MEDICAL BILL [Lords]

HC Deb 22 February 1978 vol 944 cc1623-72

10.30 a.m.

The Minister of State, Department of Health and Social Security (Mr. Roland Moyle)

I beg to move, That the Chairman do now report to the House that the Committee recommend that the Medical Bill [Lords] ought to be read a Second time. The Bill is designed to change the constitution of the General Medical Council and to make provision for certain of its functions. The Council, which was first set up under the Medical Act 1858, is an independent statutory body responsible for regulating the medical profession. At the moment, it has three main functions. First, it maintains the medical register. Second, it has disciplinary powers which can be used in reepect of doctors convicted of criminal offences or who have committed serious professional misconduct. Third, it has a role in supervising medical education. The present Bill which started in another place, is directed at consolidating and improving the Council's role and functions in line with the recommendations of the Merrison Committee, which was set up in 1972.

Until 1970, the funds of the General Medical Council were provided generally by a registration fee. In 1970, the Council instituted an annual retention fee, and in 1972 it increased that fee, which led to a certain amount of dissatisfaction with the way the Council was carrying out its functions.

That dissatisfaction was expressed by a number of members of the medical profession and, as a result, the Government set up the Merrison Committee, which in 1975 produced a unanimous report with 95 recommendations ranging over the Council's constitution and functions. The Government then undertook wide-ranging consultations, and in July of last year my right hon. Friend was able to announce that the Government had found a clear consensus within the profession to accept the Merrison Report.

At the same time, we found that on many of the matters in the report there was need for fairly extensive consultation in order to resolve some points of difference which did not relate altogether to principle. Some of those matters, however, were of major importance. My right hon. Friend decided to introduce a short Bill embodying all the provisions on which there was a clear consensus and to give further consideration to the other issues.

When the Bill was introduced on 10th November last year in another place, it covered four main areas: first, the reconstitution of the General Medical Council; second, provisions relating to the termination of the agreement with the Irish Republic; third, provisions on fitness to practise; and fourth, the creation of a statutory education committee.

In the House of Lords, the Bill was generally criticised for not going far enough, but during the time that debates were taking place there rapid progress was being made in a series of discussions. Wider agreement developed and was eventually reached on a number of additional proposals relating to medical education and to giving the General Medical Council power to offer positive guidance on professional standards.

At the same time, there had been discussions with the profession, the General Medical Council and organisations representing the overseas doctors relating to the registration of overseas doctors. As a result of those discussions, the Government will be moving amendments to effect a more rational system of registration in respect of overseas doctors. I shall say a little more about that later.

I turn to the contents of the Bill. The reconstitution of the General Medical Council is dealt with in Clauses 1 to 3. No specified number of members is laid down, but the proposals closely follow the Merrison Report. The Council will continue to have a predominantly professional membership but, for the first time, once the Bill is on the statute book, it will have a majority of elected members—members elected by practising medical practitioners.

Voting rights, and the right to sit as either an elected or an appointed member on the Council, are extended to provisionally registered doctors and to doctors who have held temporary registration for a specified period preceding an election or their appointment. The Bill also provides for an increase in the number of education bodies which can appoint members to the Council. All these reforms are designed to make the Council more generally representative, and this in turn should give greater confidence in the Council's proceedings. I need hardly say that these proposals are warmly accepted by the profession and are completely acceptable to the existing Council.

Clause 4 relates to the legislative provisions that are necessary to allow the termination of the agreement that was made in 1927 between Great Britain and Northern Ireland and the Irish Free State to allow the General Medical Council to operate on a British Isles basis. Both Governments now wish to terminate this arrangement because, to a large extent, it has been superseded by the implementation of the EEC medical directives. Both the Irish Republic and this country, being members of the EEC, of course, come within the purview of those directives. Consequently, it is no longer appropriate for the GMC to exercise a supervisory role over medical education in the Irish Republic.

The clause is necessary for the repeal of the statutory provisions arising from the agreement when it is terminated, and second, to safeguard existing rights on termination. Since the negotiations are not yet complete, the Bill provides for the preservation of the status quo until the agreement is terminated.

Clause 5, which was introduced into the Bill in another place, gives the GMC a new power to provide guidance to doctors on standards of professional conduct and medical ethics. The clause is directly intended to secure the maintenance or improvement of medical standards. It arises from the Merrison recommendation that the GMC should be given a statutory power to promote high standards of professional conduct, and has been welcomed by the GMC because it gives it legal cover in issuing advice to doctors on what constitutes good professional practice and medical ethics, and enables it to depart from the present practice of confining its guidance to the issue of what constitutes professional misconduct. It therefore gives the GMC a wider and more positive remit.

Clauses 6 to 14 deal with the fitness to practise committees of the Council and again follow closely the relevant recommendations of the Merrison Report. There are two major innovations which will make the GMC's procedures more effective for the protection of the public and give greater flexibility in the sanctions which can be applied to a doctor, who has to face those procedures, in the unfortunate necessity of such a situation arising.

First, the Merrison Committee discovered that there were doctors whose physical or mental ill health put their patients at risk. The committee felt that action should be taken to eliminate this problem. Such doctors were a very small proportion indeed of the total medical profession, but as the GMC, as the law now stands, can take action against doctors in this category only if they have committed certain criminal offences or acts of serious professional misconduct, it was felt that the existing position was too limited and too rigid.

A new committee called the health committee will therefore be created under this legislation. It will enable the General Medical Council to suspend a doctor's registration for up to 12 months, or to make registration conditional on the doctor complying with specified requirements if it judges his fitness to practise to be seriously impaired by reason of mental or physical ill health.

There are other fitness to practise committees. There is the professional conduct committee, which will replace the present disciplinary committee and will inherit its powers, although it will, too, be given the power to impose conditional registration. There will be the preliminary proceeding committee, which will take preliminary proceedings once a case is notified to the Council and will have the power to exercise, on very rare occasions, a new power of interim suspension. One of the functions of this preliminary proceedings committee will be to decide the course which a complaint against a doctor should take, either towards the health committee or towards the professional conduct committee.

The Bill will also make the necessary statutory provision for the conduct of business by these committees, rights of appeal against their decisions, and transitional arrangements.

Clauses 15 and 16 deal with the functions that are to be given to the Council's new statutory education committee. As the new committee is to be solely concerned with medical education, the Government have accepted—again in line with the Merrison proposal—that it should have a statutory majority of appointed members, that is, members appointed by various education bodies. It will assume directly most of the present Council's existing statutory functions relating to medical education along with the general function of promoting high standards of medical education and co-ordinating all its stages.

The education committee will provide a forum for general debate on medical education matters and it will also have certain specific tasks: first, the maintenance of adequate standards at qualifying examination, and, second, the determination of patterns of experience which may be recognised as suitable in the pre-registration period of education, that is, a period of training following graduation. The present arrangements came in for some fairly vigorous criticism by the Merrison Committee which recommended that improvements be made.

These changes and Clause 16, which amends the existing statutory provisions as regards the experience required for full registration, are widely accepted, and I think that they will help to maintain and consolidate high standards of training.

I mentioned at the outset that the Government intend to introduce one or two amendments during the passage of the Bill. They consist, first, of technical amendments to assist the future consolidation of the Medical Acts, and second, of a number of amendments on the registration of overseas doctors. Amendments on the registration of overseas-trained doctors were tabled in another place. The Government spokesman in the other place indicated that those amendments did not go far enough, and they were withdrawn on the understanding that we would in this House put down our own amendments embracing the same principles but presenting what we hope will be a more coherent package.

At present, overseas-trained doctors may be eligible for three different sorts of registration, according to their qualifications and experience: full registration as granted to United Kingdom graduates, which allows the unrestricted practice of medicine; provisional registration as granted to United Kingdom graduates who have not completed the necessary 12 months' pre-registration experience; and third, temporary registration, which is available only to overseas doctors. Temporary registration may be granted at the discretion of the General Medical Council to doctors who do not in some way meet the requirements for full or provisional registration.

Mr. William Molloy

I shall be grateful if my hon. Friend will explain the overall term "overseas doctor". Is there any difference in treatment between a doctor from overseas who is neither EEC nor British Commonwealth, a British Commonwealth doctor and an EEC doctor?

Mr. Moyle

I am grateful to my hon. Friend for raising that point. Although it does not directly arise from the content of the Bill, I think it would be helpful to the Committee to get the flavour of the difference in treatment between EEC doctors and overseas doctors.

There are at the moment some overseas doctors—primarily Commonwealth doctors—who can come to this country on the basis of the qualifications that they have obtained in medical schools in the land of their birth and get full registration and be able to practise here.

Mr. Molloy

Full registration.

Mr. Moyle

Yes, but that is under a system of reciprocity which we intend to bring to a conclusion if this Bill is passed.

EEC doctors, under the EEC directives on the free movement of labour and mutual recognition of qualifications, can come to this country, receive full registration and can begin practising immediately. However, under present arrangements, they must undertake a language test within six months of coming to this country. If they fail that language test, the full registration may be taken away.

The position with regard to Commonwealth doctors with recognised qualifica- tions is that if they come to this country they will, under the Bill, have to undertake a language test straightway. If they pass that language test, they will be able to get full registration.

Certain overseas doctors may at present qualify for temporary registration. Temporary registration is related to a particular job in this country, and it has to be renewed every year, with consequent expenditure on fees by the doctor. Temporary registration is not satisfactory. It was intended to provide for a temporary situation but, in fact, it is being applied to doctors who are here for quite considerable periods. Therefore, we wish to replace it with limited registration.

Once language and professional knowledge tests are surmounted, the overseas doctor will have limited registration for five years. Provision will be made for the limited registration to be converted into full registration at any time during the five-year period if the appropriate conditions of medical qualification and experience are met.

Dr. Alan Glyn

The Minister said that reciprocity will be given up. Is that correct?

Mr. Moyle

That is right.

Dr. Glyn

So, presumably, those now practising under the existing arrangements will continue, but nobody else will be allowed to do so. Is that correct?

Mr. Moyle

Yes, there will be protection provisions for people who are in this country at the moment.

Mr. Molloy

May we have this point clear, because it is, I believe, of more than marginal relevance? I think that my hon. Friend said that an EEC doctor, for example, can come straight to Britain, be here six months, and then be subject to a language test, whereas a Commonwealth doctor would be subject to a language test immediately.

Is there any suggestion in the Bill—I confess that I have not read it in detail—whereby some fairer method can be applied to a doctor who needs a language test? Many of us would think that, irrespective of where the doctor comes from, the fundamental issue is his standard of his English, not the language of the country whence he came.

Mr. Moyle

The language test is a test of the doctor's ability to express himself in English. The two channels are subjected to the different controls that I have explained. The Overseas Doctors Association was consulted by me. It fully appreciates that, ideally, we should like to deal with all overseas doctors on the basis that we shall deal with doctors from outside the EEC countries. The Association is prepared to accept the existing situation because, generally speaking, it finds that the provisions relating to its members are desirable from its point of view and a considerable improvement, as the Association sees it, on the existing conditions.

The difference in the treatment of EEC doctors arises from our membership of the EEC. It is one of the imperatives that we have to accept. Even our existing provisions for testing EEC doctors are criticised by some members of the EEC, and that may lead to eventual proceedings in the various European courts. However, that is something for the future and something which may not come about.

Mr. Michael Morris

I do not expect an answer from the Minister this morning, but my understanding is that the French are insisting on a language qualification. I understood that it was not on a six-month basis but on a more immediate basis, rather on the lines of the query raised by the hon. Member for Ealing, North (Mr. Molloy). Could that matter be checked?

Mr. Moyle

Certainly. I have no intimate knowledge of the French arrangements. If that is so, possibly they, too will be criticised by some of their EEC colleagues.

Perhaps I could now expand a little on the provision which will replace temporary registration by limited registration. Limited registration may be held only for a total of five years and will require a doctor to work under supervision. This has the great advantage that a doctor will not be tied down to a particular post as he would be under temporary registration. It provides a means for a doctor who fulfils the necesasry requirements to progress to full registration.

In addition, limited registration could be granted for a single employment or a range of employments, and is therefore more flexible than temporary registra- tion. The five-year time limit will not apply to those doctors who have established themeslves in the United Kingdom at the time when the Bill becomes law on the basis of temporary registration. In other words, they will receive personal protection. However, there will be provision for the GMC, if it sees fit, to withdraw limited registration, and there will be a right of appeal against such a withdrawal.

There are two other points I wish to make. First, we propose extending voting rights in the GMC elections and the right to be elected or appointed as a member to those doctors who have held limited registration for four of the five years prior to an election. Periods which they have spent in this country on the basis of temporary registration will count towards that qualifying period.

Second, the present appeals structure is to be replaced by an overseas appeals committee within the framework of the GMC. This committee will have an outside chairman and it will hear appeals from overseas doctors against refusal of full registration or refusal to grant a further period of limited registration or withdrawal of limited registration.

The Bill is no longer a short first-stage measure. It is considerably longer than it was on its original introduction. The reason is that a consensus on the additional provisions has developed more rapidly than at one time was thought possible, and we want to meet that consensus in full. I hope that, during its passage through the House, the Government and the Committee will be able to make the Bill even more comprehensive.

The only outstanding major issue, which was covered in the Merrison Report, is the question of specialist registration. The Merrison Committee thought that there ought to be three clearly recognisable stages of education—under-graduate, postgraduate or pre-registration, and specialist.

Unfortunately, the suggestions made by the Merrison Committee concerning specialist registration have given rise to acute controversy in the medical profession. Therefore, it is not possible to proceed at this stage with those proposals.

Specialist registration raises legal difficulties with regard to our position in the European Community, and is therefore a matter for further consideration at another stage. The Bill will be an effective measure for helping to secure and maintain higher educational standards. It is a measure agreed by the profession and the General Medical Council.

10.56 a.m.

Dr. Gerard Vaughan

I should make clear at the outset that there is so much agreement among the main parties over this Bill that I am able to speak briefly today.

The Bill follows very closely the recommendations of the Merrison Committee. It is a great tribute to Sir Alec Merrison that not only was the Committee's report unanimous, but since then, its recommendations have been virtually universally accepted by the medical profession. This makes our task relatively simple today. We shall do all we can from the Opposition Benches to support the Bill's passage through the House.

That does not mean that we shall not have a number of questions to put to the Minister and will not suggest some improvements that we should like to see in the Bill. I should tell the Committee that the Government have met virtually all the main points that we have already put to the Minister. I thank the Minister for his co-operation in this matter, and for circulating the notes on the clauses from him Department, which will be very helpfuly to the Committee.

I thought it might be generally helpful in speeding up the progress on the Bill if I mentioned the broad areas which still concern us. We are still worried about the size of the GMC and that some of the members will have insufficient work to justify a body of this magnitude. We entirely accept that it will be a much more democratic body than at present but even so we shall want to be sure that all the main sections of the medical professions are properly represented on it.

We are still left with the thought that 98 members is an awful lot of people and the body will cost a lot to run and to service. Who will pay for it? At present the whole cost of the General Medical Council falls on the medical profession. It has been suggested that the Government should pay part of the larger new bill, but that could mean that the new GMC will lose some of its independence. The Merrison Committee thought it extremely important—and we agree—that the new GMC should be a completely independent body. We ask the Government what they have in mind for the financing of the new body and, if they suggest paying part of the costs, we ask how it will remain independent.

We are concerned also about the open-ended nature of the Bill. So much is to be left for the new GMC to be decided by Orders in Council. We believe that Parliament should hesitate several times before giving total freedom in this matter. We want to be sure that there are adequate safeguards against abuse.

I remind the Committee that when the Bill was introduced in another place and the question arose of leaving all this to be decided in the future, it was said that this would be an infinitely simpler procedure than continually returning to Parliament. We accept that entirely, but we shall want to be sure that parliamentary responsibility and control is exercised.

That brings me to one of our other concerns. When the Bill was introduced in another place it was a very simple, short, enabling Bill setting up the new GMC and also the health committee and really no more. The rest was merely technical details. It was intended that the remainder of the Merrison recommendations should come later. We understood that there was to be another Bill within a year. We wish to know what the position is now, and whether there is to be another Bill on specialist registration quite soon.

Thanks to the way Lord Hunt presented his case and certain amendments in another place—we should all congratulate him on his work—the Bill before us, as the Minister said, has been changed into something far more significant than was originally intended. But it still does not include all the main Merrison recommendations on specialist registration which would bring us into line with the rest of the EEC. We should like to know more about that.

I shall not go into much more at this stage except to say that the old General Medical Council, if I may so call it, was primarily set up to safeguard patients from doctors. The new General Medical Council will have the task of protecting doctors, too. The health committee proposals are part of that.

It is not generally realised how restricted was the old GMC in giving advice. For example, I was involved in the case of a 14-year-old girl who was pregnant and wanted to keep her child but whose parents wanted the pregnancy terminated. The GMC and the BMA were unable to give direct clear advice on what the medical profession should do. The GMC said that it could not give an opinion on what was the ethical course until action had taken place, which was an unsatisfactory medical situation. But the new body will be able to give guidelines and advice before the event.

Mr. A. J. Beith

I am most interested in what the hon. Member says. I do not want to go into the specific case, but I invite him to suggest what kind of advice the new-style GMC would give in a case of that kind.

Dr. Vaughan

That is one of the matters we shall want to discuss when the Bill goes into Committee. The wording of Clause 5 still seems to us vague and unsatisfactory.

There is also a division within the new structure between the committees dealing with negligence and misconduct and the committee dealing with health. The Minister said that there is to be a signposting, steering preliminary committee which will decide to which part of the GMC cases will go.

We are rather concerned here. A preliminary committee may suspend a doctor for two months, which could totally ruin his career. We should look carefully at the safeguards for a doctor in those circumstances. We shall also question the confidentiality of these committees.

Finally, there is the question of registration and the status of doctors who trained overseas. The Government have given some idea of the lines they will follow, and I hope that the Minister will let us have as quickly as he can the wording of the amendments he has in mind.

We welcome the Bill. We believe that it will bring to life a very important medical body. It will be far more democratic than has been the case in the past, and it will have powers to ensure proper general standards of medicine in this country. We shall do our best to support it.

11.4 a.m.

Mr. A. J. Beith

We in the Liberal Party join in the welcome that has been given to the Bill. Comments from both Front Benches indicate that the old proverb is untrue; a rolling stone does gather moss, and this has gathered quite a bit in the course of its gentle roll through one House so far. Our proceedings here indicate that it will have a fairly gentle roll through the House of Commons, too.

Perhaps because we are in the relative obscurity of the Second Reading Committee, the wider context of argument and dissent about the National Health Service seems to have left us undisturbed and unaffected in this quiet upper corridor. The public might find it difficult to understand that we are able to debate a measure of reorganisation without pausing for breath and wondering whether we dare reorganise anything further in the National Health Service, considering to what extent the responsibility of doctors has been undermined by the reorganisation that took place a few years ago.

In this case, the consultations that have taken place and the very nature of what we are trying to do—to reform the body by which doctors govern themselves, to a large extent—indicate that we are on sounder lines. We welcome both the original provisions of the Bill and some of the additions.

It is particularly valuable that separate provision has been made for dealing with the problem of sick doctors so that there will be a procedure available and, perhaps, more readily used, for dealing with cases where a doctor is unfit to practise and is clearly a danger to the public. This problem should now be handled with the sympathy and understanding appropriate to someone who is genuinely sick rather than with the full rigour of disciplinary procedures which are more appropriate to cases of deliberate misconduct.

We think it sensible to sort out what has now become an anomaly in medical matters in the relations between this country and the Republic of Ireland. It seems a natural corollary of both the existence of a separate State and our EEC relations with the Republic of Ireland.

I welcome what has been said this morning about overseas doctors. We shall look at the new Government amendments with great interest. It is satisfactory that, with the Bill going through the House, consultations have none the less been able to make considerable further progress, enabling us to expand the Bill in that important direction.

I have merely two problems to refer to, and one has already been mentioned by the hon. Member for Reading, South (Dr. Vaughan). Before going much further with the Bill, we must have a clear idea of what the end cost is to be for the doctor. Doctors are entitled to know what the effect on retention fees may be and to have an assurance that the mere size and extension of the work of the General Medical Council will not involve them in further bills which, however the Minister may say they can be met through practice expenses, never seem to appear in the opposite column of the double entry book-keeping at the end of the day. I think that doctors are genuinely concerned about the cost implications of this proposal. If, indeed, this is to be offset by help from the Exchequer, we need to know the implications of that.

The second problem concerns the very introduction of Clause 5, to which my noble Friend Lord Winstanley made considerable reference in another place. I intervened in the speech of the hon. Member for Reading, South because of my concern on this point. We must pause and think carefully about what is involved in inviting and encouraging the GMC to make general statements and give general advice on issues of medical ethics. The very case to which the hon. Member referred vividly illustrates that.

It is not clear to me why the GMC should be able to make a professional judgment which the doctor himself ought to be able to make. Nor is it clear why the GMC should be invited or encouraged to make much wider judgments with far-reaching implications in cases on which Parliament or the courts ought ultimately to give a judgment.

Dr. Glyn

The case raised by my hon. Friend the Member for Reading South, was a complicated legal one, as I understand it. He was suggesting that what was required in such circumstances was a clear decision on the law, because not just one law but several are affected. If the GMC could have got its lawyers to give some advice, I think that my hon. Friend would have felt much happier.

Mr. Beith

Yes. For the GMC to put at the disposal of practitioners the advice of its lawyers is one thing, but, as I said, the wording must be considered carefully. If the invitation is for the GMC to make a pronouncement on the law, that will be of no help to the doctor because, at the end of the day, the courts could decide in a way contrary to the GMC's advice.

That is why I was puzzled when the Minister used the phrase "give it legal cover" in his opening comments. I think that he simply meant that the Bill would give the GMC the statutory right to make statements of this kind. It would be a misrepresentation to suggest that the GMC could in any way override or do away with the courts' responsibility in these matters. There is a world of difference between the quite genuine function which many professional organisations perform in simply supplying a legal advisory service to their members—advice which a local solicitor might give but which might be much better given by a lawyer retained for his professional experience in a particular field—and giving indications about directions in which the law ought to go, whch is a matter for the courts and for Parliament.

We must look at these provisions carefully. There may already have been some second thoughts about the rightness of giving to the GMC responsibilities which could ultimately conflict with those of the courts and of Parliament. I hope that, as we discuss the Bill in its later stages, we can clear up that matter.

11.11 a.m.

Dr. M. S. Miller

I always feel that we should take care when we are dealing with the rights of the medical profession. I do not see the responsibility of the medical profession in these matters as the total responsibility, or the only responsibility that matters. Primarily, the doctor's responsibility arises at the point of contact with his patient. The doctor, in my opinion, has only a specialist voice in the responsibility for policy matters. He has not necessarily the whole controlling influence over any of those matters. I do not think that he should have complete responsibility for action.

Indeed, I may say without wanting to inject a note of bitter controversy into the debate, that any medico-political matter which receives the unanimous approval of the medical profession fills me with a certain amount of fear. It means ipso facto that once again the consumer, the patient, is left out in the cold.

I want to make one or two points about some of the clauses in the Bill. On the constitution of the GMC, I suppose that we have to have some kind of organisation with control of a certain kind over the medical profession and that, if we have it, it is better that there should be on it more elected than nominated people.

I think that I speak for everyone in the Committee when I say that we support the democratic principle of election. The trouble is that this election of members has a kind of phoney air about it. It is a highly selective electorate that will elect members of the GMC—the medical profession, and only a tiny proportion of the profession at that. I assure the Committee that the vast majority of general practitioners will not get a look in, and if any of those elected enjoy the humble status of a GP they will have to devote almost their entire free time to medical politics. Indeed, such a person will have to devote even more than his free time. He could be passing off some of the medical work that he should be doing in order to be involved in medical politics.

I believe that we should be considering—though I appreciate that it is more of a Committee affair than a Second Reading matter—the possibility of electing to the GMC some representatives of the public—some consumers—not nominated, but elected. However, I shall let that pass for the moment.

Let me say something about language requirements. This fills me with a certain amount of fear. Many doctors come from the Commonwealth—the new Commonwealth as it is called—where English is the language in which they learn medicine. If there is no longer any reciprocity, these doctors will be at a disadvantage.

In addition, it seems strange to me that our obligations to our EEC partners mean that we put doctors coming from France, Germany, Italy, Belgium and so forth in an entirely different category from doctors coming from India or Pakistan. I can think of examples of doctors coming from Pakistan or India, or other parts of the new Commonwealth, who do not speak English very well but who speak it no worse than do French doctors. Yet the French doctor has an advantage. The interesting thing is that Indian or Pakistani doctors could find a ready-made practice in this country with people who speak their language. But there are very few people in this country whose sole language is French, Italian, German or Dutch. I find this worrying because again it seems that we are discriminating against one section of the medical community because of the colour of their skin. I am sorry to have to bring in this aspect, but this is what it appears we are doing in order to try to close the door to the immigration of doctors from the new Commonwealth.

I turn now to the subject of medical education. I confess immediately to being somewhat out of touch with the present state of medical education in this country, in relation to the curriculum. I suspect that it is not all that different from what it has always been. I suspect that it is oriented more towards the development of the specialist than it is towards the development of the generalist.

Medical education should take cognisance of a state of affairs which we have had 30 years to observe in this country since formation of the National Health Service—namely, the ever-increasing prominent part the general practitioner is playing in our Health Service and, indeed, the ever-increasing part that he ought to be playing in our Health Service. I submit that the curriculum when it is set up should take this into account. The worse thing that could happen to medicine in this country would be to allow general practice to degenerate into the pseudo-specialisation of continental Europe. The GP is the first point of contact that the public have with the National Health Service. Indeed, for most people he is the only point of contact.

I can see a situation developing in this country where, if we paid the GP what I think he ought to be paid, we would get such an influx of the best—if I may use the term—of the medical profession into general practice that no one would want to go into the specialties. That is where it should begin. That is where the best doctors should be. This is a little wide of what we are discussing this morning, Mr. Bonner Pink, but I submit that it is relevant to the full field of medical education. Since medical education is part and parcel of what is being done by the GMC, there is a certain relevance in it this morning.

I do not think that there is any disagreement about these matters. It is merely a question of the niggling doubts that some of us have about these matters. I think these are matters which we could take up in Committee in order to try to smooth out some of the rough edges and to try to get some assurances which were not implicit in what the Minister said this morning.

11.20 a.m.

Mr. Michael Morris

I am not sure whether in this Committee one declares an interest. I think perhaps I should, being married to a practising general practitioner.

There are two or three points which are worth airing on Second Reading. I come as a layman to this matter, and I share the concern raised by hon. Members about the General Medical Council consisting of 98 persons. As I understand it, that is not the absolute number. Indeed, it can be greater than 98. I wonder whether in Committee we ought not to consider putting an upper limit on it, rather than leaving it open-ended.

Certainly, I shall want to question the need for any form of branch council At the moment there is a natral inclination in the House that anything to do with this country immediately has to be devolved to the four parts of the United Kingdom. If there is evidence that branch councils heretofore have played an important role in the control of medicine, I shall be willing to listen and be converted. But it appears from my observations that branch councils have been fairly moribund, suggesting to me that there will be no great impetus to change their role in the future.

Hon. Members who raised queries on Clause 5 were right to do so. We in this House are sceptical of guidance from bodies of one kind or another. But in this case I believe that there is a need for guidance to be given or for a view to be expresed on some of the difficult areas in medicine, albeit that the final decision must rest with the practitioner to do what he or she thinks appropriate. But it will certainly help medical practitioners to know the view of their governing body so that that view may be used as evidence should the matter go to court.

In Committee, we should look in some depth at the fitness to practice committees. I welcome the differentiation between health and professional conduct. All of us who have had contact over many years with the medical profession know sad cases where health has been impaired. It is right to differentiate between health and professional conduct and to treat the matter with sympathy and understanding, both for the protection of the patient and in the interest of the doctor.

I am concerned about the lack of appeal procedure in relation to the preliminary proceedings committee. My hon. Friend the Member for Reading, South (Dr. Vaughan) made the valid point that if a doctor got to the unfortunate situation of a hearing at the preliminary proceedings committee and was later completely cleared, there would be a long-standing smear on that practitioner. It requires a person of great resolution to survive that experience.

There is a case for differentiating between health and professional conduct on the question of an appeal. On the health side one should perhaps take the view that there should be no right of appeal. If the matter has got that far, it is obviously serious. But on professional conduct, we may wish to consider in Committee the possibilities of having an appeal.

Although I have read the education clauses three times, and although I was assisted by the Minister's notes, I confess that I remain a little confused, particularly with regard to who would have the final say if the education committee put forward proposals which were not in keeping with the general views of the elected members of the GMC. I raise that subject as one who sat on a university council where, at certain stages, there were difficult relationships between the senate and the council. I sat on the council of the City University in its formative years, and thankfully the problems were resolved in the end. However, it can be a very contentious area, and we should make clear who controls what.

The Minister has assisted us this morning on the subject of registration. It is a pity that we cannot see the Government's new proposals in detail. Hon. Members will want to look hard at those new proposals. I have worked overseas—as has my wife—and I share hon. Members' concern about discrimination. Clearly, language is important in medicine, whether one chooses to practise in this country or overseas. But we should recognise that there has to be a fairness of approach.

The other aspect—I do not know whether it comes under registration or education—is that another pre-requisite before final registration of overseas doctors should be a course in drugs. There are all too many examples of an unfamiliarity with prescribing in one country or another, because there is no procedure for education or teaching doctors from overseas.

Finally, I shall want to look at Schedule 1. It is probably not sound to have a simple majority in relation to decisions of the Council. If the Council is having a contentious argument about some aspect of its affairs, it is probably not right merely to have a simple majority. We have seen in our debates on the Floor of the House that there must be safeguards. If it is a matter on which there must be a vote, I should have thought that a two-thirds majority is a sounder way forward, rather than a simple majority.

Generally, I welcome the Bill and look forward to taking part in the Committee proceedings.

11.26 a.m.

Mr. Laurie Pavitt

In my experience 95 per cent. of health matters are matters of consensus. Of all the Bills coming before the House, this Bill is even more than usual a consensus measure. It has received a welcome from all sides and most of us wish it a very speedy passage because even if it receives a speedy passage, it will take about two years to bring it fully into effect.

I therefore join the hon. and qualified Member for Reading, South (Dr. Vaughan) in welcoming the Bill and speeding it on its way. We shall not delay the Committee too long this morning.

Like my hon. Friend the Member for East Kilbride (Dr. Miller), I immediately had the same political reaction as the hon. and qualified Member for Reading, South when he pointed out the complete unanimity of the medical profession. My political hackles automatically rise and I wonder what is the catch if all the medical profession are so much in favour. My hon. and qualified Friend the Member for East Kilbride (Dr. Miller) made the point much better than I could that of course we should be concerned—as, indeed, is the Bill—with the rights of the patients. All too often we lose sight of the fact that such a Bill is not for the benefit of the doctors, but to help look after patients. From time to time in our debates we find ourselves dominated by the professional opinions and advice being given by the medical profession.

I do not want to go much further than my hon. and qualified Friend the Member for East Kilbride in the problems that arise in relation to different specialities. The hon. and qualified Gentleman is a well known consultant, on the one hand, and my hon. and qualified Friend is an ordinary GP on the other. As the unqualified one in the middle, I am not prepared to go very far into the way the Bill affects those two sectors.

I accept on the educational provisions that it was very much the primary care of the general practitioner that for years was supposed to be the front line of defence. But invariably the general practitioner has found himself at the rear when it comes to the way in which legislation is brought forward.

We shall all be looking forward to the Committee stage, particularly with regard to Clause 15, to see how medical education can best be distributed.

I join with the hon. and qualified Member for Reading, South—you must forgive me, Mr. Bonner Pink. I am getting fed up with "hon. and learned" and "hon. and gallant". When we have doctors on the Committee, at least we should recognise that they are qualified.

This Bill enables us to express gratitude to Lord Hunt. I join the hon. Member for Reading, South in saying that he did an excellent job. The Bill has been transformed as a result of what Lord Hunt said in the other place. It has been to our benefit that a good deal of the debate that took place elsewhere, and the acceptance by the Government of some of the provisions that were put forward, have strengthened the Bill.

The Bill implements the Merrison report and is long overdue. We all recognise that; we know the problems. The Minister said that there would be a short Bill to start with and that major provisions would be introduced when we reached the controversial stage. We are grateful to the Minister for providing notes on the Bill, and it would be helpful if, before we reach the Committee stage, there could be a memorandum for lay Members which will bring forward, in some logical arrangement, the kind of matters left out of the Bill even though the other place has included some of them and which would indicate what might be included in a subsequent Bill. Many hon. Members may wish to table amendments in Committee. However, we do not wish to delay progress by moving amendments on this Bill if we can be sure of being able to table them subsequently. However, if we cannot be sure of getting them later on there will be a series of Merrison-type amendments which would delay the Committee stage.

I join my hon. Friend the Member for Ealing, North (Mr. Molloy) in showing considerable concern—we have had discussions elsewhere—about the difference in treatment of doctors coming from the new Commonwealth and elsewhere, and those from Common Market countries. The matter has been helped by changes to the Bill in another place, but there is still disquiet. It would be unacceptable if, through our membership of the Common Market, doctors from the British Commonwealth, who have been part of our family system for generations, were disadvantaged compared with those from overseas. The crucial question here and in Committee will be on temporary times. We shall be looking at timetables and we may wish to table amendments to bring the two things more into line. It is a tragedy that the directive of the Common Market, giving free mobility to professional people, including doctors, over-rides anything that we do here. It is one of the tragedies of the Treaty of Rome that, even though the House of Commons may decide on a different procedure, it has no power to alter it in relation to decisions being made by the EEC.

There is a provision relating to one member of the EEC, the Republic of Ireland. I know that all members of the Common Market are equal, but some have to be more equal than others, and Ireland has a special relationship. For years we have benefited from the highly qualified doctors that have come to this country, supplementing the number of medical practitioners that we need. However, I should like further information from my hon. Friend on what the situation is likely to be as a result of this Bill becoming law compared with what I believe to be, although I may be wrong, the 1976 provision relating to Irish doctors. Perhaps my hon. Friend will explain that.

I should like to raise the question of the professional conduct committee and the way in which advice can be tendered. It is a good provision because, instead of a doctor being allowed to practice or not, guidance can be given at an earlier stage and some of the earlier blunt decisions may be averted. Would my hon. Friend also deal with the problem of the age of doctors, and how the Bill will affect that. At the moment a doctor in general practice may not practise after the age of 90.

It may well be that there are many knowledgeable nonagenarian medical practitioners, but there can be an imbalance here. For example, the average size of a general practitioner's list in the North is about 2,900 whereas in Bournemouth it is 600. Quite a number of elderly doctors who desire to retire and keep their hand in, supplementing whatever pension they get, might find it more salubrious to practise in Bournemouth than in Stockton-on-Tees or some other place in the north of England.

Therefore, in terms of the length of time that a general practitioner may practise, I wonder whether the General Medical Council will have any way by which, apart from questions of sickness or incompetence in dealing with patients, some limit could be put on the age to which practitioners may continue.

On the question of the cost of running the enlarged Council, I am inclined to agree with my hon. Friends who have said that a system of election is always preferable to appointment. The appointee is usually the person who keeps his nose clean, who is very much on the side of the Establishment and whose presence is accepted. But reforms and changes in committees and councils are often effected not so much by the conformists as by the rebels who are prepared to speak up, and the latter are more likely to be members of bodies which are so much part of the medical establishment within the General Medical Council if they are elected, as the Bill provides.

Nevertheless, the problem of the size and the extra cost involved are germane to our consideration of the Bill. The Committee will recall that a few years ago there was a pay strike when a number of doctors decided that they would not pay their fees because they felt that the increase was too much. As I understand the position, in the main it does not affect the basic income of the doctor because his fees paid for various things are allowed for in general practice, as practice expenses. Therefore, if a doctor pays out fees on the one hand, in a few years he will get the money back because the amount that the Review Body will give for remuneration will enable that amount to be reimbursed to him.

However, there is a difference here between junior hospital doctors and doctors in general practice. The way in which the remuneration is set is different. Perhaps my hon. Friend the Minister of State will deal with the question whether the enlarged fee will mean that one section of the profession is disadvantaged against another. If that is so, one might seek to put down amendments in Committee.

The only other matter I wish to raise applies to the way in which overseas doctors may practise here. Again, it is affected by the speciality in which they are practising. There can be a vast difference between a surgeon coming from Bonn or Paris and performing an operation in one of our teaching hospitals and going back again—leaving home early in the morning and being back in time for tea in the afternoon, exercising a right to practise which could be an aspect of competition which our consultants might not always welcome—and a person who intends to set up practice here and take a contract with a hospital for a period, or become a community physician or a doctor in general practice.

I am extremely concerned that in Italy there are twice as many doctors as we have and the failure rate on international examination is 60 per cent. compared with 6 per cent. here. This could mean not just that we could have a large number of Italian doctors settling here—I do not think that that is so—but we could have a large number of doctors moonlighting for specific short-term appointments which may or may not be to the advantage of the National Health Service, from both the patients' and the doctors' points of view. I hope that that aspect will be considered when we reach Committee stage.

I welcome the Bill. I hope that Clause 15, the education clause, will at long last facilitate some vital changes in the medical curriculum. It is said that it is more difficult to alter the curriculum of the medical faculty than it is to get a camel through the eye of a needle.

Certainly, the Todd Report is very much older than the Merrison Report and, although some reforms have gone through. I echo what was said by my hon. Friend the Member for East Kilbride (Dr. Miller). The amount of general practice included in teaching a doctor to do his job is still woefully inadequate compared with the amount of training a person is given to be a hospital doctor. Yet it is the general practitioner who has the greater responsibility on his shoulders.

I hope that out of Clause 15 will come not just the setting of standards by the General Medical Council but much greater provision for it to make not just suggestions but vital changes. For example, in the pre-registration year, for one year, the idea of just six months' surgery and six months' medicine could well be altered to some advantage. In view of the large increase in, say, psychiatric medicine and the way in which obstetrics play an important part in general practice, I wonder whether, instead of their being part of a six-month or one-year pre-registration period, there could be basic changes in certain areas which would be to the benefit of the patient.

I look forward to the passage of the Bill through the Committee. I feel sure that all parties will give it their full support.

11.42 a.m.

Mr. David Crouch

The Bill both when it was in the Lords and as it now comes before us, together with the Merrison Report, has concentrated the mind remarkably on considering what the GMC is. As someone who has worked as a layman in the National Health Service for the past seven years, I confess that I had never given very serious thought to the exact position of the GMC.

We were reminded this morning by the hon. Member for East Kilbride (Dr. Miller) that the Bill may not go far enough in recognising the place of the public in health care and health provision. The Bill is very much a medical Bill—a Bill for doctors and consultants—for the medical profession. It is designed not just to set up a new constitution for the GMC but, as it were, to safeguard the GMC, and there is not enough, in my opinion, about safeguarding the public.

After all, 120 years ago, the Medical Act 1858, which established the GMC, made quite clear what the GMC was being established for. The first requirement was to safeguard the public. The second was to establish and create for the first time a register of doctors, a system in which we gave the lead and which was followed throughout the world. Third, the GMC was given power by Parliament to take disciplinary action.

In reading the debates in the other place and hearing the discussion this morning, I was interested particularly in the questions that arise on Clause 5, namely, the power now to be given to the GMC not just to take disciplinary action but, in a wide and general sense, to give advice.

I have never seen a clause so generally and widely worded as Clause 5. I am not a draftsman or lawyer—I shall learn as we go along—but, as I read it, it gives open-ended powers to the GMC. I am not against Clause 5, but I am concerned about it. It is necessary that doctors should be able to get advice from time to time regarding what could be considered correct or incorrect behaviour—or even infamous behaviour, though they will probably always know what infamous behaviour is—and there must be some occasions when being unsure of the dividing line between proper and improper behaviour holds them back from something which might make a valuable contribution to medical knowledge.

For example, the publishing of a paper might be determined by the Council at some later stage to be advertising on the part of the doctor. But too late—already he has been summoned to the GMC, not just to be told off but to be struck off.

In the other place, Lord Gardiner, speaking from his long experience as a lawyer, said that, of course, it was not so bad for lawyers. Lawyers could go to the Bar Council. They could go to others and say "Will this be all right? Can we have a little advice?" Guidance can then be given before any error is made.

Even in our profession as politicians, we know that we can go not only to qualified but sometimes to learned Members of the House—to lawyers—and say "I wonder whether it will be all right if I speak on television on this matter." "Be very careful", we are sometimes told, "because you might be in contempt of court", or even "You might be in contempt of the House". We can get advice.

Doctors must find this situation arising more and more as they are more and more in the public eye and are more and more using the media. We shall hear more about this, I hope, in Committee. I do not intend to penetrate too deeply now into the subject, but there still seems to be a reluctance in the medical profession, from the existing GMC, perhaps from the Royal Colleges and other learned parts of the profession, and even from the BMA, to allow advice to be given as I think it should be given. A doctor can still ask the GMC for advice, but he may end up with the GMC saying "If you do something wrong, we will tell you off. We may even strike you off." That rather worries me.

However, I confine my observations today to saying that I am sorry the Bill does not go as far as Sir Alec Merrison and his Committee recommended, unanimously and so strongly, on two matters. The Merrison Report was, after all, welcomed by medical opinion up and down the country, and the medical Press gave it a very good reception. The Secretary of State, too, gave it a good reception last July. Representation has been improved, which I welcome. But I am not quite clear what those 98, and possibly more, members will look like. I should like to think that the rank and file doctors will have a much bigger representation. Sir Alec Merrison recognised in his report that the GMC is at present somewhat remote, out of touch and out of date. Those were the very words that he used.

Clauses 1, 2 and 3, we hope, put that right. I am not sure where the Bill specifies, as Merrison advised and recommended, that young doctors are to have a voice, but perhaps this will come out as we consider the Bill. I hope that young doctors, qualified over a number of years, will have a voice. We know that the Bill provides for an age limit of 70, which I welcome.

Mention has been made this morning of the size of the Council. Ninety-eight members is an enormous number. I know that we are saying that we want to let in all types of persons, including lay members, university representatives, persons geographically representing the country, and so on. But 98 is a very large size. Whenever I talk to members of the CBI about its Grand Council of 200 members—which is admittedly twice as big—they say "You can never get your voice heard. There is never time". I am concerned here not about all the 98 members of the GMC, but about who will be shaken to the top, and who are the top 10 who will really make the decisions. I should like to think it possible to imagine—but it is almost an impossibility, I think—that all 98 will have a fair hearing.

I am a member of a regional health authority. The previous Secretary of State, the right hon. Member for Blackburn (Mrs. Castle), increased the numbers sitting on regional and area health authorities. Today, I believe that they are cumbersome and unwieldy, and that when there are more than 30 persons sitting round a table it is not as good as when there are 15.

I must confess to my hon. Friend the Member for Reading (Dr. Vaughan), who leads us so admirably on this side—and to the Minister, who, I am sure, will lead his own team admirably, too, for there is not much dispute here this morning—that I am intrigued by this Bill in all its dimensions. But, above all, I continue to be intrigued—I have had my eyes opened—by the relationship between the GMC and the general education of doctors at various stages in the profession.

I am intrigued by the relationship which has grown up between the GMC, the universities and medical schools and the Royal Colleges in connection with education. It has lasted very well. I do not say it is not working well. Who am I to say that? I am not in the profession. However, here is a Bill which must be concerned with seeing whether the relationship will work well in the future. I understand that it has worked well in the past, but is the Minister satisfied with this relationship? If not, now is the time to speak and to adjust. The Minister has had plenty of opportunity to seek advice throughout the profession and bodies such as the GMC and the BMA. The relationship has worked well and has had a good history, but is the Minister satisfied that the relationship has a good future with the new constitution on educational responsibility? We shall not have another medical Bill for many years.

There are two major omissions from the Bill concerning overseas doctors and the strong recommendations for a specialist register. These omissions seem to indicate a reluctance on the part of the Government—or perhaps it is just reluctance on the part of the profession which is being reflected through the Government and the Minister—to take a step further down the road to democracy in the National Health Service, and not just in the National Health Service but in the whole of health provision in this country, because the medical profession is concerned not just about one side of the health service but about the private sector as well.

It suggests to me that the Government are hesitant, that they have had some questions put to them by advisers and that the very strong recommendation made by Merrison regarding specialist registration has been turned aside for all sorts of reasons. I do not think that they can be hesitant. I do not know to what extent the Press will report our deliberations, both today and subsequently, but I should think that the public would be very concerned.

The public were concerned to have their interests safeguarded by a register of doctors 120 years ago. Surely there is a very strong case for a register at the far end of the scale in the medical profession, of the specialists. After all, the National Health Service does have a type of register, but it does not go far enough, and I think that it is accepted in the medical profession that it is not the National Health Service which should be setting these standards, but the GMC at the pinnacle of the profession. Does the hon. Gentleman agree?

Dr. M. S. Miller

I agree wholeheartedly with the hon. Gentleman that the responsibility for setting standards lies with the medical profession. It is not the responsibility of anyone else, and the medical profession itself must not take the blame for what is happening in the Health Service.

Mr. Crouch

I am grateful for that observation. It does not really differ from what I was saying.

The other omission concerns the problem of overseas doctors. It is not just a question of language that is involved, it is sometimes a question of standards. I quote briefly from an article in the British Medical Journal on 26th April 1975, at the time of the publication of the Merrison report, on the performance of the overseas doctor who carries out such a valuable service in our Health Service and, as the article says, fills a very real gap. The article states: Measured on their performance in postgraduate examinations these doctors have lower average standards than British graduates; out of 1,000 candidates for the MRCGP examination (essentially a voluntary test of competence) the pass rate for doctors from the United Kingdom and Ireland was 82 per cent., but for the others—mostly from India and Pakistan—it was only 21 per cent. It goes on to say that there is no doubt about the contribution that they make. I am sorry, too, that the Bill does not seem to take care of that point. It is a very real one.

Mr. Molloy

Is not it much more important for the Bill, if it could, to ensure that the real ethic of the National Health Service was applied, and that those brilliant men and women in consultancy should not put up a bar against someone who needed their services, purely on financial grounds?

Mr. Crouch

I am not quite sure what the hon. Gentleman is driving at there. Whether or not he wishes to elaborate. I do not know. But perhaps we shall have an opportunity to further it when we are in Committee, and hear his views on that subject.

The Bill does not seem to recognise sufficiently the concern of the public that our health care and medical standards should be improved and safeguarded, and seen to be improved and safeguarded. The public have been brought into the act by the National Health Service Acts. By recent health service legislation, we have today community health service councils. The public are very much aware and taking part in decisions to improve our health care and health provision.

We have a considerably enlarged membership of health authorities—not just at random nomination, but by the nomination of elected members from local government authorities. I feel that this Bill, concerned as it is with medical standards, has ducked the issue and forgotten that the public are looking at it. They are concerned about health provisions in this country, and concerned about medical standards. Perhaps as we go through the Bill we might bear this in mind.

I sensed as the Minister was talking this morning that he had wanted to go along with Merrison on the question of overseas doctors and on the specialist register, but that he had run into difficulties. I reiterate, the GMC has existed for 100 years as a safeguard to the public.

Mr. Moyle

I do not know whether the hon. Gentleman is under a misapprehension, but possibly I did not express myself sufficiently clearly this morning. The Government intend to introduce amendments to the Bill in Committee to improve the arrangements affecting overseas doctors.

Mr. Crouch

I am grateful to the Minister. I did not take that on board when he was talking. I am glad that he has made that further correction. I welcome the Bill and I look forward to having my eyes still further opened about the functions of the GMC. Above all, I hope that we will not forget that we are here as Members of Parliament in considering this, to do what the GMC itself was required to do when it was set up—namely, to safeguard the public all the time.

11.58 a.m.

Mr. Molloy

I do not intend to hold up the Second Reading to any great extent. I was delighted by the intervention made by my hon. Friend. If he had not made it, I intended to ask him about it. Though I believe he said earlier that it was the Government's intention to introduce an amendment to remove what is a patently obvious distasteful discriminatory measure against overseas doctors.

If one is a Common Market doctor, one can come here straightaway. It is quite all right. One even has six months in which to learn the language. But if one is a British Commonwealth doctor or any other overseas doctor, one has to take the language test immediately. It is in this regard, as I pointed out to the hon. Member for Canterbury (Mr. Crouch), that I want to clarify what I said in my intervention.

In my ethic of the National Health Service, I see nothing good whatever in any brilliant doctor from any part of the world coming here, passing the language examination, having standards of which both I and the hon. Gentleman would approve as being superb, and then spending most of his time in private practice to make money out of those high standards. I can understand the need for some form of qualification. To ensure that certain standards are maintained we have to see to it, I suppose, that language qualifications will enable both the doctor and patient to be able to communicate one with the other. But, at the same time, I welcome this provision in one respect.

I am one of those who believe that only when we have a worldwide free, comprehensive health service instead of NATO or Warsaw pacts or things to blow up, destroy, maim, blind, kill or obliterate will we really have put sanity on the agenda.

It would be wrong for me to put Committee stage points, as you will tell me, Mr. Bonner Pink, but a previous speaker has mentioned the role of community, area and regional health councils. One cannot see in the Medical Bill any correlation between its aims and objects and those of other organisations that we have established. I am bound to say in parentheses that we seem to go on establishing all sorts of organisations and adding more and more to the Health Service except the real quintessentials that are required from the Health Service—that doctors and hospitals can treat people who are ill.

However, we have community, area and regional health councils whose primary job is, when they have a serious complaint, to write to the MP or to a group of MPs. We all know this. Therefore, I have a request to make. I do not want any more letters. The prime job of CHC's, AHAs, RHAs and all the vast number of people who sit on them, when they hear of a problem from someone in a particular area—a tricky problem involving a complaint against a doctor, or whatever it may be—seems to be to work out whose constituency he resides in so that they can find out to which Member of Parliament they can send the complaint. I ask my hon. Friend to indicate in Committee whether he can find some hanger for this submission, so that we can discuss the possible relationship between the new GMC, with all its appurtenances, and the other bodies that I have mentioned for the purpose of submitting complaints, getting answers back, making suggestions, and so on.

Although, technically speaking, there may be no immediate relationship betwen the organisations that I have mentioned and the new GMC, I believe it inevitable that, at some stage, there will be a connection between the organisations already established and that anticipated in the Bill. I am aware that it is a matter that we should examine in Committee, but I would be grateful if my hon. Friend could give even the slightest adumbration that it may be possible for us to do so.

12.3 p.m.

Mr. Robin Hodgson

I, too, approach the Bill as a layman. As such, I have noticed that the curse of our modern age is the everlasting increase in administrative requirements and administrators —the point has just been powerfully made by the hon. Member for Ealing, North (Mr. Molloy)—the consequent everlasting increase in committees to look after the administrators and administrative requirements, and the way in which those parent committees spawn children called sub-committees and grandchildren called sub-sub-committees.

While that is in part a reasonable response to public demand for higher standards and improvements, it is a process that must be carefully watched over to ensure that increases are justified. My concern about the Bill is therefore in the broad context of the increase in the numbers of new bodies that are set up.

This is not only because it is not yet clear to me that that increase in number will necessarily lead to more effectiveness or to higher standards, but also, equally importantly, because there is the other side to the equation—namely, the cost involved—the cost to the doctor, the consequent cost to the National Health Service and to the patient.

The Explanatory and Financial Memorandum to the Bill tells us: The General Council will be put to some extra expense in servicing the increased membership … and in operating the new Health Committee. If this extra expense were to cause the General Council to increase the annual fee … the increase would be reflected in practice expenses reimbursed to general medical practitioners in the National Health Service and to that extent there would be an effect on public expenditure. The amount is not expected to be significant. We have heard of all kinds of projects which have gone through the House which were not expected to cause significant increases in expenditure but, when the time came, somehow the "insignificant" figure became a quite large one. I hope that during the Committee stage we shall have an opportunity to explore this in a little more detail.

That leads me to my second point. If the GMC is to be asked to work on an increased range of topics which are more complex and quite difficult—we have heard several speeches about the difficulties of Clause 5, which will undoubtedly require the GMC to have expert advice available—is there not some argument for the GMC to look to the Government for some support in this area?

I do not know what goes on in the EEC and how our partners there deal with this matter. Perhaps, again, when we come to the Committee stage, the Minister could say something about how the regulative authorities in Germany and France deal with the medical profession and whether the Governments are involved at all.

I entirely underline the comment made by my hon. Friend the Member for Reading, South (Dr. Vaughan) about the need for the GMC to remain independent of the Government. However, to some extent, the Government are asking the GMC to do some of their work in this Bill.

I have one other general point. Here, if I may, I shall use a medical analogy. I believe that the Bill is something of a skeleton in that there is a lot to be fleshed out by Orders in Council and by Statutory Instruments of one sort or another. When introducing the Bill in another place the noble Lord, Lord Wells-Pestell said: This Bill is mainly an enabling measure. It leaves the fine detail … to be worked out and he went on to say: It is also a flexible measure."—[Official Report, House of Lords, 29th November 1977; Vol. 387, c. 1150.] It is, perhaps, not an unworthy sentiment to try to get flexibility; to try to make it as easy as possible for the GMC to respond to changes in conditions—advances in medical technology, ethics and public morality. But on the other hand, we should bear in mind that we are here today—and this was the reason for Professor Merrison's report—because there was considerable disquiet in the medical profession about the activities of the GMC. I wonder whether we do not have a duty to ensure that, as far as possible, the areas which lack definition—the grey areas—are cut down and illuminated as much as possible.

Therefore, when we come to the Committee stage I shall certainly be seeking to find out from the Minister something more specific about the make-up of the General Medical Council. My hon. Friend the Member for Canterbury (Mr. Crouch) referred to the problems of handling large committees. Of course, if we have nominated members who comprise a significant body of that overall large committee, they will be a powerful force because they will talk with a united voice whereas the other elected members will reflect the far more vociferous and more broken-down body of opinion. It is possible that nominated members, because they will vote as a block, will have a power that far outweighs their actual number. Therefore, I think that it is important that we should be clear, if not about exactly how many members—there should be a maximum and minimum, perhaps—about the sort of proportions that are likely to be taken on board.

Second, there is the question of the elections in the electoral districts. Here we have a grave difficulty because the size of the constituencies must be great in relation to the number of doctors practising in England as opposed to those in Wales and Scotland. We have seen in our discussions on the Floor of the House in the Committee stage of the devolution Bill some of the problems that would come from a federal system where one part of the federal system was so much larger than the others.

The final point I make on the constitution question concerns the branch councils to which we have already referred. Once a council has been set up, or even promised, the possibilities of getting rid of it are greatly reduced, because once it is in being, it finds a reason for existing.

We already have a branch council for Scotland and that has existed in a nominal way, meeting once a year. There has been no particular demand for extension or expansion of its functions. It seems that here we may be creating and proliferating unnecessarily the committees that are involved in the Bill.

The only other point I wish to make concerns the education clauses which have already been referred to. As I said earlier, I am a layman, but I could make no sense of the clauses despite re-reading them. To a layman they are extremely vague. Co-ordination, composition, make-up of committee—all are left for Statutory Instruments or Orders in Council later, or for the GMC to nominate in the way that it thinks fit.

It is not clear how liaison will take place, particularly between universities and the Royal Colleges. They will have a definite interest in future medical edu- cation. I understand British medical education has a good reputation around the world and it is essential that we do not allow our reputation to slip away. On this Bill, which is obviously a rare event, we should take every possible opportunity to bring our educational standards, and the co-ordination and planning of the future development of medical education, as up to date as possible.

With those two main provisos concerning the increase in the complexity of administration and the way in which it has been set up and the educational standards and the future planning of medical education about which I have some worries, I, too, extend the welcome that other hon. Members have given to the Bill. I look forward to discussing it in Committee if it receives its Second Reading today.

12.12 p.m.

Mr. Robert Boscawen

I think that the hon. Member for Brent, South (Mr. Pavitt) will agree that it is a welcome change to have the consensus on both sides of the House that we have seen this morning. It is very different from the last medical Bill on which he and I were engaged for many months.

Nevertheless, this is an important occasion for the House because we are guardians of a good deal here that affects not only the profession but the public. We must ensure that the public's confidence in the medical profession and in the National Health Service is maintained and improved. It is a vital job that we are doing as Members of Parliament.

Second, we must ensure that we have, as far as possible, a contented profession. The fact that the GMC is being restructured for the first time for a great many years does not necessarily mean that it will be in any way more effective or more responsive to the trends and thinking of the medical profession than it was before. Therefore, to achieve a satisfied profession we must ensure that the new GMC will be a positive body giving a positive lead to its members as well as a fair body, bearing in mind the great power that it has in judging the conduct of the profession.

The Committee has shown that there are four or five particular issues about which it is particularly concerned and on which it wants a great deal more information. I suspect that there will be a number of probing amendments tabled on some issues. One issue which hon. Members are particularly concerned about is the question of any discrimination between the treatment of doctors from overseas and doctors from the Commonwealth. We hope that we can somehow engineer into the Bill equal treatment as soon as possible for Commonwealth immigrant doctors and doctors from the EEC. Nevertheless, I welcome the new system to do away with temporary registration by means of limited registration. I hope that we shall be able to go along with the Government amendments, when we see them, as we have been able to go along with the Government on this issue this morning.

An issue which worries my hon. Friend the Member for Northampton, South (Mr. Morris) is the preliminary proceedings committee, the question of appeal against its decisions, and whether a doctor's whole career might be affected if he were subsequently cleared. My hon. Friend has had great experience of the pressures on a family doctor and the feelings that exist. Being married to a doctor, no doubt, he can understand that better than other hon. Members can. He is fully justified in seeking a solution to this difficult problem.

One issue which has not been mentioned, but which was taken up by the Merrison Committee, is the anonymity of doctors who are brought before disciplinary committees. I hope that anonymity will be allowed in certain cases in the Bill. I know of cases that came before the executive councils, on which I sat for many years, when it would have been totally unfair to allow full Press publicity of proceedings when a doctor was being charged—in those cases—with breaches of his terms of contract, not with breaches of ethical conduct. Publicity could have meant total disaster for the rest of that doctor's life. I hope that a provision will be included in the Bill giving the GMC powers to see that for some proceedings the doctor's name should remain undisclosed.

The other major issue which came up this morning and which worries many of us is the size and composition of the GMC. The Government should explain why they have sought to double the size of the proposed GMC. The Merrison Committee gave a lot of consideration to the matter. Paragraph 387 of its report states: We consider it to be important that the GMC should be constructed so as to ensure that its considerable powers and duties do not pass to a very few members, still less to officials. The danger of a large committee of 98 people is that that is exactly what happens. The power passes to a small caucus of individuals and their officials and advisers, and the main body becomes just a talking shop passing ineffective resolutions. The Government should explain the size of this body more carefully, as my hon. Friend the Member for Canterbury (Mr. Crouch) and others have said this morning. Its size is a matter about which we want to be more confident before allowing the Bill to pass.

A number of my hon. Friends brought up the question of specialist registration and its omission from the Bill. We understand that this is because of divisions within the medical profession itself. That may be, but we should like more information as to whether the Government are convinced that they cannot give a lead on this matter. It is appropriate to a Bill which, as several hon. Members have suggested, is not the sort of Bill that will be repeated for a very long time. It would be better to get it right now than to have to bring in an enabling Bill or order later.

I echo what my hon. Friend the Member for Reading, South (Dr. Vaughan) said, that we welcome the Bill. We hope that it will go through quickly. It is important not only for the medical profession but for the public's view of the standards of medical care in this country. We must be confident that the GMC is an effective, fair and positive body of which those who work in today's vast Health Service can be proud.

12.21 p.m.

Mr. Moyle

In the course of this morning several matters have been raised on the assumption that I was to reply to the debate, so, with your permission, Mr. Bonner Pink, I should like to address the Committee again.

First, I welcome the offer made by the hon. Member for Reading, South (Dr. Vaughan) of the co-operation of the official Opposition in getting the Bill enacted with reasonable dispatch, subject to discussion of the points which are worrying members of the Committee. I should also like to thank the hon. Member for his expression of appreciation for my decision to circulate the notes on the clauses. I hope that they will serve to concentrate minds, to remove misimpressions, and to speed up our debates generally.

Finally, I join the hon. Gentleman in congratulating Lord Hunt on the work he has done in the other place. I also congratulate members of the medical profession on the way in which they have resolved their differences. Also, I should like to thank the officials in my Department for the speed with which they reacted to that so that we have a very much improved Bill before us.

I approached these proceedings with some feeling of relief as someone who qualified as a lawyer, in that the snide remarks which are usually passed against my profession were directed this morning against members of the medical profession. I find that a welcome change.

Some hon. Members have given me advance notice of a number of points that they want to raise in Committee and, obviously, the correct time at which to reply will be in Committee, but I am grateful for the notice that has been given to me in order that we may be able to prepare an informed debate on those points.

A number of points of some substance have been raised this morning on which I should like to comment. The size of the Council has attracted a certain amount of attention. The only point that I should like to make at this stage is that the figure of 98 members of the Council does not appear anywhere in the Bill. It was a thought in the minds of the Merrison Committee, and the number of members of the Council is at present unspecified, although there is a likelihood that it will be a considerably enlarged Council. I must concede that. The Merrison Committee's view was that the Council would work largely through committees as, indeed, any large body of that sort must work, and we must have regard to the full representation of a wide range of interests which have a bearing on the deliberations of the GMC, not least being the members of the public as well as the elected members of the profession, those representing education interests, and others.

The question of the cost of the GMC was raised. If there is to be a larger council with extended functions—and that is bound to happen, I think—then the correct deduction is drawn that the cost of maintaining the Council is likely to be increased. The cost of the existing council is, of course, borne by the members of the medical profession. The position remains open. There has been no decision in principle about how the future costs of the new General Medical Council are to be met. But all the elements which will go into consideration about a solution to this problem were mentioned this morning. One of these is that if members of the medical profession wish the General Medical Council to remain completely independent of all outside influence in considering the affairs of the profession, the best way to ensure that is for members of the profession to meet the full cost.

However, there is a substantial argument which says—I shall return to this in a minute—that the General Medical Council exists as much, and perhaps even more, to protect members of the public than it does to look after the interests of members of the profession. If that were accepted, there would be a case for the Government to meet at least a proportion of the cost. These are all factors that will have to be taken into consideration. Obviously, the Government and the medical profession will have to come to an agreement.

As my hon. Friend the Member for Brent, South (Mr. Pavitt) said, the whole machinery of the Bill—even if it is pushed through the House reasonably quickly—will take about two years to set up. Therefore, we have some time in which to resolve that issue.

Reference was made to the open-ended nature of the Bill. Worries were expressed about safeguarding the public and safeguarding members of the medical profession, and mention was made of Orders in Council. A great deal of the Bill, when it becomes an Act, will have to be put into operation by Orders in Council. I think that that is conceded as part of the legislation.

There are a number of safeguards, and the primary safeguard to the public is, of course, the registration of medically qualified people in the first place. This is the fundamental safeguard, and we should not lose sight of it. It has been in existence since 1858 and has been carried forward. The fact that it has been in existence since 1858 is a tribute to its general success and effectiveness as a way of protecting the public from unqualified persons.

Furthermore, there will be a number of public nominees on the General Medical Council. The number, of course, has still to be settled. But from that point of view the public interest will still be maintained. There will be people on the Council who can speak on behalf of the general public when questions of the future policy and actions of the Council are being discussed.

From the point of view of the profession, we are establishing for the first time a majority of elected members on the General Medical Council. The Committee does not need any lectures from me as to the pressures elected persons are subjected to, and the way in which they perform their duty. This is particularly important with regard to Clause 5, which was referred to by a number of hon. Members, and will have an important bearing on how that clause is administered.

Of course, the contents of the Bill will have to be fleshed out by Orders in Council. This means that there will have to be some general agreement between the Government and the GMC on what should be in an Order in Council. It will also be incumbent upon the Government to consult widely in the drafting of Orders in Council and, finally, although they will be subject only to the negative procedure when laid before the House, those who wish to pray against them may do so.

The knowledge that a debate could take place on any one of them will, I think, help to reinforce, through Members of Parliament, the interest of the public in what is being done by the General Medical Council. Therefore, there are quite a number of general safeguards built into the machinery.

The question of specialist registration was raised, and a number of hon. Mem- bers expressed their disappointment at the fact that we are not including it in the Bill. They went so far as to say that they thought there was a powerful case for specialist registration. I do not deny that that view is strongly held in certain quarters. Certainly, the Merrison Committee came to the view that there was a powerful argument for specialist registration and urged it upon the profession and the Government as a development devoutly to be wished.

The main problem that arises is that there is no general agreement as to how the machinery to implement the concept of specialist registration could be cobbled together in such a way as to ensure that justice was done to all the parties with an interest in this matter. This is why specialist registration is not in the Bill. There is at present no general agreement in the medical profession as to how it should go forward, but if any reasonable scheme for agreement on the matter were reached within the not too distant future, I could not see this Government, or any Government, being anxious to stand in the way of its legislative implementation. I am afraid that is the furthest I can take the matter.

My hon. Friend the Member for East Kilbride (Dr. Miller) was worried about increasing specialisation, and I think that he was particularly worried about the future of general practitioners in that respect. Under the Merrison recommendations, general practice would become a specialty in its own right. In other words, generalism would become a specialty. But I do not think that from that point of view it would adversely affect the position of general practitioners. Indeed, it would rather strengthen it.

I have been impressed by the idea that medical graduates should do a period of training as general practitioners before they can be accepted as general practitioners—that is already written into other legislation—and also by the good work being done by the Royal College of General Practitioners to raise standards in general practice.

Mr. Crouch

The Minister has just said that he cannot go further on specialist registration because there is a failure to agree in the medical profession. But the whole purpose of the GMC is to safeguard the public. The setting up 120 years ago of a register of doctors was an essential safeguard. Surely, it is vital for the Government to represent the public in this professional problem of setting up such a register. The public have a part to play and should have a voice in the matter. I hope that the Minister will not give up all hope of seeing that the public are safeguarded and their concern represented so that the difficulties can be overcome.

Mr. Moyle

Certainly, I have not given up all hope. I have indicated the general way in which we should like to see things go forward. I do not think that this is the time for the Government to go in for the fairly draconian step of imposing on the profession legislation in respect of specialist registration. After all, it is still early days for the resolution of these fairly complicated matters. For some time at least, we can hope that the profession will turn its mind to the resolution of these problems, and when the opporunity arises the Government will be prepared to act, with the advice of the GMC.

Mr. Pavitt

Can my hon. Friend assure us that one of the bodies which he is consulting on these matters is the Royal College of General Practitioners?

Mr. Moyle

I am certain that the College will have its say on all these matters. Indeed, it has been consulted in the legislative provision—I forget the name—which has ensured that there will be a specific form of training for medical graduates before they can become qualified general medical practitioners. That is a move towards making general practice a speciality.

I was about to refer to the contribution of my hon. Friend the Member for Brent, South (Mr. Pavitt) when he asked for a memorandum on points in Merrison not included in the Bill which might be the subject of legislation later. The only major outstanding subject on which we have not legislated is specialist registration. If it would help to have a memorandum at the Committee stage on the issues involved, I am prepared to let hon. Members have it. It is a valuable suggestion which we shall consider. Apart from that, there were some minor and almost technical points which have not been included. They may be of some importance, but I do not think that they are fundamental.

I am grateful to the hon. Member for Berwick-upon-Tweed (Mr. Beith) for calling attention to some sentences in my speech which might possibly have been misconstrued. He felt that my use of the phrase "legal cover" for the General Medical Council might mean that it could lay down the law of the country on medical matters and supersede Parliament and the courts.

That was not my intention. My intention was to highlight the point that had been made by the hon. Member for Reading, South, namely, that the powers of the existing General Medical Council are extraordinarily narrow and that the new provisions will enable the Council to give guidance—the hon. Gentleman introduced an illustration into our debate—on medical ethics and, possibly, advise Parliament and the Government on what the law ought to be.

The Bill will give a wider remit. The clause has been criticised for being too wide. The whole object of the exercise is to give the General Medical Council a fairly free hand in these matters. But its announcements and pronouncements on these issues will be circumscribed by the fact that there will be an elected majority on the GMC who, while wishing to give guidance to the profession, will generally not wish to be tied down wtih too much intricacy and have the Council making too many pronouncements on the details of medical ethics and conduct. The two factors will be working in balance one against the other.

Several other points have been raised by various hon. Members, and I think that I have covered a great number of them already.

The hon. Member for Northampton, South (Mr. Morris) raised the issue of branch councils. The question of interim suspensions has also been raised. Perhaps I should deal with those matters fairly generally. This country seems to be moving towards the concept of devolution, and this is recognised by the institution of branch councils for England, Scotland, Wales and Northern Ireland under the Bill. The hon. Member wondered, as did the hon. Member for Walsall, North (Mr. Hodgson), whether this might lead to a proliferation of bureaucracy.

We are empowering the General Medical Council to set up these councils. They will have to be set up under the Bill, but the GMC will decide, in the light of practical requirements, whether the branch councils will be used. It will decide that in the light of pragmatic experience. If it comes to the conclusion that there is no justifiable need for the branch councils, it need not use them. I assume that in such circumstances the councils need not meet, and they certainly would not require any of the elaborate bureaucracy of which hon. Members, are rightly afraid, in view of the experience we have had in the National Health Service over the past few years.

The situation with regard to Republic of Ireland doctors, which was raised by my hon. Friend the Member for Brent, South, is that present doctors would be protected by temporary provisions in the transition period. Once the transition period is over, Irish doctors will enter this country on exactly the same basis as will other EEC doctors—that is, we shall recognise their medical qualifications on a reciprocal basis with our own. After six months in this country on full registration, they will have to undergo a language test. As I have never yet met any Irishman who was likely to fail any test in the English language, I do not see that as any great obstacle. There will be free movement of doctors between this country and the Republic of Ireland, and vice versa. I do not think we need worry unduly about that.

My hon. Friend asked also about the age of doctors. The health committee which we are setting up will be able to pass judgment upon the relationship of a doctor's age to his ability to practise, should that be raised. Under Clause 5 more detailed and general guidance, ahead of hearings, could be issued by the General Medical Council if it thought that appropriate. That is how that problem will be solved.

There has been discussion about increases in fees and the cost of the Council. Practitioners would have their fees covered by practice expenses if they had to make a contribution to the General Medical Council. At the moment, the Doctors' and Dentists' Pay Review Body has to make a calculation as to what doctors' expenses are in fixing their general remuneration. I suppose that an increase in the retention fees of the GMC would have to be taken into account by that body in passing judgment on doctors' remuneration.

The hon. Members for Reading, South and for Northampton, South expressed worries about interim suspension. This is the proposal that the preliminary proceedings committee might suspend a doctor for an interim period of two months. The hon. Members wondered whether there should be a right of appeal against it. The power to impose an interim suspension would be used only in extreme circumstances. There would always be a fear on the part of the preliminary proceedings committee that, in instituting interim suspension, it was prejudging the case of the doctor appearing before it. As the interim suspension could last for only two months there would be a tremendous desire to get the case, with all its rarity and its implications, before either the health committee or the professional conduct committee for an early hearing. There is written into the procedures the equivalent of an appeal from the preliminary proceedings committee to the professional conduct committee.

The hon. Member for Canterbury (Mr. Crouch)—who has now left—asked whether I was satisfied with the educational responsibility of the General Medical Council. In this, as in all matters, the proof of the pudding will be in the eating. All I can say is that there has been full consultation and there is general agreement on the part of both groups—the medical profession and the education profession—on the arrangements which have been agreed. From the point of view of the Government, we think that it is a sound arrangement. So far all that can be done to make the new arrangements workable has been done. From that point of view, I am as satisfied as I can be at this stage that the arrangements will work.

The rest of the points raised were essentially Committee issues, and we shall have a chance of debating them at length at that stage. We shall also be able to discuss the issues relating to overseas doctors. Between now and that stage it will be worth while pondering on the general desire for the equal treatment of overseas and EEC doctors which has been expressed this morning. I should point out that, although EEC doctors get full registration and can work in this country for six months before they undergo a language test, if they fail their language test their full registration can be taken away from them.

The non-EEC doctor will have to undergo his language test before taking up a post in this country. If he surmounts that, he may be granted full registration. The Overseas Doctors Association was very keen to get that provision written into the Bill. If there is too much emphasis on total balance or equality between the two groups, not only will something have to be done about the

THE FOLLOWING MEMBERS ATTENDED THE COMMITTEE:
Pink, Mr. R. Bonner (Chairman)	Morris, Mr. Michael
Beith, Mr.	Moyle, Mr.
Boscawen, Mr.	Pavitt, Mr.
Crouch, Mr.	Shaw, Mr. Arnold
Glyn, Dr.	Stallard, Mr.
Hodgson, Mr.	Vaughan, Dr. Gerard
Miller, Dr. M. S.	Walker, Mr. Terry
Molloy, Mr.	Young, Sir George

time when the language test is taken but something may also have to be done about the length of registration following or preceding the language test. I hope that hon. Members will bear that aspect of the problem in mind when considering what they would like to do in Committee about overseas doctors.

Question put and agreed to.

Ordered, That the Chairman do now report to the House that the Committee recommend that the Medical Bill [Lords] ought to be read a Second time.

Committee rose at fifteen minutes 10 One o'clock.