Medical Education

HC Deb 18 June 1982 vol 25 cc1207-47

Motion made, and Question proposed, That this House do now adjourn.—[Mr. Gummer.]

[Proposed subject for debate: Fourth Report from the Social Services Committee, Session 1980–81, on Medical Education, House of Commons Paper No. 31, and the relevant Government observations.]

9.35 am

Mrs. Renée Short (Wolverhampton, North-East)

The Select Committee owes a great debt of thanks to all those who helped us during the course of the inquiry, not least our medical advisers and our clerk, Donald Morrison, who has since retired from the House. I should like to thank the members of the Select Committee for the work that they did during the course of this long inquiry.

The Committee visited Birmingham and Liverpool and Newcastle. So we looked at problems in teaching hospitals in those regions as well as at problems in the peripheral hospitals, with special reference to the shortage specialties in those areas. We also went to Aberdeen and Edinburgh, and we are greatly indebted to all those in the hospitals there who helped us in our work.

The main burden of the report is to show the need for more consultants to be appointed. In a nutshell, it is better for patients to be treated by fully trained doctors. We discovered that the need varies considerably in different specialties. General medicine and surgery are still the most popular specialties that young doctors apparently aspire to, but there are many shortage specialties such as geriatrics, psychiatry, pathology, radiology and anaesthetics, although the position is gradually improving. Senior posts in those specialties can be advertised over and over again without any applicants. That, surely, shows how serious the situation is.

Besides the shortage specialties, there are shortage areas. When those coincide, patients have a very raw deal. We heard of those difficulties in the West Midlands and other regions that we visited during our inquiry, and the peripheral hospitals and their patients in those areas are, in many cases, the Cinderella of the National Health Service.

It is important to understand the difference between the teaching hospitals and the peripheral hospitals. It may surprise the House to know that, in 1979, no fewer than 421 whole-time equivalent consultant posts were occupied by locums, and 292 whole-time equivalent consultant locums were occupying posts without a permanent holder. That, too, shows the seriousness of the situation.

Of course, junior doctors do not all wish to become consultants. The needs of general practice, community health and industrial health all have to be taken into account, and more junior doctors are needed when expansion of a specialty is planned. There are the career prospects of women doctors, who are becoming more ambitious and keen to do much more than they have done in the past. There are also the overseas doctors, who do not all want career grade posts in this country. Many of them get shunted into the unpopular specialties in junior posts, and seem to be stuck there for years. That is unsatisfactory for them and for their patients. I refer particularly to geriatrics and psychiatry in this regard. If hon. Members will look at the evidence that we took in those two specialties on Merseyside, they will understand how serious the position is—and Merseyside is not the only area that is suffering in this way.

All those factors have to be taken into account in planning the education and training of doctors. Attempts by some consultants to make us believe that massive unemployment among doctors is on the horizon are rot well founded.

I see the logic of the case that the Department put to the Select Committee about the cost of the proposals that we make for shifting the balance gradually over a period of years to a better ratio of consultants and juniors. That is set out clearly on page 1056 of the appendices. I hope the Department will be able to bring these figures up to date. Dramatic as they are as quoted for 1978, they must be much more so now. If more resources are needed to implement our recommendations, those resources must be provided.

Ours, of course, was not the first body to consider the problems in this area. Many have gone before us. Some of the consultants tend to overlook the fact that the Platt report in 1961, Wright, which dealt with the situation in Scotland in 1964, Todd in 1968, Godber in 1969, the progress report on medical staffing in 1972, Merrison in 1975, the Royal Commission in 1979, the King's Fund report in 1979 and the BMA working party in 1979 all considered the problems of medical staffing. Many of these reports have drawn attention to the potentially disastrous implications of increasing the number of junior doctors relative to the number of career posts but nothing effective has been done to correct the situation.

So it was our earlier report on perinatal mortality that pointed the way for the Select Committee. We saw the effects of too few neonatologists, paediatricians and anaesthetists on the practice of obstetrics and the danger to which women and their new-born babies are exposed as a result during the intrapartum and postpartum periods. We were impressed by the evidence presented to us then by the Royal College of Obstetricians and Gynaecologists and also during this inquiry on medical education.

We asked questions about the shortage specialties of the Royal College of Obstetricians and Gynaecologists and of many other of the Royal colleges, too. We are greatly indebted to all of them for the help they gave us. It is unacceptable that women in childbirth should not have relief from pain. Even more unacceptable is it that women should die in childbirth because incompetent, untrained, juniors are administering anaesthetics. That was evidence given to us during the perinatal mortality inquiry.

The need for anaesthetists could absorb all the increase in consultant posts in anaesthesia that current plans allow for during the next five years. That would allow only one whole-time consultant in obstetric anaesthesia and only one-third of a consultant devoted solely to the treatment of chronic pain for each district general hospital. So clearly there is a long way to go in this specialty.

As long ago as 1969, the first progress report by the Department of Health and the joint consultants' committee suggested an expansion of the consultant grade by 4 per cent. and the training grades by 2.5 per cent. This was intended to change the consultant-junior ratio from 1:1.5 in 1969 to 1:1.3 by 1978. The Secretary of State told the Select Committee that he would like to see the ratio of one consultant to 1.8 juniors reversed. At present, about 650 consultants are appointed each year, of whom about 450 are in replacement posts. This will rise to 650 replacement posts by 1995 to take account of those in post who will reach retirement age. In 1980 there were nearly 3,000 senior registrars, so with only 650 going to National Health Service consultant posts the imbalance is clear. The 1980 totals of senior registrars could provide 1,000 consultant appointments after three years in the grade or 750 consultant appointments after four years in the grade.

If we are to make more progress and double the number of National Health Service consultants by 1996—I emphasise again that we are not suggesting that this can be done overnight—about 10,000 additional posts will be needed in the following 12 years. That means 850 a year, an increase of about 7 per cent. per annum plus replacements.

For the full explanation of the problem of the staffing ratios I am greatly indebted to Doctor Vaughan of the North-West regional hospital authority, whose article in the British Medical Journal recently dealt with this in some detail. He concludes that in 1988 we would need at least 4,200 training posts for senior registrars, 3,400 for registrars, 6,500 for senior house officers and 3,250 for pre-registration house officers. That makes a total of 17,350 over the period with, at the same time, about 17,000 consultants in post. This would give the 1:1 ratio that has been suggested as an interim target.

The changes required would be 1,200 more senior registrars, 2,500 fewer registrars and 3,000 fewer SHOs. So there we see the connection with the case put up by the Department for the costing of the exercise that we put forward. There could be savings. There must be an increase in senior registrars otherwise many doctors will have to find career posts outside the NHS hospitals. General practice needs more doctors if long lists are to be reduced and elderly doctors are to be relieved of full-time work.

How are we to achieve these changes? Are the present controls to be maintained? I hope that the health Minister will be able to answer some of these questions. If the controls are to be maintained, no senior registrar post can be created until after April 1983, expansion will be delayed and distortion in recruitment will continue.

What discussions is the Secretary of State having with the central manpower committee about changing the establishment of consultants and senior registrar posts? How is this generally long-drawn-out process to be speeded up? We must make sure that suitable appropriate employment is available for doctors. It will be crazy if we are unable to carry out our priority for a better service to patients because of a lack of suitably trained consultants.

Regional authorities need to bring about the necessary changes in the balance of hospital medical staffing. Will they be allowed to establish consultant posts and training posts corresponding to these plans? I am sure the regional authorities are keen to do this. In the past we have seen an inappropriate number of senior house officers being appointed because of the demands of consultants, in other words, pairs of hands to do jobs but without the proper training and ability to rise up the promotion ladder.

The King's Fund organised an interesting seminar recently which was revealing. Can the Minister tell the House whether he has had any feedback from the seminar? Can he tell us what discussions about targets are taking place in the current round of regional reviews? I understand that letters from the Under-Secretary of State to the Mersey and Trent regional authorities make no mention of medical manpower, nor was it discussed at a meeting with the South-Western regional authority recently. Several speakers at the King's Fund Centre referred to the need to start planning changes now from local level to assess problems of local cover and so on. It is clearly part of the burden of our recommendations that discussions must take place rapidly at local level so that the planning can be carried out in a reasonable and sensible manner. Is the Department monitoring those districts that have made good progress towards the target? Good examples need to be held up to those making less progress so that they know how to go about it.

There are two main goals in our report: first, that patient care is best provided by full-time doctors, and, secondly, that junior doctors should spend as much time in the training grades as their training requires and not as the service needs of the particular hospital require.

We were grateful to the Department and to the Minister for their response to our recommendations. I hope that the Minister will say something about the rapidity and the forcefulness that the Department will adopt in ensuring that the recommendations are carried out. I should like to thank the Minister's officers who helped the Committee during the inquiry and who accompanied it on its visits to the regions. We are grateful for the contact that we were able to have with the Department, and on the whole I am pleased with the response that we received from doctors in important posts of influence within the medical profession. There are some who as always tend to dig their heels in and say "So far and no farther. We are not going to progress as you wish." That has always been the position when previous inquiries have taken place. However, we have been conducting inquiries and producing reports over 20 years and it is time that we made some progress.

Junior doctors are understandably keen to see the opportunities for promotion available to them much more readily. I hope that when the current generation of junior doctors become consultants they will maintain their enthusiasm for the structure that we have set out in the report. That does not always happen. All the present senior doctors were junior doctors at some stage in their careers.

Mr. W. R. Rees-Davies (Thanet, West)

Does the hon. Lady agree that it is essential that we reinforce the need for the Government to have a strong commitment to correct the present imbalance, and that that is the real value of the Government's reply? It is important that the Government should say that they will correct the imbalance and, therefore, achieve what the Committee sets out in its recommendations.

Mrs. Short

The hon and learned Gentleman, who is a valuable member of the Select Committee, is correct. At a fairly early stage the chief medical officer called a conference at the Department at which he drew together a number of doctors from different disciplines and different areas to debate the progress that could be made in implementing the proposals. As I have said, I am grateful to the Department and to the Secretary of State for the response that the recommendations have received. I hope that that indicates that we shall make good progress. Over 20 years have been spent talking about it, and a number of high-powered reports, including a Royal Commission, have shown that we must make progress.

I am delighted to be able to present the report to the House. I hope that it will receive the general acclamation of hon. Members on both sides of the Chamber. This is clearly not a party political issue. It is an issue that affects patients throughout the country, whatever their problems. It is an issue that affects the attendance and treatment of patients at out-patient clinics as well as in-patients. It involves the entire range of the medical profession and, indirectly, many of the ancillary services that support the medical profession. I hope that we shall see progress made, and I shall be interested to hear the Minister's responses to the Committee's recommendations.

9.54 am

The Minister for Health (Mr. Kenneth Clarke)

May I begin by apologising to the House for intervening somewhat earlier in the debate than I might normally have done. I see a number of hon. Members in their places who are obviously ready to make speeches, especially my hon. Friend the Member for Belper (Mrs. Faith) and my hon. and learned Friend the Member for Thanet, West (Mr. Rees-Davies). The right hon. Member for Norwich, North (Mr. Ennals) is also in his place. My hon. Friends and the right hon. Gentleman are members of the Select Committee that has done such valuable work. The importance of its work is reflected by the fact that my right hon. Friend the Secretary of State and the other two health Ministers were all in their places while the hon. Member for Wolverhampton, North-East (Mrs. Short) introduced her report.

The House will appreciate that there are other rather grave and important matters taking place in the Department and it will he necessary for my right hon. Friend and myself to slip away at an early stage. Thereafter the Government's interest will be protected by the competent hands of the Under-Secretary of State, my hon. Friend the Member for Hampstead (Mr. Finsberg). My right hon. Friend and I will study with considerable interest the report of the debate that will appear in Hansard.

The hon. Member for Wolverhampton, North-East and her Select Committee colleagues are to be congratulated upon producing a valuable report. I am delighted that we have a day to debate it so that we can underline the message that the report contains. I am happy to say that a level of agreement was quickly formed between the Select Committee and the Government when the report was produced. The full extent of the Government's response is set out in the White Paper which the House will have before it.

I can recall very few responses by Governments of any colour to a Select Committee that have been so favourable. It is clear on reading the White Paper that response after response represents a ready agreement, a ready welcome and an undertaking to take steps to implement the desires of the Select Committee. I hope that the Select Committee, the Government, the medical world and the public generally will indicate their general acceptance of the objectives and the need to adjust the staffing structure of the medical profession to ensure that a greater proportion of medical care in our hospitals is provided by fully trained doctors.

The hon. Member for Wolverhampton, North-East was realistic—I trust that her colleagues will be—in accepting that the recommendations cannot be achieved overnight. The Government have talked about a 15-year timescale. That shows the gradual way in which we must move towards the objectives because of resource and other implications. The pace and exact nature of the change in the career structure will depend on a variety of factors, but especially on a multitude of small local decisions that will have to be made by individual health authorities within individual specialties. We hope that those who have to take those decisions will respond to the needs of their specialties and the resources that they have available. We hope also that they will bear in mind the general objective of the policy and will be assisted by the guidance that the Government intend to give to them in implementing it.

The pace and nature of the change will depend on the consensus within the medical profession and will require the continuing support of the profession. It will depend also on the availability of resources to finance medical manpower over the next few years.

As a comparative newcomer to my present position I am aware that the report has generated some controversy in some sections of the medical profession. The hon. Lady and I recently attended a conference at the King's Fund Centre. She asked me what feedback I have received. Among the feedback has been a continued level of controversy from those who find that the recommendations are not to their liking. The Government continue to reassure those who are worried by the Select Committee's report and the enthusiastic White Paper that there is no intention to override the tradition of self-regulation in matters of this kind by the medical profession. Nevertheless, clear guidance has been given and a clear policy is to be followed. I agree with the members of the Select Committee that the basis on which we are working and our purpose in creating the policy is to improve the service to patients in the hospital service.

The two key principles contained in the report on the Government's policy appear to have been agreed upon for the past 10 years in various reports. The two main objectives contain the recognition that patient care is best provided wherever possible by fully trained doctors, and that as part of the career structure in medicine doctors should not remain longer in their training grades than the requirements of their training make necessary. There has been broad agreement on those two objectives over the past 10 years, but progress towards their attainment has not been very good. The report is a valuable reminder that everyone is agreed on the objectives and it is a further stimulus to see how far it is practicable to make progress towards them.

My first general principle was that general care is best provided by fully trained doctors. One response to that by some more skilled and experienced consultants is that it means that some of their skills will be wasted if they spend too much time on routine procedures that should be carried out by junior staff. I can see some force in that argument, but there are fairly authoritative replies to it. I can do no better than to quote part of the evidence from the president of the Royal College of Surgeons to the Select Committee: It is a general principle that there is no such thing as a minor procedure. Though we have artificially designated minor operations, they are not minor for the patient and one of the bad things about the service in the past has been too much of the so-called minor procedures have been done by junior doctors in training whereas the senior has done very little of this type of work. The result is that this type of procedure has not been improved in quality as it might have been. That underlines the point that as much patient care as possible should be given by fully trained doctors.

The second principle is the quality of training posts and the importance of the right career structure. It should be fundamental that the quality and distribution of training posts is such that they attract good applicants, retain their interest and keep up the morale and motivation of those who hold the posts. That is especially important as we try to improve the output of our medical schools. Successive Governments have aimed at self-sufficiency in our medical manpower and to reduce our dependence on overseas-trained doctors. That becomes important and slightly more possible because there are some signs that the number of overseas doctors who wish to come here might be falling and there are fewer outlets abroad for people qualifying from our medical schools. Perhaps we are about to enter a period when we shall get nearer to the objective of being able to rely on our medical schools for the bulk of our medical manpower.

I do not wish in any way to undermine the valuable contribution of overseas doctors in the past and in the foreseeable future. It is rather striking that about 50 per cent. of the posts at both senior house officer and registrar level are filled by overseas-born medical graduates. We must remember our responsibilities as a health service towards those overseas doctors, who are providing a substantial proportion of the patient care in our hospitals. I am anxious, as is my right hon. Friend the Secretary of State, that they should obtain the quality of training and career satisfaction for which they came to Britain. It is unfair that an overseas doctor may drift into a dead end junior post that cannot be filled by a British graduate. Very often it is in a specialty for which there is no demand in his country, so he is receving training in an area which, from his point of view, is blighting, although he is making a vital contribution to the care of British patients.

The Government especially welcomed recommendation 10 of the Select Committee report, which states: If a junior post loses its recognition for training purposes, it should be closed by the health authority".

Mrs. Gwyneth Dunwoody (Crewe)

There is a problem not just with overseas doctors in the future but with those doctors who are trapped in unsuitable posts, often in specialties that they do not need, and who can see no way of obtaining the training that they need for higher qualifications. What does the Minister intend to do and will he open talks with the Overseas Doctors Association about it?

Mr. Clarke

I described the same problem. I hope that the policy that I have described, which is in accord with the recommendations of the Select Committee, will reduce and eliminate that problem. As we are talking about a gradual change in the career structure, it does not offer much short-term help and I agree with the hon. Member for Crewe (Mrs. Dunwoody) that we should consider what can be done to remove people from those dead end posts now. The suggestion that I might have talks with the Overseas Doctors Association is sensible. If I am approached, I shall fit in such a meeting as soon as possible.

I dealt with the general principles, which seem to be non-partisan, and I doubt whether any hon. Member will disagree with them. That makes it all the more surprising that during the past 10 years successive Governments of all colours appear to have been going in opposite directions. We must consider the practicalities.

Mr. David Ennals (Norwich, North)

rose—

Mr. Clarke

That was not an attack on the right hon. Gentleman.

Mr. Ennals

I did not consider it as such. Has the Minister seen the vituperative attack by the British Medical Association contained in an advance copy of a document that it is sending to its consultants? Often the opposition comes from the consultants themselves.

Mr. Clarke

I have encountered consultants with strong views on the subject. They may have had a considerable influence on matters during the past 10 years. However, although the principle has been agreed by the bulk of the medical profession, it is not just consultant resistance that has stopped anything happening but the practicalities of medical manpower and resources. We must address ourselves to that. The Committee laid stress on the vital part that must be played by medical manpower planning. We agree with that.

Arrangements for medical manpower planning are being discussed by Ministers in the regular reviews that we plan to hold yearly with each regional health authority as part of our policy of acountability. The House will know that the Government believe that we need a stronger system of accountability to the Government for the broad policy and planning objectives of the Health Service. We cannot have a close relationship with each of the 192 district health authorities to which we have devolved responsibility for day-to-day decisions. They are accountable for their broad policy and their use of resources to the regions. A meeting will be held each year to call them to account and to review their progress. Manpower planning is an important part of that.

The hon. Member for Wolverhampton, North-East asked me how far that policy had been raised at the meetings, because she saw the leters sent by my hon. Friend the Under-Secretary of State after two meetings that he held with regional health authorities, which contain no reference to the policy. If she sees my letter to the South-West regional health authority, after a prolonged review meeting, she will again find no such reference. There has been much discussion about getting a better system of manpower planning and control in the Health Service. However, in those meetings we do not go into the depth that her question would presuppose. We are not taking over the day-to-day decision-making or even the formulation of broad policy from the regional health authority, so the letters express matters in general terms. That it is not specifically raised in the letters that arise from the reviews does not mean that we have not got down to specifics with the health authorities.

In particular, we have circulated the Social Services Committee's report and our response to it to all health authorities. First, we have asked authorities to apply a standstill to all the senior house officer posts in their regions. Secondly, we have asked them to draw up plans to redress the balance between the numbers of consultants and training grade posts in their regions and have suggested that they adopt a target achievement of a one-to-one ratio between the grades by 1988. Thirdly, we have asked them to take particular notice of the effects and overall costs of alterations in the medical career structure.

We shall be discussing progress in those directions with authorities. The fact that we do not achieve that degree of detail in the ministerial reviews does not mean that in the follow-up to them, and in the contact between my Department and authorities, we do not get down to specifics in discussing actual progress.

Mrs. Renée Short

What period does the Minister intend to give the regional authorities to consider the matters that he has put to them? What sort of time scale does he envisage?

Mr. Clarke

We have not put a time limit on the propositions that I have just described. However, as there is fairly steady contact between the medical officials in my Department and the regions we should have a fairly steady comeback during the coming year. Although I have not considered the time scale, my present understanding is that by the end of this year we will begin to have a fairly clear picture of how far authorities are beginning to respond to our suggestion.

We must also consider resources, which will be a factor in the particular plans that local authorities draw up. I should remind the House of paragraph 12 of the White Paper in which we explained exactly the relationship between this policy and the resources that are likely to be available. It says: There are some encouraging developments and the Government hopes that they will lead to change in the desired direction. It is, however, important that the expansion of the consultant grade should not use up extra resources at a time when the growth of expenditure on hospital and community health services is bound to be constrained, and provision for old people and other groups needing long-stay and community care is likely to be under particular pressure. The Government therefore looks for a commitment from health authorities and the profession to ensure that as the consultant grade expands, there is no failure to reduce the number of junior doctors appropriately and that hospital case-mixes and working practices fully reflect the better use of resources, as well as the higher quality of care, which the increased use of clinically independent, and more widely experienced, doctors should make possible. That means that an increase in the number of consultants to redress the balance should mean a reduction in the number of junior posts to get the better mix that the Committee wants. We do not simply want an overall increase of manpower without redressing the balance. The change could also achieve a better use of resources and patient care by improving the through-put of patients, and a higher performance would result from the higher standards of training. However, in moving towards that policy we must ensure that we do not jeopardise other objectives within the service. That is an important constraint.

It is within the context of their overall planning that the Government are telling authorities that they should consider how best to meet the training needs of junior doctors. The main criterion for the allocation of training posts should be the quality of training available, not just the need for pairs of hands to provide services to patients. However, we fully appreciate that that may be a difficult distinction to make in the light of the importance of the job and the overall training of a doctor.

I should like to move to another important recommendation of the Committee on junior doctors' hours of work, a subject that the Government take seriously and on which they agree with the opinions expressed by the Select Committee. The Committee recommended that a reduction of the junior doctors' contracted week, initially to a maximum of 80 hours, should be one of our top priorities. As I have already said, we fully recognise that the hours of work of some junior hospital doctors are excessive.

We are as anxious as anyone else to achieve significant reductions. Again, this is not a new problem. For many years junior doctors have worked long hours. The average hours for which junior doctors are contracted have stood at nearly 90 for some time. It is a long-standing problem because it is not an easy one to solve.

First, there is the clear and obvious need to provide round-the-clock medical cover. That is the main cause of long hours. We all recognise that medicine is not a nine-to-five job and never can be. It is also the case that out-of-hours work is regarded as an important part of a junior doctor's training by the bodies responsible for post-graduate medical education. It is important that doctors should see cases as they develop and that they learn to take difficult decisions at inconvenient times. That is undoubtedly what they will have to do when they become fully trained consultants or general practitioners.

We are taking steps to tackle the problem. Whatever steps we take, we must ensure that neither the service to the patients nor the doctors' training suffer as a result.

In February, the chief medical officer held a conference on the subject that was foreshadowed in our response to the report. Participants spoke as individuals and included senior and junior hospital doctors, individuals from National Health Service management and the royal colleges and faculties.

Many valuable points were made at the conference and its findings have helped to set out the course that we are now following. Those who spoke made a clear distinction between being on call and working. Being on call may be inconvenient, but it is not necessarily tiring. They al so distinguished between the specialties. They thought that the immediate target in the acute specialties should be to have no doctor on a rota more arduous than one night and one weekend in three if possible, with a half day off per week.

In others specialties, where the demands on the doctor during his on-call time are much less, what would appear to be a heavier commitment on the face of it would not in practice be too onerous. Several suggestions were made for improvements. Those at the conference were certain that the method of achieving reductions would have to be decided locally as a matter of agreement between all the doctors concerned.

Finally, the conference considered that it was important that, in reducing junior hours, continuity of care—the idea that an individual doctor accepts personal responsibility for a patient throughout his treatment—should not suffer. Those are valuable conclusions.

Although the overall problem is stark, the problem takes on a different nature in the case of different specialties. It cannot really be solved by blanket recommendations across the whole field. That is why legislation on the subject is not a sensible way to proceed. One does not doubt the motives of those proposing the legislation. They appear to agree with the Government's objectives. However, such legislation would produce on the ground some extremely anomalous cases. I only say that by way of parenthesis. It is the conference conclusions on which we hope to build.

Mrs. Dunwoody

If there is no overall limit and no direct guideline, those specialties that continually use junior hospital doctors for much longer than 80 hours a week—some hospitals are making junior doctors work one night in two and in some cases every night—will never improve. It is not good enough to say that the matter should be left for negotiation with the doctors concerned. Negotiation between a senior and junior partner is never an evenly balanced one and in the matter of doctors' hours it becomes virtually untenable.

Mr. Clarke

I note the hon. Lady's view and I will bear what she says in mind. The conference, which included senior and junior doctors, came to the conclusion that I outlined. Although everybody is agreed on the objective, the position between the acute specialties and some of the others is quite different. The demands that we are talking about when we discuss doctor's long hours are variable. There is no way in which one can impose a solution. A purely artificial ceiling may have a direct effect on patient care if those involved have not discussed and considered the effects that it may have on patient care before implementing it.

We are now discussing with National Health Service management and the profession what can be done to follow up the conference's conclusions. We are aiming to establish a framework for local reviews of rota commitments and a timetable by which those reviews will be completed, by which time we hope to have made substantial progress towards achieving at least the more immediate aims set out by the conference. So far the discussions have gone well and are continuing. I hope that we shall gradually see the end of the heavier working commitments which some juniors undertake.

Fears have been expressed from time to time that we are training too many doctors and that that may cause unemployment in future. I have heard such fears from a number of quarters in my three months at the Department. I take them seriously when they come, as they often do, from people in the medical profession. They suggest that we might be putting too many people through our medical schools and thereby creating an unemployment problem for the future.

I have found no evidence to make me believe that the fears are justified, but I take the matter seriously and if evidence emerges we will need to reconsider the present position. We have a target for our medical schools intake on which the Government and the Select Committee are at one. There is no evidence to suggest that we should adjust that target.

Forecasting medical manpower demands is difficult. Some spectacular errors were made in the past when needs were underestimated. Setting the number of medical school places must be related to the projections of demand for doctors as well as the best estimate of the number of doctors that the country will wish to employ in 15 or 20 years. That requires difficult judgments, but I ask people who call for an immediate cut in the intake of medical schools to bear three matters in mind.

First, changing the level of medical school intake now would have no effect until 1988, when this year's entrants will qualify. Secondly, if one examines the recent past one sees that between 1979 and 1981 the number of doctors working in the hospital service in England and Wales increased by 1,734, while the number of qualified doctors graduating from our medical schools increased by only 80.

Thirdly, recognising that a number of factors will affect the demand for doctors in future, we have agreed to carry out periodic reviews of likely demand and to consider whether there is a need to adjust medical school intake. The first of the reviews is about to be undertaken. We are pleased that the profession has nominated a number of experts to help with the work. I assure the House that the Government would take it seriously if there were any sign that prolonged unemployment among doctors was increasing. Such unemployment would be distressing to the individuals concerned. It would also have an adverse effect on morale and be a terrible waste of the resources devoted to the training of doctors. We shall keep the matter under close surveillance. There would have to be a dramatic change in present medical employment prospects for the fears to be even remotely justified.

We are in broad and welcome agreement with the Committee and its report. We are grateful to it for its valuable work. We shall seek to tackle the problems presented by the imbalance in the hospital career structure. Many in the profession have been quick to draw our attention to problems which cause them concern. Some of the anxieties will be expressed later in today's debate. We shall take them seriously.

We want to do nothing to undermine the fine, longstanding tradition of self-regulation which characterises the medical profession. We have no plans to force anything on the profession. We are aware that morale is one of the keys to the smooth working of any service. Unless our policies have the confidence and support of consultants already in post and doctors in the training grades we shall not achieve what we have set out to do. So long as everyone appreciates that that is the careful and considered approach that we are adopting, that we seek to take the medical profession with us, that we propose to achieve the objectives over a reasonable time, and that we have thought out the problems of manpower planning and resources, we shall achieve the changes and improvements that we all desire.

The Government and the Select Committee believe that the climate of opinion increasingly is in favour of finding solutions to the problem. As the hon. Member for Wolverhampton, North-East enjoined, I accept that we must ensure that the opportunity is not missed and that the impetus towards solving the problem given by the Committee's investigation is pursued with vigour.

10.45 am

Mr. David Ennals (Norwich, North)

We are sorry that the Minister has to leave us to go about other urgent business. If that urgent business is what I hope it is, I wish him success.

I welcome the Government's official reaction and the Minister's response today. The Minister said that as much patient care as possible should be provided by fully-trained doctors. That is an essential recommendation of the Select Committee, of which I was proud to be a member. It is encouraging to hear the Minister use almost the same words as the Committee.

The Minister accepts that there must be a change in the balance between consultants and training posts. We all agree that the position cannot be changed overnight. When making its recommendations the Select Committee wanted some dynamism in a move in that direction, but it recognised that it will take time.

I was even more delighted at what the Minister said about the number of doctors in training. He has had to face pressures from people who suggest that we are admitting to or turning out from our medical schools too many potential doctors. When I was Secretary of State I examined the problem on a number of occasions. I published a document on manpower. I thought then that it was unwise to change our targets. There might be a little slippage, but the targets are there. I was encouraged to hear the Minister because the problem affects not only the hospital service but the community and general practitioner services.

The Minister correctly reminded us that tragedies occurred in the past when decisions were taken to cut the number of medical students. That was done because it was thought that we would overprovide. It took 15 years to catch up on the mistakes.

I congratulate my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short) on her chairmanship of the Committee. A number of hon. Members who served on the Committee are in the Chamber. None of could do other than admire the way in which my hon. Friend steered our deliberations. We saw an enormous number of individual witnesses from organisations. We considered voluminous documentation. I doubt whether we could have tackled the problem more seriously. As a former Secretary of State, I wish that my hon. Friend had produced such a report five years ago. I should have found it enormously helpful.

The Government's response shows the extent to which they appreciate the report. It gives them a driving force to do what they and I believe should be done, although obstacles stand in the way. I should like to pay a personal tribute to the four advisers—Professor Clark, Dr. Engelman, Mr. Hendry and Professor Parkhouse—who gave outstanding service to the Select Committee. Without their advice, assistance and wisdom we could not have produced the report that we did.

As the Minister said, Governments do not always accept Select Committee recommendations, but on this occasion they have. The Government recognises that any major shift of emphasis in the medical staffing structure is bound to have implications for other health professions, in particular the nursing profession, and will, therefore, be including representatives of other professions in the NHS and other professional organisations in the further consultations on the Committee's recommendations referred to in Chapter 4. I welcome that, We were looking at medical education, but one cannot look at medical education without dealing with the role of the NHS and other members of staff who are part of it.

Paragraph 3 says: It is hoped that the publication of the Committee's Report will bring the issues of medical education, doctor numbers and the hospital medical staffing structure before a wider public. They are matters of wide concern both to the public and to other professional groups. The following extracts from the Committee's Report illustrate the point. There is then a quotation from our report: At first glance. it may seem that these … are problems internal to the medical profession, which they can sort out for themselves. Clearly they are problems that the medical profession has not been able to sort out. The quote continues: Unfortunately, however, although it is the doctors, and more especially the junior doctors, who are most aware of the problems, they are not the only ones to suffer from the current situation. The way in which medical services are structured in this country is also adversely affecting patients. The Minister said that patients must come first, and that is the principle that runs through our report. The paragraph continues: and at the same time the taxpayer is paying for a service which is less efficient than it could be. I shall quote further: When junior doctors move from one hospital to another at such frequent intervals and in the current piecemeal fashion, it takes them time to become familiar with the hospital and its procedures, their colleagues' working patterns, not to mention the tasks to be performed. Also long-stay in-patients and outpatients on return visits may find that they are treated by a string of different doctors, none of whom stay long enough to get to know the patients and their problems. That was an important statement. We are constantly aware—we have all had our own experience—that patients see one doctor and then have to start all of over again with another. It is the consultant who has to provide the continuity of understanding and care. Our proposals in the report deal with that, not only by suggesting that there should be a different ratio, but in an organisational way.

One can best summarise the report by saying that our country will soon be producing almost twice as many doctors as it was a decade ago. In spite of that, we have serious medical care problems. There is inadequate recruitment to a great deal of important medical work. The Committee was especially worried about the shortage of specialties in psychiatry, geriatrics, pathology, community medicine and other areas. There is a heavy pressure on resources of every kind. Staff may frequently carry an unacceptable work load. That does not only apply to the medical profession. It often imposes heavy pressures upon others within the Health Service.

Individual health authorities, often with guidance from the DHSS, have made continuous attempts to solve that problem. The Minister said that unfortunately the solution had usually involved the creation of junior posts without full regard to the cumulative effect upon the level of responsibility, and without regard to the long-term local and national consequences. Short-term solutions to immediate problems—often by the appointment off a doctor from overseas who may not be suitable and who may not have the prospect of a career structure before him—have been bought at the price of a progressive imbalance in the ratio of junior to senior posts. There is a consequent dilution of supervision and a blurring of the vital issues of clinical responsibility. That grave and continuing distortion of the medical career structure has clear repercussions upon standards of patient care.

The Minister said that attempts have been made over the past 10 years to improve the position. We have to accept that virtually no progress has been made in that direction. In fact, there has been a backwards step, not in the numbers of doctors in the Health Service—we can all take credit for that—but in the imbalance.

The report said: Consultants' time certainly costs more in salary terms than junior time but consultants function more efficiently and may therefore provide less expensive care". I am encouraged that the Government have accepted that. The Select Committee feared that the Government would be required to reject any proposals that cost money. A good deal of our work concentrated on whether a higher proportion of consultants would lead to greater efficiency, not only improving the quality of care, but without additional cost to the Health Service. Some sections of the medical profession doubt that. The Department has accepted that, and it is an important part of their acceptance of so many of the recommendations contained in the report.

I quote from the report: This higher productivity might well reduce waiting lists". Both sides of the House want to reduce waiting lists. It was the objective of the Labour Government, and it is the present Government's objective too. There may be some devastating consequences now as there were in 1979 at the time of the industrial action, but that remains our objective.

Throughout our report we have had three main priorities: first, to improve patient care; secondly, to ease the problem caused by shortage of specialties; and, thirdly, to relieve the intolerable burden placed upon some junior doctors. The Minister said that that may not be as bad as it seems, and that if a doctor works 80 or 90 hours a week a great deal of that time is spent on stand-by duties. During accident and emergency duty most of that time is not spent on stand-by. The doctor is actually on duty and is called upon to deal with patients in the middle of the night as well as working throughout the day. One has often met a doctor who has been on duty for 24 hours. We sometimes complain in the House about all-night sittings, but we have the opportunity of putting ourselves on standby and resting. When a young doctor is training he is often actually working for an intolerably long time. One has to recognise that the quality of his work suffers.

The Central Committee for Hospital Medical Services has proved to be the most vociferous opponent of some of our proposals. In general our report has been—the Minister accepted this—widely welcomed. It is probably the most compact and carefully thought out report that there has ever been on the subject. I believe that the majority of those who have studied it have reached the same conclusions as the Select Committee.

Nevertheless, there is tough opposition from the CCHMS. Indeed, I am prepared to accept one of its criticisms—that we perhaps did not deal as fully as we should with general practice and the movement of as much medical care as possible from the hospital to the community. There is no doubt, however, that our report has made those concerned think. It has forced them to come up with alternatives and to recognise that changes are unavoidable. Mr. David Bolt, for whom I have the greatest respect and who was one of our witnesses, wrote to me on 16 June in his capacity as chairman of the CCHMS enclosing an advance copy of a letter and ballot to be sent to its members. The letter, dated 25 June 1982, is headed: CCHMS Ballot on Manpower Initiative". It begins: Dear colleague, As you will be aware, the whole consultant body has been greatly disturbed by the Report of the Parliamentary Select Committee … with its serious implications for the future of the nature and pattern of consultant work.

Mrs. Renée Short

That is not true.

Mr. Ennals

My hon. Friend says that that is not true, and the whole medical profession and the consultants' body have not seen it as a threat. Nevertheless, the CCHMS sees it as a threat, and the CCHMS has great power and influence. The letter goes on to say that the consultant body has been disturbed by the activities of the Department of Health and a number of the Regional Health Authorities in seeking to implement the recommendations of the Report, creating a situation in which consultants in medicine, surgery and obstetrics may be appointed with no appropriate juniors support"— that was certainly not part of our recommendation— with a requirement to work a time-based programme by day to fit in with junior rotas and"— just listen to this— on occasions, to sleep in the hospital at night to provide essential cover.

Mrs. Short

We never mentioned that.

Mr. Ennals

No, but we recognised that our proposal must imply some adjustment in consultant practice. If we say that the main responsibility for patient care must lie with the consultant—and Mr. Bolt says that as much as we do—it must mean that there will be times at night as well as during the day when a consultant must be available. To refer in his first paragraph to sleeping in the hospital at night "on occasions" as though it were a monstrous demand shows an extremely reactionary—I can think of no other word for it—reluctance to change patterns, and we shall not achieve the improvements that we want unless there is a willingness to change patterns.

The concluding sentence of Mr. Bolt's covering letter says: I would remind you that, however strongly we may resist the Short proposals and their implementation"— I object to reports being referred to by the names of their Chairmen, as the proposals are those of the Select Committee, although I of course pay tribute to "Short" in this context— progress in that direction is inevitable unless we have alternative and strongly supported proposals to put forward, which will improve the career prospects of our junior colleagues while preserving the reality of consultant work as we have understood it for the last thirty years. One can, indeed, imagine men of 30 years' experience drafting that plea not to change their pattern of behaviour. The Minister will therefore be aware that there is opposition. Nevertheless, we hope that the Government will stand firm in accepting the main recommendations of the report.

I wish to deal briefly with three other matters, all of which are related to the main issues of the report. First, I greatly regret the extent to which many consultants exploit the private sector in health care and are indeed encouraged to do so. Had I tried to write that comment into the report, of course, some of my Conservative colleagues on the Select Committee would no doubt have objected. One of the great advantages of a Select Committee is that one does not try to write into the report recommendations that do not carry one's colleagues. One of the strengths of a report such as this is its unanimity.

Nevertheless, when we debate the report, we must be able to express the views that we hold dear. I very much regret the amount of consultant time given to the private sector, because every minute of it is time that cannot be given to the NHS. That is one reason why this is directly linked with the question of consultant time. One cannot expect to have the same arrangements for juniors working in the private sector. The private sector provides no training and lives like a leech off the State-provided system of patient care. Even though BUPA seems to be facing financial difficulties this year—a matter that causes me no great worry—there has been an expansion of the private sector, which is always to the detriment of the National Health Service.

The second related question is one with which I hope that Ministers are currently dealing. I refer to the damage caused to the NHS by the Secretary of State's handling of the pay problems and the current industrial problems associated with them. These matters are highly relevant and affect the service throughout the country. Newspaper headlines in my constituency refer to Patients in Peril as City heads for Disaster". We are told that about 90 per cent. of patients being admitted to the Norfolk and Norwich hospital were urgent cases. Surgeons have been asked to cut admissions by half, which means that a large number of urgent cases will not be admitted. Indeed, some departments say that they have not taken any non-urgent cases from the waiting list for about three years. The reference to "three years" has a certain relevance, of course, but the comment is a consultant's, not mine. The same spokesman went on to say that consultants have a good deal of sympathy for the pay claims of others in the Health Service. Indeed, we know that the employers made the position clear in a very strong resolution passed by the National Association of Health Authorities.

In this context, I thought that the Daily Mail headline "Fowler's Folly" was a little unfair. Even when I was Secretary of State and there were industrial relations problems in the NHS, no such extreme headline appeared in a newspaper that traditionally supports the Conservative rather than the Labour Party. I therefore say this to the Secretary of State in his absense. I very much hope that he will take urgent action, as I should not like his reputation to be so damaged that he cannot command the respect necessary to carry through against powerful odds the recommendations of the Select Committee.

My third and final point is touched on in the most recent report of the Select Committee, published only last month. Again, the matters involved are directly linked. Paragraph 2 of the First Report of the Select Committee, House of Commons document 191, entitled UGC Cuts and Medical Services", says: Besides teaching and research, university medical staff make a significant contribution to the clinical work of the National Health Service. Clinical academic staff in universities normally hold honorary contracts within the NHS, mainly at Consultant, Senior Registrar and Registrar levels. This means that they are expected to provide the same sort of clinical services to patients as their NHS colleagues. The service thus provided is part of their regular workload In our Fourth Report on Medical Education, which we are debating today, we noted that recent cutbacks in the UGC funding have made future prospects in some academic departments less certain". One can say that again. The problems are serious. The cuts in the Department of Education and Science budget for the universities and the part that the UGC must carry are doing serious damage to our medical schools. I welcomed the Minister saying that he accepted the targets that are set in our report for the intake in the medical schools, but they will not be met if the cuts are to be carried through.

I speak only for myself. When the Minister of State came before the Select Committee, he showed some complacency. He suggested that cuts of between 8 per cent. and 15 per cent. in medical schools would have no serious effect on medical education in Britain. When we gave our estimate, which was given to us by universities and medical schools, that probably by 1983–84 300 clinical posts would be lost, he thought that that was a gross exaggeration, although it was based on that evidence.

This action by the UGC, with no protection for the medical schools, is a form of vandalism for which we must hold the Department of Education and Science responsible. I hope that the Minister will convey to his colleagues the fact that, since they did not put up a fight against what the Department of Education and Science was going to do to medical education, there must be renewed efforts to ensure that some of the funds are put back in. Otherwise, much that we say in the report and much that the Government have accepted about the report will not be carried through.

Ministers are faced with fights on three fronts. First, there is the fight with consultants to carry through the recommendations contained in the report. Secondly, there is the fight with their Cabinet colleagues to get a settlement of the pay dispute, which is far more threatening than anything that we saw in 1979. Thirdly, they must restore some of the cuts in medical education. We shall judge the Government not just by the written words of their reply to the report, which I warmly welcome, but by their actions in those other areas.

10.53 am

Mr. W. R. Rees-Davies (Thanet, West)

I congratulate the Chairman of the Select Committee, the hon. Member for Wolverhampton, North-East (Mrs. Short), on the way in which she conducted the proceedings of that Committee. It was no easy task. I do so as the leader of the Conservatives on the Select Committee, on behalf of my colleagues. I stress the fact that the report was unanimous. It is important that I do so for this reason. We were helped by Tim Clark, Steve Engelman, Professor Parkhouse and particularly Neil Hendry from Aberdeen university. The Scots have a remarkable knowledge of much of these matters. They were the consultants to the Committee. None of us was a doctor. We had one dentist, but not a doctor.

I had considerable misgivings before concluding that we should take this subject on board. The reason can be put radically. I said that I did not welcome the thought of cross-examining the president of the Royal College of Surgeons to tell him that he must substantially reduce his consultant team and alter the acute specialties by having many more consultants and fewer junior doctors. At least I had the intelligence to recognise immediately that this was not likely to be a popular subject. We all recognise the legitimate and immensely powerful influence of the leaders of the medical profession, to which they are entitled. However, in part of the report it was inevitable that we were bound to make suggestions that at least some consultants would find undesirable.

The purpose of our report is to be found in our first two recommendations. The first is: A much higher proportion of patient care should be provided by fully trained medical staff than at present. The second is: In most hospitals and most specialities there should be an increase in the number of consultants and a decrease in the number of junior doctors. Those recommendations are fundamental. It is that matter to which I want to give direct consideration at the outset.

It is important that we should not allow the Government off the hook. I assure the House that the Government were glad that we took the subject on board, although, as the hon. Member for Crewe (Mrs. Dunwoody) rightly said, it had been considered many times before because nothing had been done to correct the manifest imbalances in the hospital medical career structure.

I am delighted to read on page 30 of the Government's reply to our recommendations that they have a strong commitment to moves to correct the present imbalance in the hospital medical career structure. It states that Ministers will be seeking regular reports on progress". Ministers say that they will find a way forward and that they do not underestimate the size or complexity of the job. I agree with every word of that. If they are to do so, it is no good shilly-shallying and saying that they will allow doctors to have exactly the say they want. The time has come when a problem that has existed for nearly 20 years must be solved to the benefit first of the public and second of all the medical profession, including junior doctors.

I am perhaps more indebted to orthopaedic surgery than any man in the House of Commons. I know some orthopaedic surgeons very well. My story illustrates the background of why we must make certain changes. When I was smashed up in the war, the great surgeon Rowley Bristow came to have a look at me at Pyrford. He realised that he could do nothing to save my arm and shoulder. He was there together with six other consultant surgeons and no fewer than nine junior doctors. I know that Rowley had a particular reason for wanting to try to save my arm and to treat me, but often the leaders of surgery have a large team that follows them. Acute specialty is most popular. It is a great honour to be with great surgeons, one of the greatest honours in the world. They are people who protect the background that has obtained for 30 years. The large teams that we had during the war still continue, but we have to recognise that there must be some changes there.

What is the difficulty? There has been in the past decade an increase of no fewer than 10,000 doctors, but of those about 7,000 are junior doctors and just under 3,000 are consultants. That picture has to be changed rapidly. We have to ensure that there is a ratio of 1:1 at an early date. There must be a rapid increase in the number of consultants.

There will not be any great objection if there is an increase in consultants in the shortage specialties. Indeed, in the shortage specialties there are in some instances almost enough consultants at present. In fields such as community medicine and psychiatry, there is not such a great shortage, although there is an increasing demand for more consultant anaesthetists, as there is in certain other fields. The position is serious, distorting the whole balance of the medical service. It does not require a doctor to see it. It is in the acute specialties—and particularly in surgery, orthopaedics, obstetrics and gynaecology—that a substantial change is needed.

The problem began when, unfortunately—I do not say this in any party sense—the Labour Government, in the days of Barbara Castle, got into great difficulty with the junior doctors, who were not being given a proper salary scale. As a result, there was brought into operation a diabolical system known as UMT—units of medical time. That is a system whereby the junior doctors are paid, not for their hours of work, but for being on call throughout the night. It is a necessity that they shall be on call, and they are paid very large sums of money, not for work done but for availability for work. That system was introduced because the doctors were not getting a decent salary. That is the background to the gross overwork of all the junior doctors.

I strongly agree with our recommendation that the junior doctors should not work or be on call for more than 80 hours, but it will, of course, involve, as we point out, a renegotiation of a work-sensitive contract. The Government must be sensitive about it, and all those involved must be sensitive to ensure that the junior doctors do not suffer in having their contracts altered.

Obviously, junior doctors would prefer to have more reasonable hours and to be on call for more reasonable periods, and it is essential to bring that about. The difficulty is that in the acute specialties about £3,500 to £4,000 of the income of the junior doctor is derived from the units of medical time—the period that he is on call. It forms a large part of his income.

In the shortage specialties, the doctors do not do nearly as well because they do not have to be on call. Therefore, they are unable to make as much money. Thus, in many of the shortage specialties there are much lower salaries than there are in the acute specialties. That in turn means that it is not so easy to get people to go into the shortage specialties, because they are not nearly as well paid as the acute specialties. The whole of that imbalance needs to be looked at and remedied.

As we have said in recommendation 27, the doctor's contract needs to be renegotiated, with a maximum of 80 hours. That, of course, involves changes in shift work and different patterns of work-sharing.

What advantages are the patients to get? I think that they will get considerable advantages. If there is more patient care by experienced consultants, much will be gained. First, as a result of greater efficiency, there will be shorter stays in hospital. Secondly, there will be reductions in the out-patient attendances. Thirdly, there should be fewer diagnostic tests.

Although in the past decade we have added about £100 million a year towards the pay of the doctors, very little additional cost will arise from the proposed changes if it is recognised that an increase in the number of consultants will provide increased efficiency and better patient care, as I believe it will.

In Birmingham, where we learnt a great deal about these matters—as we did in Aberdeen and elsewhere in Scotland—we found that two of the junior doctors on the surgery side were earning more than two of the consultant surgeons, because they were doing 120 hours a week. With a considerable volume of work, they were on call for an excessive period. They were getting up to about £13,000 a year. That illustrates the ridiculous nature of the system. We must recognise that it is a very difficult subject and must be looked at carefully and sympathetically.

It is said that the doctors can hit very hard. They can, and I do not see any reason why they should not. In recommendation 32 we say: The Health Departments and the GMC should work together in a positive alliance and assume joint leadership … to bring about the reforms". That was no idle recommendation. It was made because we recognised that there has to be a joint leadership.

There are too many disparate committees and organisations in the medical service, but it is very difficult to reduce their number. Obviously, once they have been set up and have been in existence for many years, supported by very able members of the medical profession, it is extremely difficult to reduce the number. But if success is to be achieved by the Government in this area, they have to recognise that they and the General Medical Council must work together in a positive alliance.

We want to see the Government carry out their commitment to consultant expansion without delay. We want to reduce the on-call and the working hours of junior doctors. We wish to achieve a ratio of 1:1 between consultant and junior doctors almost immediately, so that the leeway can be made up rapidly. I understand that we have got the regional standstill that we wanted on the senior house officers' establishment. We need to develop the hospital practitioner grade for GPs. I do not agree with the right hon. Member for Norwich, North (Mr. Ennals) who claimed that we left out consideration of hospital practitioners.

Mr. Ennals

I was quoting the BMA conclusion and agreeing that there was some justification for it. Perhaps we did not give as much attention as we should to the whole area of general practice.

Mr. Rees-Davies

That is true, but we were primarily concerned about consultants, junior doctors and acute and shortage specialties. GPs have an enormously important part to play in future hospital developments and I am sure that that is recognised by GPs and by the medical world in general.

The DHSS should start discussions to secure manpower control over clinical academic posts. The Committee said that it would like to see an appreciable increase in the number of mature students.

The Committee referred to the University Grants Committee cuts. We should remember that the responsibility lies with the UGC and not with the Government. It would be wrong for the Government to interfere with the independence of the committee. The UGC does a good job, but it is clear that it will have to inform the professions of the areas in which protection is needed for the future. It will have to outline which of the shortage specialties and academic posts should be protected. If necessary, the Government can supply additional funds from the special research fund.

The hon. Member for Wolverhampton, North-East and I attended a BMA seminar this week. I do not believe that the profession need have grave fears for the future. I am sure that the academic position will be safeguarded by the UGC and that we will not lose manpower control over clinical academic posts. I recognise that there are legitimate fears in that regard.

Mr. Ennals

Was something said at the seminar to imply that there would be replacement of the cuts? If so, the House ought to know about it.

Mr. Rees-Davies

Nothing was said by the medicos, but I say that, in the light of the evidence given by my right hon. Friend the Secretary of State for Education and Science, we can be assured that he has wide powers to provide additional research funds. That is his responsibility, and not that of the DHSS, and I believe that funds are available for research. I have been diverted from the subject of the debate, but if we are asking for control over clinical academic posts, and for more mature students, we must will the means.

The DHSS and the joint consultants' committee must try to solve some of the more difficult problems, including the scope for cross-consultant cover, flexibility in the allocation of registrar posts and the age structure of consultant teams. Greater cross-cover is needed at junior levels. Unless we consider the problems in the round, strong feelings may be aroused in the profession that would make it difficult for the Government to achieve success.

It is worth while to study and understand the problems of the manpower structure in the medical service. It is essential to recognise that the problem is largely psychological and, to that extent, political. The powerful and intelligent bodies of medical opinion represent an immensely strong lobby.

If we are to succeed in our aims, Ministers, the UGC where it is involved, and Government Departments must create an alliance in the recognition that we are seeking to improve the profession in every way, to sweep away anomalies that have crept in over the years and to introduce an improved service of patient care, with more consultants, particularly in the acute specialties, and better conditions for doctors who are almost all overworked.

I hope that many will believe that the Select Committee, which was chaired so well by the hon. Member for Wolverhampton, North-East, has arrived at some conclusions and made some proposals that will advance medicine.

11.18 am

Mr. Ronald W. Brown (Hackney, South and Shoreditch)

I welcome the excellent report on behalf of the Social Democratic Party and congratulate the Select Committee on the thoroughness with which it carried out its valuable work. We have had all the information for many years, but for the first time it has been brought together by politicians rather than by academics and that will make it much more valuable, because we can see it in the round from Parliament's point of view.

The hon. and learned Member for Thanet, West (Mr. Rees-Davies) was a little unkind when he was talking about the clinical academic posts. The problem is the Government's responsibility. When we discuss university cuts, the UGC says that it has been given a global sum by the Government. One goes back to the Government and is told that it is for the UGC to decide how it spends it, but on going to the UGC one is told that it is for the universities to decide how to spend it. Everyone pushes it down one stage.

The real problem lies in the total resources available. What happens thereafter is that everyone tries to maximise resources that are insufficient for the job. As the House knows, I serve on a regional health authority and I am also joint treasurer of a medical college. As a lay person, I am involved in these matters at the sharp end. That is why I find the report so excellent. Those with whom I work have welcomed it, although with one or two cynical comments asking what is new in it and suggesting that they have heard it all before.

One area where I am a little concerned is the ease with which the Government have accepted the report. Their response is quite outstanding. I do not recall any Government responding so well and so fully to a Select Committee report as they have done to this Fourth Report of the Select Committee on Social Services. But I come back to a point made by the right hon. Member for Norwich, North (Mr. Ennals). If the present university cuts are allowed to remain in force, it is almost impossible to consider the implementation of the aims of the report.

I identify especially the problem of the difficult specialties—pathology, geriatrics, psychiatry and general practice. Those of us who have had any responsibility to do something about it on the ground are aware of the difficulties. Unless positive steps are taken to take care of the already serious position in geriatrics, for example, no development will occur in that specialty. If we could compensate for the problems now it may be that the position would not be so serious. But the real issue that the House has to face is that these university cuts are to continue for the next two years. If that is the case, the future looks very serious.

I am especially anxious about general practice. I have raised this topic on a number of occasions because my own constituency has a particular difficulty. In my area we have an ageing group of general practitioners many of whom are located in less than attractive surroundings. The House has heard me deploy the arguments about the shop fronts from which they work. I pay tribute to the Department for helping me four or five years ago in trying to resolve some of these difficulties. However, it is hardly attractive for young doctors to go into general practice, and here we have to do the maximum amount of work to encourage young doctors to take up general practice.

I was extremely proud when St. Bartholomew's set up a chair in general practice—one of the few in the country. It has been established for some years, together with an enthusiastic team of local general practitioners in my constituency. The programme that they have created for training young doctors has proved remarkably successful and popular. I have seen it in operation. I have watched four or five young doctors being trained in GP work, and I want to put on record my tribute to the tremendous work that has been done by Dr. Salkind and his colleagues. It is a good example of what must be done in the rest of the country, because my understanding is that there are the same problems elsewhere.

The Committee's proposal, again supported by the Government, to double the number of consultants is to be welcomed. The need cannot be challenged. But here again the expansion rate is bound to be restriced by the revenue likely to be available over the next 15 years. It is no good the Government making pious statements to the effect that they are committed totally to such an expansion. They know that it is insufficient simply to say, as the Minister did, that they are committed to doubling the number but that they also have to ensure that there is a concomitant reduction in the number of junior doctors. The Minister knows that that is only part of the story. I do not accept that the resources are available to undertake this work immediately or even over the next two or three years. I hope that the Minister will be able to assure me that a study is being undertaken to measure the proposed expansion against the revenue likely to be available over the next 15 years.

I discuss briefly the problems facing the medical schools. In order to meet the Department's university cuts, my own college has suffered seriously because our students have been redistributed. That has resulted in the extremely difficult problem of having to reduce our academic staff by 50 per cent., which is an enormous step to have to take. Some will retire, some will go to industry, some to other jobs, and some will follow the students. Over the years, many of these people have made a very important contribution to the National Health Service but at the same time have contributed to teaching and to research. They have been able to obtain large sums of what we call "soft" money with which to continue the research work that is so necessary in many of these areas.

The Minister knows that we have this difficulty of trying to readjust to the situation demanded of us by the Government. It creates a problem for him and for us because, although, obviously, the consultants will give priority to the NHS part of their commitment, it follows that there will be a reduced teaching element and a severely reduced research element. I do not believe that the medical world can accept that. It is vitally important to continue teaching undergraduates and to give due weight to the importance of research.

I hope that the Minister will say what he sees happening in the future. Has he all the available information? Is he being kept up to date about the traumatic situation facing the medical schools, and does he intend at any time to have discussions with the Department of Education and Science about the dangers that I see in the route that we are following? The position will be irrecoverable if urgent action is not taken, and the medical colleges will be in dire straits.

Although the Select Committee and the Government place great reliance on putting junior doctors' contracts with the regional health authorities, I am not persuaded that a great deal will happen as a result. At the moment, the majority of non-teaching junior doctors are with the regions, anyway. The consultants are there. Since they form the majority, not surprisingly they support the status quo. But I have not heard anyone discuss what will be the effect in the teaching areas. What great advantage will there be? I hope that we shall hear the Minister's views. The Select Committee does not make it clear in its report why it made this recommendation.

The Minister spent some time discussing the hours worked by junior doctors. He rightly observed that their working hours were excessive, and he argued the need for a reduction. That is nothing new. It has been said for a long time. The right hon. Member for Norwich, North suggested that the consultants were being a bit obvious in saying that they would now have to do shift work, but it would not be quite as easy as the right hon. Gentleman suggested.

How does the Minister see these proposals working? We must remember that a junior doctor is anxious to be available and to keep an eye on cases.

Mrs. Dunwoody

He or she.

Mr. Brown

He or she—the hon. Lady is quite right. Whether or not the work is excessive, doctors who are dedicated to their work are anxious to be present. I accept that we have to do something to alleviate the situation. I do not accept the strictures of the hon. and learned Member for Thanet, West about UMTs. There must be some way to compensate people for giving up a large part of their life in pursuance of their profession, and in my opinion the UMT is one way to do that.

The right hon. Member for Norwich, North was caustic in his comments, but the BMA's document dated 16 June, of which I was sent a copy, makes an important point: Furthermore, implementation of the Short proposals, particularly in relation to hours of work, will inevitably require closure of numerous small acute units around the country, and a transfer of the work to more distant large centres where staff can be concentrated. I hope that the Minister will answer that important point. If it is said that the document was irresponsibly put out by the BMA, the Minister should say so, but thinking back to my own experience, it could be true. It is a situation that could arise in pursuance of the objective of reducing the enormous number of hours that are worked by junior doctors. It is incumbent on the Minister to tell us whether that statement by the BMA is wrong, and if it is why it is wrong. If it is right, perhaps he will explain what it will mean and how soon we can expect action to be taken.

I welcome the report. It has achieved a great deal in bringing together much that many people have known. For the first time, the information is contained in a whole document, and has been dealt with by our colleagues in the House, whom I congratulate on its production.

11.32 am

Mrs. Sheila Faith (Belper)

I am glad to have the opportunity to participate in this debate, as I am a member of the Select Committee. I add my congratulations to the Chairman, the hon. Member for Wolverhampton, South-West (Mrs. Short), who has handled this complex report fairly and well, and also to our specialist advisers, without whom we could not have managed to deal with such a complex medical subject.

I know that the Select Committee's report has received much approval by the Government, and I am grateful for that, and that many members of the medical profession are also pleased with it. However, I know, too, that many senior consultants have done a lot of heart-searching about it. Perhaps some of them feel that because similar recommendations in earlier similar reports have not been implemented in the past, this report may also be forgotten. I hope not, because when the Committee was looking for a subject for inquiry this matter seemed to be one that needed most urgent consideration, and after we started our inquiry, we realised that our concern was justified.

All the members of the Committee have the greatest respect for the consultants who work in our hopsitals. We know that their standards are very high, as was mentioned by my hon. and learned Friend the Member for Thanet, West (Mr. Rees-Davies). They have emerged to their present high status after an arduous and extended training, and they do not want the apprenticeship arrangements to be changed. It is understandable also that they do not want to reduce the number of junior doctors who support them. I am glad, therefore, that the Minister has assured us that the Government will not override their wishes.

However, the present situation cannot be allowed to continue. I know that we must have a real reduction in the number of junior hospital positions and a corresponding increase in the number of consultant positions over the next 15 years. Indeed, negotiations for pilot schemes have been commenced by the health authorities and the specialties. It is important, because it will mean that more hospital treatment will be carried out by fully trained doctors, and also because the most academically able of our young people are being recruited by the medical schools. It is sad if their talents are not correctly utilised, as they can spend years training for a specialty only to find no relevant consultant vacancies at the end of that long training. The problem has been recognised for many years. Yet during the past 10 years, the number of junior hospital doctors increased by 62 per cent., while consultant numbers increased by only 29 per cent. Thus, the problem has become more acute.

Previously this was not so important, because if a young doctor spent several years training to be a consultant and could not find a suitable position he could move sideways into general practice or community medicine. Now, community medicine and general practice have long training periods of their own. Moreover, emigration is not as easy as it was. As a result, there are now bottlenecks and even unemployment.

It is understandable that consultants feel that, if there is to be an increase in their numbers, and if the competition for jobs is not as great as before, there will be a drop in standards. If that is true, it is a sad reflection on the selection procedures in medical schools. As well as the intellectual ability which all successful applicants have, young men and women who are to become consultants need certain leadership qualities. If those attributes are not evident among these brainy young people, it is a sad reflection on our education system as a whole. Perhaps more important for this investigation, it means that there should be more careful selection of students. I welcome the recommendation in this connection, and also the recommendation which relates to proper career guidance for undergraduates in their final year and shortly before they qualify. During our inquiry we were appalled by the lack of guidance that was given in many medical schools. That was so many years ago when I was a student, but I had hoped that the importance of helping young people to make the right decision had been identified long ago.

Our Committee recommended that the student intake should continue to grow as arranged, but since we published our report I have heard of several instances of young doctors who cannot find suitable work, either in general practice or in the hospital service. Many of those people, both young and older doctors, do not register as unemployed because they are taking up temporary positions as locums. The situation is far from satisfactory.

I was pleased to see an advertisement in the British Medical Journal asking unemployed doctors to come forward so that their numbers could be ascertained. I know that the situation requires careful monitoring, because of the unhappiness and waste of resources that are involved. I noted that the Minister is aware of these difficulties, and that the Government are undertaking reviews and keeping the matter under scrutiny.

Because of the increasing number of elderly people in the population, there must be a suitable supply of doctors who are prepared to study geriatrics and work with elderly people. When the Committee visited Sweden, one prominent doctor thought that the problem was so acute that it warranted undergraduate training being extended so that all students could spend six months studying the problems of the elderly. This may be an extreme way of tackling the problem, but I welcome the Committee's recommendation that all newly qualified doctors should have early postgraduate experience in the shortage specialties, particularly geriatrics.

I heartily endorse the recommendation, as have other hon. Members, that a doctor's contracted week should be a maximum of 80 hours. Certainly Members of Parliament are well aware of the debilitating effect of sleepless nights. Nevertheless, it must also be noted that long hours are part of the intensive training required if young doctors are to develop into physicians and surgeons able to withstand the stress of long operations and clinical emergencies. Concern was expressed during our visit to Sweden that doctors were not receiving the intensive training necessary because of the shorter hours already in operation there and also that continuity of care was being affected.

We must also bear in mind that part-time jobs are particularly important to women doctors with families. I welcome the fact that the percentage of women students in the medical schools is increasing; it is up to 50 per cent. in some schools. But these women need to be assisted to continue to practise while their children are small so that they do not lose touch. They need part-time jobs which should be counted as part of their training for higher positions. It is regrettable that so many women are not being given opportunities in many specialties and tend to work in general practice and community medicine.

In our report we referred to geriatric and psychiatric medicine as caring services as opposed to curing ones. We have been rightly criticised for this by the Royal College of Surgeons. I take the Royal College's point and regret this terminology. "Caring" is an adjective much overused and I am sorry that we used it to appear to discriminate in this way. All doctors must be very concerned people if they are to take up this profession which is so arduous and difficult.

Young people who enter medicine are anxious to develop their talents in the best possible way. They need to be helped to recognise their real ability. Also, they require a real career structure if many of them are not to end up in a log jam.

I hope the report will be taken seriously. I welcome the Government's response and hope that the report will be implemented so that both the medical profession will benefit and the general public will receive a higher standard of medical attention.

11.42 am

Mr. Clement Freud (Isle of Ely)

I should like to begin by congratulating the hon. Member for Wolverhampton, North-East (Mrs. Short) and her Committee on the report and by commending the Government on the timely—if seven months is the right term for timely—response, and for having the debate only four months after that.

In common with most hon. Members who have spoken I should like to pay tribute to doctors, especially the doctors in my constituency. I remind the House that my constituency is a growth area, one of the few parts of England in which the population is steadily rising. In the nine years in which I have been a Member of Parliament I have lost all but cold surgery in the hospital at Doddington, I have seen the closure of the geriatric hospital in Wisbech and I have lost completely the maternity homes in March and Wisbech. Throughout this time my doctors in their health centres have done a splendid job in looking after the health of my constituents caring for them and covering for the loss of genuine hospital services that my constituents deserve.

I should like to raise several points in respect of the report. I was pleased to hear the intervention by the hon. Member for Crewe (Mrs. Dunwoody) during the speech of the hon. Member for Hackney, South and Shoreditch (Mr. Brown), because there is a bias against women in medicine, and particularly in medical education. The Government might well look at the numbers of medical students. I am not at all sure that the fact that the majority of these are men is not because there is an in-built bias against women medics. Of course, the argument is that women might get married and might have children and that the expensive training might be lost to the country. That is a poor argument because children grow up and medics last for a long time. There is an interesting chapter in the report that shows that women can come back and play an important part, if not in Parliament, then certainly in medicine.

I believe in the need to encourage and enhance medical education in the Cinderella services such as geriatrics, mental handicap, psychiatry and anaesthetics. In Japan, when one buys a motor car the whole specification of the car is computerised. When it comes off the assembly line it has the colour, the windscreen wipers, the overdrive and the silencer that the customer asks for. When a regional hospital authority is set up, one knows the number of anaesthetists, psychiatrists and other specialists that will be required. Yet the Minister will know how often there are closures or temporary or partial closures because in one of the disciplines one key person is missing. I hope that more careful planning will take place.

There is also a great need to enhance the status of general practitioners and community care in general; doctors must see themselves as part of a team. At present only the science of medicine is being taught; social skills and the correct approach to patients are being neglected. It has become ever more important, when we believe in ever greater education of the people, that a patient becomes a co-operative person and not a lump of flesh. There is an ever greater necessity to explain the choices to patients. The Minister said rightly that a minor operation might be minor in real terms but it is a major thing to the patient who is undergoing it.

The Minister should also pay attention to paramedics. In terms of the report it should be considered particularly in respect of those students who want a medical education but who fail in their application because their A-levels were not good enough or there were no places. As the whole House will know, there is a great need for people in chiropody, in speech therapy, in chiropractic and in osteopathy. On the last two I know there is the stigma of quackery, which is absurd because an osteopath is a highly qualified man, as is a chiropractor. One still finds doctors who have no cure for a disease but who are unwilling to refer the patient to someone who does not have a medical qualification. There are people who have troubles with their backs, troubles that will remain with them because of the bloody-mindedness of the odd doctor who did not say that this was a matter not for him but for a qualified osteopath.

All those who represent rural constituencies will know about the shortage of chiropodists. We who represent country people who walk from place to place and from ever more places to further places, because public transport has gone and stations have closed, will know that country people have trouble with their feet.

They have a right to have someone to come and see them and to make their feet better. Why is it that when my constituents want to study chiropody only discretionary grants are available, which more often as not are not awarded? I know that the right hon. Member for Norwich, North (Mr. Ennals) will have had experience of these problems. We in East Anglia suffer from bad feet and a shortage of chiropodists. If someone fails to get into medical college, there is no machinery that operates to refer him or her automatically to a paramedical discipline in which he or she can practise a science that is desperately needed by the community. Speech therapy is another example.

I would not be averse, and nor would anyone else, to seeing fewer indians and more chieftains. However, if we are to have more consultants and only a limited sum for expenditure on medical services, that is bound to lead to the diminution of doctors in general. There are many doctors—I refer especially to the advice from my hon. Friend the Member for Truro (Mr. Penhaligon)—who express doubt about the recommendation, and fear that it will lead to less care for patients. When the career structure is re-examined and more doctors become consultants, I hope that those who suffer will not be the pensioners. They are the ones who least deserve to suffer.

I will not take the time of the House beyond this point other than again to commend the Committee. It is so easy to read a report of this nature without realising how much work, thought and energy has gone into it. The whole House owes a debt of gratitude to the Committee.

11.52 am

Mrs. Gwyneth Dunwoody (Crewe)

I join those who have already spoken in welcoming the Select Committee's report. I especially congratulate the Chairman, my hon. Friend the Member for Wolverhampton, North-East (Mrs. Short), on her success in bringing together what must have been different strands of thought. It is a subject on which many people have many personal opinions.

Since its inception the National Helth Service has grown in a rather particular way. It has become a firm pyramid. Although the base is extremely wide the point of the pyramid has become sharper and more difficult to ascend as we have progressed. It is important, when we are talking seriously about patient care, to think about the best ways in which we can improve facilities to ensure that at every level of the service the very best possible patient care is available at the moment when it is most needed.

I welcome the report because it tackles two subjects that are vital. First, it deals with the need to extend consultant cover. The Minister for Health, who unfortunately has had to leave the Chamber, seemed to suggest that the reaction to the report would almost inevitably be a non-party one, that there would be total agreement throughout the House and that we would all be able to accept many of the recommendations and the Government's response to them. That may be true in terms of general principles, but totally lacking in the Minister's speech was any understanding of the one basic fact that very few changes can be brought about unless they are properly funded.

Resources form the basis of many of the improvements that we need in the NHS and it is fundamentally hypocritical to suggest that we can increase the number of consultant posts, slow down the recruitment to SHO and registrar grades and somehow find the money to fund those consultant posts by changes within the service. The average consultant is rightly one of the greatest expenses in the NHS. If we were to sack every ancillary worker in the average district hospital, we would still not make anything like the cuts that would be made by changing the consultants' posts. Consultants do not operate in a vacuum. They are a part of the team. It is the consultant who decides on bed use, writes prescriptions and demands back-up teams and investigations. I am sure that the Under-Secretary of State has learnt already in the short time that he has been in the Department that any attempt by hon. Members to introduce restraint in permitting access to such services would be strongly resisted by the medical profession.

When we are discussing a change of the sort that is suggested in the report we must be realistic about the talks that will take place with the members of the medical profession who are most concerned and about the way in which we can positively assist in bringing them about. I welcome the suggestion that there should be an expansion of consultants' posts. The career opportunities for registrars and senior registrars will be improved enormously by the changes that are recommended. However, there are a number of areas in which we need to give rather stronger guidance.

It is true that most of us who generalise about junior doctors from time to time fall into the trap of giving excessive weight to the difficulties of some acute posts. However, the reality of the junior hospital doctor's life is that he spends far too many hours on call. If he is in a busy unit, he will inevitably be working for many of those hours.

One of the techniques of brainwashing that is used unfortunately only too freely throughout this unhappy world is to deprive people of sleep. It is well known that if people are consistently deprived of sleep they will be incapable of making coherent decisions or of using their own brain effectively at the end of a number of days. Unfortunately, there are occasions when young doctors, male and female, are on call for many, many hours and are required to make important policy decisions and clinical decisions at the end of their period on call, decisions of the same importance that they were called upon to make at the beginning. This is a crazy way of working. The Department must take a lead in limiting the number of hours that junior hospital doctors work.

In dealing with consultants who were junior hospital doctors 30 years ago, it is inevitable that there will be an element, conscious or unconscious, that will say "I had to go through all that. That was the way that I learnt. I had six months when I hardly went to bed and why should these people be any different?" That is not a real answer. As junior hospital doctors' posts change so frequently it is almost inevitable that they will be unable to build up a good pressure group to defend themselves.

The role of the senior consultant is all-important. I know that there are occasions when senior consultants could change the operating patterns of their juniors, but because of their own personal feelings they frequently do not do so. I hope that the Department will not just pay lip service to that suggestion but will do something positive to ensure that, before long, those changes are brought about.

I warmly welcome the suggestions and the evidence in the report about overseas doctors. My right hon. Friend the Member for Norwich, North (Mr. Ennals) was rather crushing about the Central Committee for Hospital Medical Services and its comments on the report. I agree with many of his strictures. However, it is a fairly realistic assessment of the problems of overseas doctors and points out that two sorts of people find themselves working in the NHS. One is the doctor who comes from overseas expecting to achieve higher qualifications and to benefit from an excellent system of university training. The other is the overseas doctor who settles here and wishes to bring up his family.

We must examine the question of posts for overseas doctors. We should have agreed training posts earmarked for those who wish to obtain higher qualifications. They should not be trapped in some of the jobs that British doctors do not wish to do. Overseas doctors should know that, in normal circumstances, they can expect to progress through the training system to consultant level. I hope that the undertaking that the Minister gave to me this morning, not just to talk to the British medical establishment but to the Overseas Doctors Association, which has much evidence to present to him, will be followed up urgently. In that way we can make a positive contribution to improving the standards of medical care in the Third world and also ensure a desirable standard of doctors in the NHS.

The changes that are suggested in the report will require much planning. There we find an ambivalent response by the Department because, while it suggests cutting the planning facilities of the DHSS, it says that it will require careful monitoring to ensure that the posts will not be filled by senior house officers but only by consultants. One cannot have an adequate planning machinery that relies on the Minister calling in regional hospital chairman once a year and asking them what they are doing in their Department. The Government's commitment to the ideas of Sir Derek Rayner will be in direct conflict with their expressed views on the report.

I disagree with the suggestion in the report that doctors' contracts should be with regional health authorities. There is a good argument for leaving consultants' contracts at district health authority level. I know that that is opposed by the profession, but inevitably the employing authorities will be one step removed from their employees, which is unsatisfactory. There are some difficulties with the suggestion that registrar posts should be monitored only at that level. It must be done by agreement, and manpower planning must be carried out in the widest sense from the DHSS down to district health authorities.

The report must be read in conjunction with the report on the cuts in the University Grants Committee funding for medical education. The Minister did not say that the changes that he is seeking in medical education will be undermined immediately by cuts in the funds available to the university departments. That is not just a question of worrying about academic posts. Universities provide a high proportion of practical patient care in clinical medicine. In Southampton, 36 per cent. of emergency admissions and 50 per cent. of children's cases are dealt with by academic clinical staff.

The Committee pointed out that Britain must improve its child care, but if the UGC cuts in medical schools are allowed to go ahead almost inevitably patient care will suffer. The regional health authorities that are already below target will be worse off this year than last year. It was suggested that the NHS would be prepared to pick up the tab for academic posts if the position did not continue for too long, but there is no evidence that Ministers are prepared to do that. Indeed, they do not even seem to be prepared to acknowledge that the position is deteriorating rapidly. Scottish universities were so worried that they conducted a survey and are prepared to earmark their own funds to ensure that the UGC cuts will not damage clinical medicine. I hope that the Under-Secretary of State will make something other than pious comments about the need to protect medical education in general.

That brings me to some omissions from the report. I wished to have a much wider examination of the intake of medical schools. There is too narrow a class base for the choice of medical students. Although I welcome the changes for women students, I wish to see a greater intake of mature students. The report says that there should be an increase but I wish to see a substantial increase. There is no doubt that one will lose a slightly higher proportion of mature students during the training period than if one takes people straight from school, but mature students have so much to offer that the Department should make positive efforts, in conjunction with the Department of Education and Science, to encourage the trend. Mature students, especially those who have worked in the NHS, often make extremely good doctors. They have not only had experience with their families but their jobs have brought them into direct contact with the problems with which sympathetic and intelligent doctors deal.

The university that makes the most effort in that direction—Southampton university—will be most damaged by the UGC cuts. That is another example of the Government's ambivalent attitude. They welcome improvements but they remove the means by which the improvements can be brought about.

Mr. Ronald W. Brown

There are no such restrictions at St. Bartholomew's hospital. It receives 2,000 applications for what used to be 200 places but will now receive 2,000 applications for only 100 places.

Mrs. Dunwoody

It does not matter how many applications there are. Unless one has the money to fund the teaching positions, it will be impossible to offer opportunities to students.

When we talk about medical education we must concern ourselves with the whole question of general practice. It is in primary care that we are most in need of an improvement in our National Health Service. It will become an increasing problem as the years progress.

I understand that there is a dichotomy of views among medical practitioners. I should like to see the universities, particularly the medical schools, extending the amount of work that they are prepared to do. Although there are some chairs of general practice, there are not nearly enough, and the departments are not often encouraged to do the wide range of work that they could usefully do.

Almost inevitably, we return to the question of the medical profession's approach to the suggestions in the report. Doctors are part of a medical team. They operate not independently, but with others. The report shows the way in which we could produce a much better standard of care within the National Health Service. It is impossible to believe that the Government are serious when they suggest that somehow or other that can be magically created without a change in resources.

If we are to change the whole structure of consultant care to encourage them to do a great deal more of their own legwork, we must give them access to improved facilities. Some members of the medical profession suggest that consultants can give a better level of care in the private sector because they deal directly with the patient all the time and yet they resist the changes in this report. They say that in future they might have to do a great deal of the work that at present is done by juniors. They cannot have it both ways. If they want to extend private practice and to use the argument that the advantage to the patient is that they would always be dealt with by the consultant, they must be prepared to use the same standards for the NHS. Surely all hon. Members would agree that on that basis there are good hopes that we can improve the service that is generally available.

I want to see a balanced medical training available to a wide cross-section of students, not just in terms of male and female but in terms of social class. It is not suitable that medical students should come from social classes 1 and 2. The results of that can frequently be seen in the gaps in communication that exist between the doctor and the patient.

There is a great deal of room for change in the attitude of some consultants towards women students. I am thinking particularly of a student who was told by her consultant that she had no hope of becoming a consultant in surgery because she was not only black but a woman. I could not decide from that which she felt was the greater disadvantage.

There are a great many reasons why we should follow the recommendations in the report. After all, the National Health Service is, as the Secretary of State is fond of telling us, one of the largest employers in the State. It needs to be one of the most sympathetic, to improve its industrial relations and to improve the quality of its care. It will do that only if the Government give it the necessary resources and encouragement.

12.13 pm

Mr. Gerard Fitt (Belfast, West)

Northern Ireland and its problems have taken up a great deal of the time of the House this week. However, it is only right that I should detain the House for a few moments this morning to place on record and highlight the fact that the problems contained in this report are also applicable to Northern Ireland. Yet there has been no input from Northern Ireland sources to enable the Committee to reach its conclusion.

I have spoken to many young junior doctors from Belfast this morning who are fearful that the Government response will apply only to hospitals in this part of the United Kingdom and that Northern Ireland will be denied the benefits that the Government are proposing to comply with in the White Paper.

The whole of the United Kingdom—if not the world—recognises the important part that hospitals and their staff in Northern Ireland have played in that troubled part over the past terrible decade. When a junior doctor is on duty in Northern Ireland he is far more likely—particularly in the city of Belfast and in my constituency of West Belfast, within which is the Royal Victoria hospital—to be called out than any other junior doctor in a comparable city in the United Kingdom.

The whole world owes a deep debt of gratitude to the medical staff in the Royal Victoria hospital, and in other hospitals throughout Northern Ireland, for the tremendous work that has been done and for the skill and sophistication that has been brought to bear on the horrible injuries that have had to be dealt with in Northern Ireland.

It is not fair that there are junior doctors in the Royal Victoria hospital at the moment who are on what is known as a "one in two rota". That means that those young doctors, male and female, are on call for 106 hours in a week. That is a deplorable set of circumstances for anyone, no matter what a person's employment may be, but particularly so in the medical profession.

With that in mind, it is particularly relevant to look at paragraph 33 of the report. It says: Patients may s lifer not only from a doctor's inexperience but also if the doctor is worried, frustrated or unhappy in his or her job. One cannot afford therefore to dismiss the complaints registered by junior doctors as self-interested pleading. The discontent of young doctors may will be affecting the standard of patient care. Moreover, on present trends this discontent is likely to worsen unless the root causes of the problems are confronted. The only way that those doctors' lives can be made more bearable and they can be given a sense of their future is to recognise that no one in 1982 should be asked to be on call for anything like 106 hours a week. Eighty hours is far too much.

The major recommendations in the report will cause controversy and will be met by opposition from interested parties. Only a few weeks ago a television programme on Aneurin Bevan highlighted the serious conflict and opposition that he met from the consultants who, at that time, were opposed tooth and nail to the implementation of a welfare state.

I agree with the hon. Member for Crewe (Mrs. Dunwoody) that there appeared to be an air of euphoria created here this morning by the Minister. He said that there was no conflict between those who compiled the report and the Government's response to it. I can foresee that there will be a great deal of conflict because it will take a lot of money to bring about the improvements that are recommended in the report. I do not believe that it can be left to the internal administration of the Health Service to find a solution to the problems without any real conflict.

I have tremendous admiration for the medical profession, particularly for the wonderful work that it has done in Northern Ireland. However, some consultants are like some QCs. They regard themselves as the elite of their profession. They do not want an increase in numbers because that may have an effect on their way of living. The Minister can expect opposition. The changes that he has envisaged are not comparable to the changes demanded in the report.

Junior doctors in Northern Ireland are entitled to a better deal and more consideration. The recommendations may never be implemented in Northern Ireland. I understand that it will be left to the Department, or some other institution, to decide whether to implement the recommendations. I should like a firm undertaking that the recommendations will be implemented in Northern Ireland.

The Minister said that he envisaged the changes coming about in a spirit of friendliness and conviviality among junior doctors, consultants and the present Administration. That will not happen. Doubts have already been expressed about whether the report is just another of those recommendations that are pigeon-holed and never implemented.

A time limit should be set so that the Government can say to the administrators and consultants "You have seen the recommendations. We agree with them. They are necessary and long overdue. Begin right away to implement the proposals. If at the end of a year, or two years, it appears that you are stone-walling and preventing the implementation of the recommendations, we shall legislate the terms and conditions of junior doctors. We are not prepared to be met by a stone-walling opposition with an axe to grind." Paragraph 108 states: At present many patients never actually meet, let alone are treated by, 'their' consultant. This is clearly unacceptable. That is a condemnation. The welfare state has many defects and is not funded to the extent that it should be, but everyone should have the right to see the consultant in charge, whenever his services are required.

The Government must accept that the report will be welcomed by the majority. Steps should be taken immediately to increase the number of consultants and to reduce the number of hours worked by junior doctors in our hospitals.

12.23 pm

The Under-Secretary of State for Health and Social Security (Mr. Geoffrey Finsberg)

The Social Services Committee has done a valuable service in drawing attention to the need to take early action to solve the present unacceptable medical staffing structure in hospitals. I pay my tribute to the hon. Member for Wolverhampton, North-East (Mrs. Short) for the hard work that she and her Committee put into the report. I sat for several years with the hon. Lady on the Expenditure Committee in the last Parliament, and I know the immense amount of work that she does. It is right that the report should bear her name. Without her driving force I am not certain that we should have such a valuable report. Of course, she had a first-class Committee to help her, but first-class Committees find it difficult to operate without a good Chairman. I pay my warm tribute to her.

It is clear that for far too long too little has been done to solve an ever more serious problem. It would have been easier to tackle it when resources were growing. If the growth in resources available for medical manpower overall in the last decade had been devoted to achieving the growth in the consultant and junior grades at the rate set out in the progress report agreed between the Department and the profession 10 years ago, the imbalances in the structure that we now face would already have been largely, if not completely, eliminated. Now, constraints on resources are likely to make it harder to tackle the problem. However we realise the need and we welcome the increasing recognition of that need among the profession. We intend, therefore, to take advantage of the change in mood.

The hon. Member for Belfast, West (Mr. Fitt) was not in the Chamber for most of the speeches after the introduction because he was talking to junior doctors. One of the most remarkable things that came through all the speeches bar one was the recognition that something unusual had happened in that one of the swiftest and most positive reponses from a Government to a Select Committee report had been made. The hon. Gentleman's words rather jarred in the face of that. I hope that when he reads the report of the debate he will accept that his remarks were less kind than they usually are.

The hon. Member for Wolverhampton, North-East referred to senior registrar posts and said that she was worried about them. The number of such posts are related to the number of opportunities for promotion to consultant status. As soon as it becomes apparent that new senior registrars are needed to meet consultant expansion, the Department, on the advice of the central manpower committee, would authorise them forthwith. If there is the need there will be no waiting until April 1983.

My hon. and learned Friend the Member for Thanet, West (Mr. Rees-Davies) underlined the importance that the Committee attached to patient care. I endorse that.

I hope that the hon. Member for Hackney, South and Shoreditch (Mr. Brown) will forgive me if I do not discuss in great detail the University Grants Committee because that is not the subject of today's debate. We have to await the Government's reply to the Select Committee that investigated that. I am sure that there will be an opportunity in due course for the House to examine what the Government say.

The hon. Member for Hackney, South and Shoreditch also referred to geriatric medicine. The position is not as gloomy as it might be. This Government, and their predecessors, paid particular attention to that aspect. With the growing numbers of elderly people in the population it is an important specialty. Recruitment to geriatrics is improving. The Department has been encouraged by that, and is encouraging it. I do not deny that much more needs to be achieved but there has been considerable progress.

Consultant numbers have almost doubled in the last 10 years from 227 in 1971 to 424 in 1981. We can look forward to continued progress. It is noteworthy that more and more consultants combine general medicine and geriatric medicine. Such posts are also being created in addition to purely geriatric posts.

My hon. Friend the Member for Belper (Mrs. Faith) made a valuable contribution in which she highlighted the often difficult personal problems experienced by consultants. She analysed the attributes and leadership required. We shall study her analysis.

The right hon. Member for Norwich, North raised the question of junior doctors. He will be encouraged by the recent survey done by the Office of Manpower Economics for the review body. It suggested that 10 per cent. of junior doctors in all grades are actually working for 80 hours or more rather than being on call or stand-by. In some hospital accident and emergency departments they may work more, but the general picture is encouraging. Those are the only kind remarks I can say about the right hon. Gentleman. He introduced the one jarring note into the debate by riding his hobby-horse of prejudice against private medicine. It was quite unnecessary to raise that spectre today. I completely disagree with every word that he said.

The right hon. Gentleman brought in a further jarring note by referring, unnecessarily, to the industrial dispute. All he did was reinforce the Government's strong view that any dispute in the Health Service harms patients. I regret that those remarks were included in what otherwise was a wholly bipartisan, non-political debate.

Mr. Ennals

The hon. Gentleman knows that the bulk of my speech dealt with an agreed bipartisan report. I am perfectly entitled to say how I approach other issues that touch on the report. The fact that the hon. Gentleman disagrees with me is no reason for him to object. This is an open House. If we all repeated each other, it would be boring to the nation.

Mr. Finsberg

That makes the point exactly. All too often individual hon. Members attack the Government, and the Government do not respond. When the Government say that this is not the time to introduce a jarring note, the sensitivities of certain right hon. Gentlemen get in the way. The right hon. Gentleman's remarks were a completely unnecessary intervention in what was, up to then, a helpful and sensible debate.

I know the problems regarding feet in East Anglia that were mentioned by the hon. Member for Isle of Ely (Mr. Freud). I occasionally buy shoes in Ely and Littleport. I shall discuss those problems with him at a more suitable moment.

The hon. Member mentioned the difficulty found by women in obtaining proper recognition in the medical profession. The latest figures available to the Department show that 40 per cent. of the current intake of medical students are women. That is an encouraging figure. Women make up 25 per cent. of junior doctors. The percentage grows year by year.

Mrs. Dunwoody

How many are consultants?

Mr. Finsberg

They make up about 12 per cent. of consultants and that figure is growing. That is important.

I shall draw the attention of my right hon. Friend the Secretary of State for Northern Ireland to the remarks of the hon. Member for Belfast, West so that they can be carefully considered in the context of Northern Ireland

Mrs. Dunwoody

Is the Minister saying that the changes that we have been discussing would not apply to Northern Ireland? It is too important a matter to say that they will be looked at in the context of Northern Ireland. The hon. Member for Belfast, West (Mr. Fitt) was seeking an undertaking that they would apply there.

Mr. Finsberg

The hon. Member for Belfast, West and the hon. Lady know that there is a Secretary of State for Northern Ireland and a Northern Ireland Health Department. I cannot commit them, as they know. I repeat that I will draw the matter to the attention of my right hon. Friend.

I return to the question of finance and the effect that reductions in spending will have on the Health Service. The debate has been important because a number of hon. Members, including the hon. Member for Crewe, referred to the report that the Social Services Committee published last month, following its inquiry into the effects of reductions in university finances on the National Health Service. We are considering that report at the moment. I cannot pre-empt the reply that will be laid before the House. A number of important issues have been raised, and some background information might help to put them in context and allay any worries that hon. Members may have.

First, as has been acknowledged, decisions as to how much of the resources available for education should be allocated to the university sector rest primarily with my right hon. Friend the Secretary of State for Education and Science. As the hon. Member for Hackney, South and Shoreditch said, it is then for the University Grants Committee to consider, within that allocation, how the available resources should be distributed among the various universities. It is then for each university to decide, within its own allocation, taking into account advice and guidance from the UGC, how resources should be distributed among its departments and faculties.

The House will appreciate, therefore, that the overall reductions in university finance are not necessarily reflected in the savings that medical schools are being asked to find as a contribution towards those economies.

Mr. Ennals

Is the Minister saying that the effects upon patient care and medical research of decisions taken by his right hon. Friend the Secretary of State for Education and Science and implemented through the University Grants Committee are in no way the concern of himself and his Department?

Mr. Finsberg

If the right hon. Gentleman will show his usual patience and tolerance, I shall come to that point. As he has pointed out, the important question is the extent to which services to patients are likely to be affected. Given the complexities of the system, it is difficult to measure the effects with precision. We shall, of course, study the matter carefully before responding to the Select Committee report. At this stage, I simply make two general points.

First, we must remember that not all medical academic posts provide patient care. Many are concerned primarily with undergraduate teaching or with research.

Secondly, the contribution made by university medical staff to NHS services must be seen in perspective. In Great Britain as a whole, academic staff who also work in the NHS form less than 10 per cent. of the total and less than 5 per cent. in terms of whole-time equivalents in the numbers of hospital doctors. Overall, the numbers affected by reductions in university finance represent a very small proportion. They tend, however, to be concentrated in particular areas of medicine.

Earlier this year, a survey conducted by the National Association of Health Authorities showed that a total of 88 academic posts in England, whose holders provided some clinical services within the NHS, had been affected by reductions in university finance. At that time, health authorities judged that six of those 88 posts were of sufficient importance to the NHS to warrant its taking over financial responsibility for them. Although the holders of a further 29 of the posts provided substantial clinical services, their contribution was not considered sufficiently important to warrant the NHS taking them over. Perhaps this is best seen in perspective if we realise that in the 12 months ending September 1981 the resources made available to English health authorities enabled them to increase their hospital medical staff by more than 700.

As the hon. Member for Wolverhampton, North-East knows, we have circulated the Select Committee report and our response to it to the health authorities. We have asked them, first, to apply a standstill to the number of senior health officer posts in their regions and, secondly, to draw up plans to redress the balance between the numbers of consultants and training grade posts in their regions, with the suggestion that they adopt as a target the achievement of a one-to-one ratio between the grades by 1988.

Mr. Freud

When that one-to-one ratio is established, will the consultants work hours similar to those worked by the doctors?

Mr. Finsberg

My immediate response to that question is that if the volume of work remained the same and if the spread of work between the different types of people carrying out the appropriate pattern of treatment to patients remained the same, there would be the change in the number of hours for consultants as opposed to those for junior doctors that I think is behind the thinking of the hon. Gentleman. As it is impossible to say what the position will be by 1988, frankly such a hypothetical question cannot receive an answer of any value to the hon. Gentleman, much as I should like to assist a fellow East Anglian.

Mr. Freud

Is "No" the word that the Minister was searching for?

Mr Finsberg

"No" might have been the word that I was searching for. Had I said it, I would have been told that I was too brief, so I was trying to give the hon. Gentleman the answer that he expected me to give.

We shall discuss the authorities' progress in those directions during our regular discussions with them. Those discussions are not held just with the regional chairman but with the entire team of officers. Therefore, the discussions are much more detailed. The hon. Member for Crewe (Mrs. Dunwoody) will appreciate if she talks to the officers who have been on those teams that they found that it was an extremely valuable dialogue, which will turn out to be constructive and in the interests of the National Health Service.

Mrs. Dunwoody

Is the Minister aware that consultants need considerable teams to back them up? In my constituency a number of consultant posts have not been kept in step with registrars, nurses or bed use. The result is disaster. Will the Minister consult multi-disciplinary teams as well as regional health authorities?

Mr. Finsberg

The hon. Lady raised the question of the reviews. There will be wide consultation because otherwise what we did would be so much in isolation that it would not help.

Much of what the Select Committee has recommended is a matter both for the professions and for the educational bodies. We shall also discuss with them how best to take the matters forward. Some aspects of our Committee's recommendations and our proposals attracted criticism from a number of quarters. That criticism has been reflected in some speeches that have been made in the Chamber.

Some comments have been made about finance. It is important yet again to set the record straight as to what has been achieved over the past few years. By the end of this financial year, funding for health authorities will have grown by about 5.8 per cent. above the level that we inherited in 1978–79. If capital expenditure and expenditure on family practitioner services are included, that increase is over 6 per cent. That has been real growth, excluding inflation.

For the next two years, 1983–84 and 1984–85, we believe that health authorities should be able to increase efficiency sufficient to provide further growth in services of about ½ per cent. per year. We shall consider during the 1982 public expenditure survey whether the provision should be revised having regard to the availability of resources and the scope for improved efficiency.

Mr. Ennals

I am obliged to the Minister for giving way. Does he realise that, if he is saying that there will be growth of ½ per cent. per year in the next two years, he is saying that there will be a reduction? The Minister should know that at least 0.7 per cent. is required simply to deal with an ageing population and the extra demands that it makes. We must get up to 1 per cent. and over before any growth starts. If the Minister is telling us that there will be only ½ per cent. growth, he is telling us that over the next few years we shall expect significant decreases in resources—not growth, but cutbacks.

Mr. Finsberg

When we are talking about the next two years we must set the increase against the increase of over 6 per cent. in real terms that already exists. If the right hon. Gentleman will add those years together, he will see that there has still been a significant real growth.

I have said that we shall consider, during the 1982 public expenditure survey, whether the provisions should be revised having regard to the availability of resources and the scope for improved efficiency. But that, I suggest, will make it even more necessary to ensure the optimum use of available resources. When resources are short, it is vital that we should be able to call on the most experienced doctors and to give them the maximum degree of freedom to look after patients. After all, experience should mean that doctors are aware, not only of the most, but also of the less sophisticated means of treatment, and better able to assess the most beneficial and cost-effective means of treatment.

What is vital, however, is that there should be the fullest involvement of all concerned in the planning and running of the service, to ensure that the best use is made of all available resources.

We shall be discussing with each region the question of the senior house officer standstill. As I have said, we have asked for a standstill and not a freeze. We shall be discussing what should be the base line for that standstill, taking account of commitments already entered into for service developments. Once that base line is established, all that regions will have to do and will be asked to do is to ensure that, where a new post is created, a corresponding post elsewhere is closed, so that overall numbers within the region may remain within the agreed ceiling. Once a ceiling and figure are in operation throughout the country, we can then assess what further fine adjustments will be needed to ensure that numbers in the grade keep in step with any future changes.

Mrs. Dunwoody

How will the Minister reach his base line? Will he take account of those SHO posts that are vacant at present? Will they be included in his calculation? It will be quite wrong if those regions that are already behind in numbers of posts lose out because they have vacant posts at present.

Mr. Finsberg

It is precisely for that reason that I said that we shall be discussing with each region what the base line of the standstill should be. We have not yet made up our minds finally, and the hon. Lady's point is one that we shall be considering.

I was asked about the nature of consultants' work. It has been implied that we are proposing a radical change in their work, and that that will prevent consultants from providing continuity of care for patients and necessitate a drop in standards for appointment to the consultant grade. That was one of the fears raised by my hon. Friend the Member for Belper (Mrs. Faith). I do not believe that any of those fears are justified, because our proposals do not envisage any substantial alteration in the nature of consultant work as it is now carried out in many areas.

The pattern and the nature of consultant work must vary. Inevitably it does, and it always has varied, from unit to unit and from specialty to specialty. Some consultants work—as the hon. Member for Crewe and many others have said—as the leaders of large teams; others have no support, or only very limited support, from doctors in the training grades. Our proposals are sufficiently flexible and will allow for either pattern to be retained if it is shown to be the best way to provide the service for patients and to provide experience for doctors in training.

The chief characteristic of consultant work, which sets it apart from the work done by staff in other grades, will continue to be the level of expertise and experience which consultants bring to a range of duties, and not the number of supporting staff. Nothing in what is now proposed will alter that.

There is no doubt that experience has shown that the subjects we have been discussing today arouse very strong feelings among those closely involved, and that is a healthy position.

However, it should be a matter of public concern that we tackle the problem. That is why we particularly welcome the important contribution that the Select Committee has made to broadening public understanding. Many of the reports that the hon. Member for Wolverhampton, North-East catalogued did not strike the public imagination as much as her report has done. Because of the importance that the Committee, the House and the Government have attached to her report, it should broaden public understanding and a report with such understanding can achieve much more than cold, clinical, analytical reports that may be first class but end up on a shelf gathering dust.

We hope that public understanding will enable us to find ways forward. The public response to the report has shown that while there are many difficulties and misunderstandings as well as entrenched attitudes to be overcome, there is also a genuine understanding of the need for progress. It would be wrong for anyone to imply that the entire medical profession is against any change. The hon. Member for Wolverhampton, North-East would be the first to agree with me on that.

There is a long hard job to be done and the way forward will not be easy, but I believe that, in the light of what has been said in the debate and of the Government's determination, the future looks hopeful and that can only be to the benefit of patients.

The Lord Commissioner to the Treasury (Mr. Peter Brooke)

I beg to ask leave to withdraw the motion.

Motion, by leave, withdrawn.