctor from overseas. They will cater for those who can train only part time. Indeed, because of the concern about the position of women doctors a special reference was inserted in another place, and I shall come to that in a moment.

We have had much useful comment on these principles and the way in which they might be put into practice. The medical profession has also suggested a timetable. proposing 1980 as the target for the full three-year training requirement, so as to give doctors adequate time to plan their careers. Our next step will be to prepare a comprehensive document on which we shall consult the various bodies which have an interest before we draft regulations. These consultations will go very wide and include matters that are exercising the mind of the hon. Gentleman, and also the position of women. I give the House that assurance. We agree with the hon. Gentleman that this consultation is vital because, as the hon. Member for Wallasey (Mrs. Chalker) said on Second Reading, the preparation must be thorough. I assure the House that that is our intention and that we shall carry it through.

The Bill is an important step marking a development not only in the National Health Service but in general practice as a speciality in its own right.

Now I come to the points made by the hon. Member for Wallasey, particularly about women's organisations. As she rightly said, the matter was mentioned in another place and an amendment was made there to the Bill to allow not only for women but, as I said on Second Reading, doctors with domestic commitments to be enabled to take advantage of the Bill, because there may be men who are in a similar position.

Our consultations so far have been with the General Medical Services Committee which includes one member nominated by the Medical Women's Federation. Doubt was expressed on Second Reading whether that was entirely adequate, and I gave an assurance in Committee that I should be happy to consult the Medical Women's Federation direct, in addition to consulting the General Medical Services Committee on which it has one nominated member.

On the more general issue of consultation, I assure the House that although we have consulted fairly widely in the run-up to the Bill, our further round of consultations, once we have produced this comprehensive document on the detail of the regulations, will be even wider. I stand by the undertakings that I have given. We want to press on, but I assure the House that it will not be a case of hasty consultations. We must get the thing right. We must take the medical profession along with us.

Criticism was expressed of the Bill being a blank cheque. I want to assure the House that if it is, the way in which it is filled in will depend very much on the course of our further consultations. With regard to people retiring from the Armed Forces it will be necessary to have further consultations with the profession on this. I do not anticipate any difficulty but, nevertheless, it is a point which I can assure the hon. Member for Wallasey we shall take on board.

The EEC question, which occupied us in Committee, is a difficult one. There is no doubt at all that at present there appears to be a division between what we are proposing in the Bill and the appropriate EEC directive and regulations. However, we have had a sympathetic response from the officials in Brussels with regard to our intentions because, as I pointed out in Second Reading Committee, a number of other EEC countries are also moving in the same direction, albeit at a different pace and perhaps in rather different detail. Nevertheless, I think it is a generally recognised objective in the EEC that one ought to move towards full professional training for general practice.

With regard to the legal position, I cannot give any more assurances to the House than I gave on Second Reading. The position is still not fully clear, but we expect the matter to be discussed further at the appropriate committee of senior officials of the EEC countries in Brussels next month. We certainly do not anticipate any obstacle from that quarter, but I take the point that we must try to get the position fully clarified before we finally go ahead.

Mrs. Chalker

I would be grateful if the Minister, following those discussions, could inform us about what is going on so that the pathway is clear leading up to the discussions on the regulations. If there is no communication through the usual channels after Brussels there may still be some unrest in the medical profession, and it would be pleasant to be able to put those minds at rest.

Mr. Deakins

I will undertake to keep the hon. Lady and the hon. Member for Reading, South informed before we place the regulations for approval. But I cannot guarantee that we shall quickly clear up this difficulty, if it is a difficulty. I am afraid that we must be advised by the lawyers. As the hon. Member for Read- ing, South will know, there are areas of Common Market law which are not entirely clear in relation to the laws of national Member States, but I take the point which has been made.

Mr. Leslie Spriggs (St. Helens)

My hon. Friend will be aware that there is a PLP House of Commons Health Group. Would he also keep that group informed on the same point?

Mr. Deakins

I certainly give my hon. Friend that undertaking. One way of keeping hon. Members informed, rather than writing to individuals—since the House may well be interested—might be to arrange that a parliamentary Question be answered on the progress when we have made some progress in Brussels.

With regard to specialties, mentioned by the hon. Member for Wallasey, this is essentially a matter for the profession and not for my Department to advise upon. Psychiatry is already included in the list of specialties recognised for vocational training allowance and this would obviously include experience in mental illness or in mental handicap.

The hon. Member for Reading, South raised an important point about appeals. I think that that was mentioned during the Second Reading Committee in my windup speech, in answer to points raised by hon. Members about what we were proposing to do about consultation. I would add that since the appeals will relate to professional assessment—I stress that—we doubt whether the Council on Tribunals will have a rôle, but we are in touch with the Council about this. There will be a final appeal to the Secretary of State, who will seek advice from a professional body. This body could well be the Council's joint committee on post-graduate training for general practice or a body similar in constitution. I stress again that this is a specialised area and, obviously, we would also take advantage of the professional advice from the profession concerned.

Dr. Vaughan

I also ask the Minister whether this would come within the sphere of the Health Commissioner—the Ombudsman.

Mr. Deakins

I think we must wait until the actual machinery has been established before we can determine whether this would fall within the remit of the Ombudsman. Obviously we shall have to proceed stage by stage. The first stage is to get the appeal machinery right, and secondly, we must see whether it would fall within the scope of the Ombudsman. But since the hon. Gentleman has raised it, and has suggested that it ought to come within the scope of the Ombudsman, it may well be that this is something we shall have to determine when we consult the medical profession about the precise form of the appeal machinery.

I cannot speak without notice on whether it would require any change in the legislation relating to the Ombudsman. One would hope not, but it is a point that we shall take on board in our further consultations.

In commending the Bill to the House I would pay tribute to the important work of those members of the Royal College of General Practitioners and others who have worked so hard and long to foster the training of GPs on a voluntary basis. I am glad, as I am sure the whole House will be, that their efforts have now culminated in this significant step.

Question put and agreed to.

Bill acordingly read the Third time and passed, with an amendment.