§ 3.59 p.m.
§ Debate resumed.
§ LORD EVANS
My Lords, in spite of the kindly comments of my noble friend Lord Taylor, I cannot rightly claim that the subject of this debate is the entire reason for my too infrequent appearances in your Lordships' House. There has been a brief time to consider some of the aspects of this subject, which has been so well introduced. If one recalls the good health of the nation during the war one might ask: is there really a shortage of doctors or not? Then, as the fantasy goes on, one hears at one moment that there are too few registrars, and the next moment that there are too many. So one wonders, perhaps: are there too many doctors doing too little? But, however fantastic these thoughts may be, the cold truth, I think, is that we are facing a fantastic shortage of doctors at the present time. In the country as a whole one quarter of all the house officers—and your Lordships will know that by "house officers" we mean resident doctors in hospitals, including surgeons 1152 and physicians—come from overseas, and actually 50 per cent. of the emergency surgery is carried out by these very people. It is I think true, alas! that without these 3,600 people the National Health Service would not grind slowly to a standstill; it would competely break down. No doubt your Lordships will bear in mind this problem of the overseas doctors when you come to consider the Immigration Bill.
This situation seems to be an extraordinary one, when at the same time we find that it is impossible for a student to gain entry to any medical school in the country until possibly, and only possibly, 1963. All the vacancies that existed for 1962 are already fully taken. As your Lordships have heard this afternoon from my noble colleague Lord Taylor, it is becoming increasingly difficult to fill general practice vacancies and registrar vacancies, even registrar vacancies in teaching hospitals. This is something that has been quite unknown before.
Your Lordships have heard this afternoon of the Willink Committee estimates, and of their recommendation that the medical student intake be reduced by 10 per cent. Although many deans were averse to this plan, which is why it was never fully implemented (I should add that deans, as your Lordships will understand, are really directors of the medical schools and I use the word in that sense), they got it into their minds that, whatever happened in the future, if and when the need arose for more doctors—and it surely would, as indeed the Willink Committee predicted it would, but not that it would come so soon—it would never exceed the need they were thinking of at the time of the estimates in the Willink Committee's Report. As a result of this, most deans have planned accordingly and, so far as I know, there are no plans ready for any major increase in medical students. It would appear that the Committee made little allowance in this respect for the constantly changing face of medicine in all its aspects in Britain.
In the past, and I think it is true in the present, the "peripheral vision"—and I use this phrase to refer to the vision of the deans in the medical schools—has appeared to some of us to 1153 be far more acute, adaptable and continuous than the central vision, and I refer to central vision as including the Ministry of Health and the University Grants Committee. I think that the "peripheral vision" is much more acute, much more adaptable, and much more continuous in regard to these rapidly changing needs.
Your Lordships are only too well aware of the difficulties in regard to the supply of medical personnel to the Services, to which I should like to refer for a moment. It has been said that Service medical officers, especially those in the lower grades, are professionally and financially at a distinct disadvantage when compared with their professional counterparts in civilian practice. Though this may be partly true, I think that these difficulties can be overcome, and indeed they are being largely overcome. The real trouble here again is undoubtedly one single thing—the shortage of doctors. It would seem now, as we have already heard from my noble friend Lord Taylor, that the hospital service can be manned properly and adequately only at the expense of the general practitioner service, which I consider is a most unhappy situation when we are trying every day to improve the position of the family doctor. I agree that especially important in the hospital service is the adequate staffing of the casualty departments. I would assure your Lordships that in many instances the long hours, the strains and the responsibility of some of these young doctors are quite unbelievable. I think that this is a problem of immense importance.
In regard to the possible remedies, we have heard of some of these, with which I would largely agree, from my noble friend. I think it is true, though, that most teaching hospitals, particularly those which reduced their intake, could very easily and without any disadvantage whatsoever take an extra 10 per cent. of students. The real difficulty is the bottleneck concerning the pre-clinical subjects, the pre-clinical subjects being anatomy and physiology, and I would not be as comforted as my noble friend appears to be in regard to getting plenty of teachers in these subjects. I should have thought that one of the difficulties might be the number of teachers in these subjects. But, of course, there is also the big question of 1154 the necessary accommodation, and accommodation is really large in only relatively few places such as Cambridge, particularly, and Glasgow. I think that there would be real difficulties in the pre-clinical phase, but some of these difficulties could be reviewed by peripatetic visitations by the Ministry, perhaps the Chief Medical Officer himself, the University Grants Committee and the Chairman of the Medical Committee. Indeed, I find it a little difficult to understand why this has not already been carried out in so urgent a matter.
I think that other points which my noble friend Lord Taylor has already touched upon are important. I think it is important that doctors should be dissuaded from emigrating. I am quite sure that better post-graduate facilities for these overseas doctors, on whom we so largely depend at the moment, should be instituted as soon as possible.
§ LORD EVANS
And I think I should like to see a little less rigidity in the National Health Service, instead of the increasing rigidity which seems to be occurring. Finally, I think that some committee should be set up to hold a continuous review of the situation. I emphasise the word "continuous", as I think my noble friend Lard Taylor did.
My Lords, I would presume to thank my noble friend Lord Taylor for his appreciation of this serious and urgent situation. The noble Lord himself recently wrote:The predominantly hypomanic personality is familiar to us all; successful in business, industry or politics. It is invaluable in collective human enterprise, especially in the phase of building and expansion".I think, my Lords, that that is the type of man we need in medicine to-day.
§ 4.10 p.m.
§ BARONESS SUMMERSKILL
My Lords, I do not recall any other occasion than this on which I have followed either a noble Lord or a Member of another place who was not of my own Party when I could have said wholeheartedly that I agreed with everything he had said. This is a very serious debate, and I am sure we are all grateful to the noble Lord, Lord Taylor, for having tabled this Motion. He has explained in a most lucid manner the 1155 serious position in which medicine is to-day, and I must say—and I am very glad the noble Lord, Lord Cohen of Birkenhead, is here to explain the position to us—that most people who have examined this situation feel that it stems from the serious misjudgment of an important Committee, the Willink Committee.
I would ask the noble Lord, Lord Cohen of Birkenhead, to read the Executive Councils Association's Report of their most recent meeting, last month, in which they say:The conclusion of the Willink Committee that there should be a reduction of one-tenth in the student intake after 1961 was misconceived.That is a most kindly understatement, as I am sure he will agree. The Management Committee of the Executive Councils Association were of the opinion that the Minister of Health should review the matter and take urgent action to remedy the position, and I hope that the noble Lord, Lord Newton, who is speaking for the Minister in this House, will tell us, when he comes to reply, precisely what the Minister is going to do in the light of this recommendation, the most recent recommendation of the Management Committee of the Executive Councils.
It has been said by my noble friend Lord Taylor and the noble Lord, Lord Evans, that already there is great difficulty in filling vacancies, not only in the hospitals but also for G.P.'s, particularly in less attractive areas. I feel we shall make a real contribution to the solution of this problem this afternoon only if we make some practical suggestions which could be implemented forthwith. One suggestion that the Management Committee put forward, and which is eminently practical, is that there should be some form of financial inducement to stimulate general practice in unattractive areas. This debate, I feel, has given us an opportunity of focusing attention on the unique position of the general practitioner to-day. If a vacancy occurs either in the North or in the South—or, for that matter, in any part of Britain—then those practitioners who are unemployed can make an application to fill that vacancy. Now, an applicant may be an older man who is anxious to go to the South of England because, 1156 temperamentally, he feels he is more fitted to serve in a seaside resort or in a rural district, but it may be that, for financial reasons, he must apply to an industrial area. There he does not fit in very well; whereas a young man has perhaps been sent to the South of England although he might well have preferred the challenge of an industrial practice where there are fewer retired people, fewer elderly people and more of those who are greatly in need of his medical services.
I would also remind noble Lords of this astonishing position in the field of medicine. To-day, there is no need for a general practitioner to retire at the age of 65. If he feels he can continue, then the Executive Committee will consider his application and, provided he is fit medically and able to fulfil his functions, he will be allowed to continue. Of course, in the industrial North there are many who may have served in those constituencies where the conditions are not ideal from the health point of view and who would quite rightly say: "I would go on working after 65 if I could go down to the South". Unfortunately, the machinery of the Service does not provide for this transference. I am glad to see that, in that, I have the support of both sides of the house.
Here, then, is something which could literally be done next week. We could say to all those men who are considering retiring at the age of 65, "If you are prepared to go on working for another five years"—which will cover a very important period—"then we will try to arrange a transfer to a more attractive district; a district more attractive climatically and because there will not be so many emergencies, and where the pace of medical life will be much slower". This, I believe, could be done forthwith. I would remind noble Lords that the expectation of life of a practitioner is not very high. Coronary thrombosis is, indeed, the occupational disease of medicine. The noble Lord, Lord Cohen of Birkenhead, agrees, and I am very pleased to get his support.
§ BARONESS SUMMERSKILL
I have come to the conclusion it was a wrong diagnosis; otherwise the noble Lord would not be looking so healthy to-day.
§ BARONESS SUMMERSKILL
Here we are discussing the practical aspect of the problem. We are talking about men and women of high integrity who give fine service to the community, who are uncomplaining and whom the community tend to disregard because they feel that, after all, a doctor is following a vocation, and therefore one need not worry if he is giving a little too much.
Having got that background, I would again remind your Lordships that the doctor is the only worker in the country who is expected to be on call day and night. Indeed, there is a medical relief service which is functioning in London, and there are those who say that the doctor really is betraying his profession by using this medical relief service at night and when he is on holiday. They say that it is the tradition of medicine for doctors to work day and night. My Lords, that word "tradition" is often misused. There are good traditions and bad traditions, and I suggest that the tradition of a medical practitioner's being expected to be on call day and night is a bad tradition. Again, next week—immediately—a reform could be instituted whereby the medical practitioner's lot could be really greatly relieved. Indeed, there is this service, but, unfortunately, it is criticised by many people, and the time has come when the Minister of Health should give it his blessing.
Now we come to the question of medical students. Is there a shortage of potential medical students? The noble Lord, Lord Evans, has told your Lordships that it is impossible to get a place in the medical schools to-day. So far as potential medical students are concerned, there are no statistics, because able boys and girls, particularly girls, have been deterred from choosing medicine as a profession because of the limited number of places in medical schools. On another occasion I quoted the number of places which were avail- 1158 able to girls in order that the noble Lord, Lord Newton, at this time, on this debate, would be aware of the position and would be able to report to me whether the position was improving.
It was in the middle of the last century that Elizabeth Garrett Anderson literally fought to enter a medical school and when male medical students barricaded the doors of the examination room against her and pelted her with rotten tomatoes because, they said, "That woman must be indecent; no decent woman would want to see the human body unclothed." Despite that, Elizabeth Garrett Anderson established the right of women to enter the medical profession, and her great memorial is seen in the Elizabeth Garrett Anderson Hospital.
Despite that, to-day—and we have heard in this debate that there is a desperate shortage of doctors—if the able girl tries to get into medical school, she finds it is very difficult. The position is that the London medical schools keep on an average only about 15 per cent. of their places for women. However able is the girl, whatever are her merits, because of her sex—because she belongs to the female instead of to the male sex—she must be debarred from medicine. In our big schools, careers mistresses know this and are compelled to dissuade brilliant girls from considering medicine. I would again remind noble Lords that it takes seven years to qualify. When talking of one of these girls, then, we are talking of a girl who is prepared to give seven years of her life, before qualification, to her career.
There are others, of course, who are in poor homes, who are very able, but who are reluctant to undertake such a long course when they can take a shorter science course which has excellent prospects. The only answer to this problem is to give more and larger grants quickly. The universities must be helped in order that we can have the more able boys and girls who are in poor homes encouraged to come forward and to go into our medical schools. The noble Lord, Lord Evans, suggested that the medical schools should increase their places by 10 per cent.; and he was supplemented by the noble Lord, Lord Taylor, who suggested more medical 1159 schools. Here are two practical contributions to this particular problem.
I feel that the Willink Committee was terrified in case there would be too many doctors and that we might be educating too many and they might become redundant. How they could ever have arrived at that decision, in view of the position in the world, astonishes me. If one thinks simply in terms of providing doctors to prescribe medicine in this country, then we might reach saturation point, but if we take a broader view and think in terms of doctors being the best kind of ambassadors in underdeveloped countries, then the shortage will continue for many years. I have only to remind your Lordships of the contribution which the medical missionaries made in the underdeveloped countries in the nineteenth century. Doctors are trusted by the coloured populations, who see that these people have served unselfishly.
In every underdeveloped country in the world there is a desperate shortage of doctors. I think I mentioned the Caribbean the other day—St. Lucia, where there are only two or three doctors. May I remind your Lordships that all the countries of Africa are in need of medical help? In countries like the United Kingdom, France, the Scandinavian countries and the United States of America, the number of persons per doctor ranges between 600 to 1,000. In, for instance, the Federation of Rhodesia and Nyasaland the ratio is one to every 8,000. The disparity of medical coverage is very marked, since there are cases where one doctor has to cope with the medical problems of 100,000 people, over a huge area, while, on the other hand, in the towns there is an enormous concentration of doctors to serve the European population and some Africans in employment. I am told that to meet the increasing population and the demands for medical services alone in this area, and as more remote areas are opened, the Federation could use up to another 1,000 doctors. And yet the Willink Committee in 1956 told the country that we could cut our medical students down by one-tenth.
The last point I want to make concerns the contribution which Commonwealth doctors have made to the medical service. My noble friend Lord Taylor 1160 mentioned this subject. I just want to say that it is rather curious that this debate synchronises with the widespread discussions on the Immigration Bill. The fact is that we could not conduct our hospitals to-day without the help of a large number of Commonwealth doctors whose skins vary in colour. It is a fact that, despite the prejudice which is alleged to exist in many quarters, a man is quite prepared to accept for himself and his wife, without protest, the intimate doctor-patient relationship with a coloured doctor. There has been no correspondence in national newspapers from affronted patients protesting that they have been compelled in our hospitals to submit to the ministrations of a coloured doctor or a coloured nurse. I have never yet heard of a man protesting that his wife has had to be examined in a hospital by a coloured doctor. On the contrary, there has been praise and gratitude for the services of our coloured immigrant doctors and auxiliary workers.
It would seem that when a person is sick he becomes more rational and less prejudiced. He no longer regards a coloured man simply as a contender for jobs and houses. And I say this to my noble friend Lord Taylor, who is in terested in this matter: that the psychologists should examine more closely this interesting quirk of human nature which is responsible for men being more sick in mind when they are physically healthy than when they are ill. On the immigration question, it would be informative to have a referendum among people who have received the services of coloured nurses and doctors, in consequence of which they have lost all sense of a colour bar.
These are questions with which we are very much concerned. It is quite impossible, in a debate of this kind, to ignore the great contribution which doctors, nurses and auxiliary workers with coloured skins have made to the medical services of this country. I hope that, when the noble Lord, Lord Newton, comes to reply, he will tell us that the Government will view this as a matter of great urgency, and that these practical suggestions that have been made by various organisations will be implemented forthwith in order to meet this pressing need.
§ 4.28 p.m.
§ LORD AUCKLAND
My Lords, in participating in this debate among so many distinguished noble Lords and noble Ladies in the medical profession, I feel that I can at least be excused on professional grounds if I make a wrong diagnosis in this case; but I feel that something ought to be said from these Benches, even though what I have to say may give the Party which I support rather lukewarm comfort. I say that because, like other noble Lords who have taken part in this debate, I am very concerned with this situation. I am, as I have mentioned to your Lordships before, on the board of a children's hospital in London, and therefore I come into contact with doctors on a number of occasions. No doctor to whom I have spoken recently is anything like relieved at the situation at the present time.
I do not think anyone will expect this problem to be solved within a short period of time, and I do not think the Government can be entirely to blame for the position. The Government have taken a number of measures to improve the situation. We are spending more on hospital building and are already re-equipping old hospitals. More than one doctor to whom I have spoken has diagnosed the shortage as due to conditions inside some of the hospitals. I am told that operating theatres which are far too small for convenience, and the storage of swabs and overalls in very confined spaces, are among some of the contributory factors.
I hope it will be in order for me to make one or two quotations to establish my case. Only this morning I received a letter from a friend of mine, an ear, nose and throat surgeon in the East Midlands, from which I quote a portion:I think conditions of service contribute to the problem. Many keen G.P.'s find that their living depends more on the number of patients on their list than on their own skill, and, being swamped by numbers, have to lean heavily on the hospital service. This is turn overloads the hospital service and leads to delays all round. When one thinks that the armed forces require one M.O. for a battalion of 800 to 1,000 men, yet in civilian life the same M.O. is expected to look after 3,000 people!As the noble Lord, Lord Taylor, has mentioned, there is a shortage of medical officers in the Services. In the supplement to the British Medical Journal of September 2 of this year, there is a 1162 scathing letter from an M.O. in the Army, from which I quote the final paragraph:I cannot echo the cry of several of your previous correspondents to the effect that I would not encourage my worst enemy to join the Medical Corps—I suspect he is already in.In view of the present strain on Army recruiting, I hope that that is not publicised too much. I can only say, from my own limited experience in the Army, that on more than one occasion I felt happier at being treated by a medical orderly corporal than by a medical officer, though in fairness I should stress that when a number of friends and I went down with a bad attack of ptomaine poisoning in Austria we were very well looked after by a medical officer of British nationality, who trained at Liverpool Royal Infirmary, but was a Hungarian by birth.
§ LORD TAYLOR
My Lords, in view of what the noble Lord has said, it may interest him to know that I used to be a medical corporal in the Home Guard, and he would have got very good treatment, I hope.
§ LORD AUCKLAND
My Lords, having heard the noble Lord's speech, which is one of the best I have heard for a long time, I can well suspect that those under his care received admirable treatment.
A number of points have been made about casualty officers. In the Sunday Times of November 19, there was an article by Susan Cooper, from which I quote:Shortage of doctors is similarly localised. London teaching hospitals such as Guy's and St. Bartolomew's are never likely to have difficulty in finding junior medical staff, but in northern regional hospitals the need is serious. In Manchester, between 46 and 48 per cent. of 'housemen' are foreign: Indians, Greeks, Spaniards, Africans and Armenians, who come to Britain to work for British post-graduate degrees. In the country as a whole, a quarter of all 'housemen' and registrars come from overseas.I should like to join with the noble Baroness, Lady Summerskill, in paying a tribute to the doctors and nurses who come here from overseas. Of course, their training is probably not so elaborate as that of our own doctors, but they show great devotion to duty. As the noble Lord, Lord Taylor, rightly stressed, it is not always easy, for example, for a Pakistani to conform immediately to English customs.
1163 I was talking only a short time ago to two hospital secretaries of my acquaintance. One is the secretary of an excellent district hospital where they have at present one woman casualty officer. They find they cope, but they had difficulty in getting this doctor and anticipate a similar difficulty if they have to replace her. The other hospital is the Lister Hospital at Hitchin, one of the major accident hospitals in Hertfordshire. From my knowledge of it, having lived in that area for a number of years, I should say that it covers a large stretch of the A.1. In the quarter ending June, 1961, they treated 5,800 accident cases, of which 3,200 were new. They have one Irish and one Indian casualty officer. The secretary expressed to me great concern at the difficulty of getting English casualty officers or junior doctors of any sort.
The solution to this problem is by no means easy. Pay might well have a great deal to do with it. As has been pointed out, doctors work long hours and are on call for 24 hours in the day; and pay in the medical profession, in comparison with industry, is certainly not very favourable. As I have said in your Lordships' House before, if a doctor makes a mistake it is not only heavily publicised, sometimes justifiably, but it also may well cost a life or a limb. But if a factory or office worker makes a mistake, the worst that may happen is that he gets a reprimand from his boss. I think that the Government should look seriously into the problem of getting more junior grade doctors, especially casualty officers. With the building of new roads and the development of science, accidents on the road, in the home and in the factory are not decreasing and this is throwing a great burden on the medical profession, particularly on casualty officers.
My final quotation is from the Lancet, dated November 25, from an article by the senior casualty officer of Grimsby and District Hospital. He concludes as follows:Our casualty departments make utterly unreasonable demands on the young doctors who are put in charge of them. More than half the patients should not be treated at hospital at all. Efficient care of the remainder, including resuscitation and other treatment of accidents, demands progressive training of the casualty officers, who should find a satisfying career in this speciality. A 1164 National Casualty Service is suggested; but, whether this service is national or only regional, the person in active charge of each casualty department must be a consultant, giving most of his time to this work.As a layman I am bound to see a great deal of substance in that remark. A person who wants a cyst removed from his face, for example, is not nearly so important a demand on the casualty officer as a person seriously hurt in a road accident. It is to the serious casualties in road accidents, on the railways and in factories that the time of the casualty service should be devoted. There are a number of distinguished speakers to follow me, but I hope that what I have said will give the Government a little food for thought. I am quite certain that from these Benches I can say that the noble Lord, Lord Taylor, has performed an invaluable service in initiating this debate.
§ 4.42 p.m.
§ LORD UVEDALE OF NORTH END
My Lords, in the first place, I must congratulate the noble Lord, Lord Taylor, in that he has made a remarkable contribution to this debate. He has put forward certain weaknesses and deficiencies of the Health Service, and in that way he has, I hope, made a real contribution towards an improvement. But let us remember what the record of this Health Service is. We do not want to condemn it out of hand. This Health Service is costing the country £900 million a year. We are paying for this Health Service twice as much as we are paying for our Army. We are paying for this Health Service more than we are paying in interest on a National Debt of £27,000 million. I think I can say, generally speaking, that we have behaved generously to this new Service.
The point brought out by the noble Lord, Lord Taylor, is a shortage of doctors, and a shortage of doctors in certain situations in the Service. There has been a suggestion that there is a shortage of doctors throughout the Service, but I do not think that was in the mind of the noble Lord when he was speaking. If doctors in this country were to work twice as hard as they do there would be 20,000 doctors redundant; if they worked half as hard as they do another 20,000 doctors would be required. But you have to look at the problem on both sides. When it 1165 comes to the question of failures, deficiencies and so on, you have to ask yourself two things. The first is, what is the strength of the medical faculty in this country—that is to say, how many doctors you have? Secondly, you have to ask yourself how you are employing them.
The Willink Committee have met with certain criticisms, but they were a strong Committee. The first thing they did, very properly, was to get to know the number of doctors in this country; and they did that by reference to the British Medical Association, again a most proper source. They found that there were in this country 60,800 doctors, which is quite a considerable number. Then they made some investigation as to how many of these doctors were in active employment, and they came to the conclusion that there were 44,000 men and over 8,000 women: so that the number actually in employment is about 52,000. Then they asked the question: has there been an increase in practitioners during the last ten years, since the Health Service started? They found that general practitioners have increased to the extent of 10 per cent., and that hospital staffs, taking the country through, have increased to the extent of 30 per cent.
I think it is important that we should know more about the distribution of these doctors. It is rather astonishing that at the present time there are as many doctors engaged in hospital practice as there are engaged in general practice. I should say that this is a situation that certainly did not obtain before the coming into being of the National Health Service. Of the number of doctors in general practice, 21,340 are principals and 2,265 assistants; and on the hospital staffs there are employed 20,950 doctors. If we come to analyse this figure of doctors employed in the hospital service, we find that there are 7,700 consultants, 2,400 senior hospital officers, 1,350 senior registrars, 3,150 registrars, 850 junior hospital medical officers, 2,400 senior house officers, and 3,100 house officers either provisionally registered or fully registered. One-third of all the hospitals' doctors are in the consultant grade, and that I venture to think is a rather large proportion. On the other hand, it must be remembered that 60 per cent. of the consultants in 1166 this country are part-time consultants. Here, again, further information is required, because most of the part-time consultants are doing nine sessions a week instead of eleven, allowing themselves a certain amount of liberty in that they may follow highly lucrative private practices.
When we have decided on the numbers of doctors and where we shall find them, the next thing is to deal with the various complaints that have been made. The first complaint with which I should like to deal is the complaint that there are too many doctors. In support of this, there is a certain amount of evidence, both in general practice and in the hospitals. In 1959, if a practice was advertised in this country the average number of applicants was 24. In 1956, if a general practice was advertised the average number of candidates was 43. In 1956, if a practice was advertised in a desirable neighbourhood the number of applicants might even be 100, or more than 100. This is pointed to as evidence that there are too many doctors.
§ BARONESS SUMMERSKILL
My Lords, I would ask my noble friend whether he would agree with me that, surely, in the early days, there was much more scope for practice—that is, in the 'twenties?
§ LORD UVEDALE OF NORTH END
Certainly. With regard to private practice now, it is going on to a certain extent, but it is so small that, when dealing with national matters, it is negligible.
§ LORD TAYLOR
Is my noble friend trying to show that the number of applicants for vacancies is not going down?
§ LORD UVEDALE OF NORTH END
For some practices there may be only one applicant, and for others none. But, on the average, there are a number of 1167 people who argue that there are too many doctors. I am not saying that I accept that argument.
Now with regard to hospitals. Since 1948, hospital beds have been reduced to the extent of 12 per cent. In 1948, there were 544,000 and they are now reduced to 477,000. That is a reduction of 67,000 beds. While the number of beds in hospitals has been reduced, the staffs have increased, on the average to the extent of 30 per cent. Take the case of one hospital in London in which I am particularly interested. In 1948, this hospital had 1,219 beds; in 1960, it had 1,018 beds. In other words, it had lost 201 beds in that period. In 1948, that hospital employed 7 full-time specialists. In the year 1960, it employed 29 full-time specialists and 13 part-time specialists. In other words, making allowances for the part-time specialists, the specialist resources of that hospital had increased five times in a matter of twelve years.
Next, the medical salary list. In 1948, it was £12,463. The medical salary list in 1960 had risen from £12,000 to £95,484. The general hospital costs of that hospital were up four times. In 1948, each bed in the hospital cost £7 a week; to-day each bed costs £29 a week. Owing to certain errors in the staffing of hospitals, many highly-qualified senior registrars are unable to obtain appointments as consultants. We have heard this for quite a number of years. The senior registrar post was originally a three-year post. It was then extended to four years. Then, as some of the senior registrars could not get promotion, they were allowed to stay on indefinitely. In the hospitals at the present time there is an excess of senior registrars.
The Platt Committee, which published its findings in 1961, put forward a useful suggestion; that was, to make a new grade in the service of assistant to the consultant, to take this excessive number of registrars. That, again, has been used as an argument that there are too many doctors. If you take the senior registrars on the surgical side of the hospital, you will find that 67 per cent. of these men are over thirty-five years of age. The question arises as to this shortage of the young doctors: Why are there not young doctors to fill the junior 1168 posts? The Willink Committee, dealing with the question of entrants, said that they could cut down the entrants by 10 per cent. between 1960 and 1970. They went very carefully into the matter. The two professors who have already been quoted, Professor Lafitte and Professor Squire, said, "Do not cut them down 10 per cent., but put them up 10 per cent." As the number of entrants was about 1,800 when the Willink Committee were dealing with the matter, they thought it could be reduced to 1,600. Professor Squire thought that the number, instead of being reduced to 1,600, should go up to 2,000. These differences are not such as in themselves should cause a severe crisis in the working of the health system. The fact of the matter is that young doctors have been doing two things: they have either been hurrying into general practice or else been going abroad. Between the years 1954 and 1959 inclusive 1,100 doctors left Great Britain to settle in Canada.
§ LORD UVEDALE OF NORTH END
1954 to 1959 inclusive. In the same period there were emigrants from this country to Canada to the extent of 217,000; thus the number of doctors admitted to Canada was five times the number that would have been required to deal with those emigrants. I understand that the Canadian faculty is taking steps to limit the number of English doctors that will now be allowed to go to that territory. So that is one reason for the shortage of doctors in that particular section of the Health Service.
I have dealt with the argument that there are too many doctors; and we do not know how to deal with the argument that there are too few. This argument has been put forward very eloquently by the noble Lord, Lord Taylor. We find that in the junior posts nearly half the doctors are from the Commonwealth. In the case of Manchester it is 49 per cent., in Newcastle it is 50 per cent., in Leeds it is about 50 or 51 per cent.; and, taking it altogether, 42 per cent. or 43 per cent. of the men in these junior hospital posts are from the Commonwealth. One reason, I think, 1169 why the junior men from our own medical schools do not stay longer in the hospitals is that the accommodation in many of our hospitals is poor for junior residents. There are no married quarters provided; and some of our older hospitals are repellent; they have even been described as dirty, and, as we have heard in this House, have sometimes even given rise to cross infection when a patient entered a ward. All those are factors which tend to make it difficult to get our own junior men to remain on at the hospitals.
What are the general conclusions? First of all there is one definite conclusion: a shortage of junior men and an excess of senior registrars. Another point that comes out of this survey is that the conditions of the Service are attractive; that the amount that has been spent by the Government on the Service is generous; and that much of the trouble that has arisen is because of what the noble Lord, Lord Evans, called rigidity. Suppose that you find yourself short of doctors in one particular section of the scheme, suppose that you find that none of the other doctors are adaptable, then you may be faced with a breakdown such as the noble Lord, Lord Taylor, has predicted; but if you can make your doctors more adaptable then I think you can get over these difficulties until such time as a permanent solution can take shape.
I have said that the conditions of the Service are attractive. A third of the hospital doctors are consultants, and a consultant's salary comes up to £3,900 a year. On top of that he gets his merit money, which may go up to another £4,000 a year, making a maximum pay of £7,900 a year, or something approaching a salary of a High Court Judge. These are attractive conditions, and unless there are reasons that dissuade men from going the full course you ought to get all the candidates, all the doctors, that the Service needs.
§ 5.8 p.m.
§ LORD COHEN OF BIRKENHEAD
My Lords, the noble Lord, Lord Taylor, in his introductory words paid a charming and enviable tribute to myself, and for that I am sincerely grateful. I should also like to thank him for what was on most counts a telling speech; 1170 but I confess that as he proceeded and roundly condemned the Willink Committee, of which not only by his words but by pointed observations he reminded Members of your Lordships' House that I was a member—and, I think, the only Member of your Lordships' House on that Committee—the words of Virgil echoed through my ears: Timeo Danaos, et dona ferentes. Noble Lords will not wish me to translate that.
The noble Lord, Lord Taylor, told your Lordships that the supply of general practitioners is going down rapidly. He said there was a grave crisis in the supply position of doctors and that this is due wholly to the fantastic decisions of the Willink Committee.
§ LORD TAYLOR
My Lords, I am very sorry but I must protest, much as I am devoted to the noble Lord. I said that the crisis was due to the failure of the Government and the medical schools to increase their intake over a whole period of years, and I pointed out most carefully that the trouble occurred before the Willink Committee reported, and had the Willink Committee's recommendations been implemented it would have been much worse, but they were not.
§ LORD COHEN OF BIRKENHEAD
May I read you the words which the noble Lord spoke in this House just seven months ago? [OFFICIAL REPORT, Vol. 230 (No. 70), col. 940]:My noble friend Lord Cohen of Birkenhead was a member of the Committee, the Willink Committee. It made a mistake.I think the following words are rather interesting in view of the noble Lord saying that when the Report was published in 1957 he knew that it was wrong in substance and in fact. This is what he said seven months ago:I must say I did not realise it had made a mistake until about a year or so ago,which brings us to April, 1960,when we began to see the awful effects of its mistake …".And then he goes on to say:… We are going to be short because the Willink Committee made a recommendation, and the Government accepted it, to cut the intake into medicine by 10 per cent., which was absolutely fantastic.Thus we went wrong because the Willink Committee made a recommendation to cut by 10 per cent. Let me deal first 1171 with these two indictments against the Willink Committee. First, he said that owing to the Willink Committee the supply of general practitioners had fallen rapidly. What do the available figures show? In the last nine years, since 1952, in England and Wales, the population has increased by 5 per cent. from 43.4 million to 45.4 million. In the same period of that increase of 5 per cent. in the population there has been over 15 per cent. increase in the number of general practitioner principals in this country, from 17,316 to 19,928. It may well be thought from all your Lordships have heard this afternoon that all the Willink Committee did was to recommend a cut of 10 per cent. in the student intake in our medical schools.
I must sketch the historical background because it is relevant to the findings of the Willink Committee. This Committee came into being in February, 1955, and Sir Henry Willink, who was a former Minister of Health, was its chairman; and it came into being because there was grave concern, particularly throughout the profession, that there was a surplus of doctors and that soon there would be unemployment. In 1953, the Lancet wrote in a leading article entitled "Too Many Doctors":The profession is probably becoming overcrowded.In 1955, after the appointment of the Willink Committee, this is what the Lancet wrote:In 1951 the Lancet tentatively concluded that the number of doctors qualifying annually in England and Wales was about 200 in excess of the number of permanent posts available in the National Health Service (as consultants or principals or partners) and in other services, while in addition there was a yearly surplus of some 300 from Scotland.And even after the appointment of the Willink Committee and after its Report, the British Medical Journal had this to say: the Committee was brought into being because ofthe growing feeling by many, including the representative body of the British Medical Association and the Conference of Local Medical Committees, that perhaps too many doctors were being trained for too few openings in the future, and that a surplus during the next few years was inevitable.And so it is true to say, as indeed the Lancet subsequently said:The Committee were appointed because it has been widely felt that the profession in this 1172 country may soon be overcrowded, with consequent unemployment.Yet, in spite of this, what were the Willink Committee's recommendations? The Willink Committee received evidence from the most expert sources in this country. It received evidence from the Government Actuary on increase in population; it received evidence from the British Medical Association, from the Vice-Chancellor's Committee, from the University Grants Committee, from the Association of Municipal Corporations, from the Medical Research Council, and others. After a searching examination of this evidence from all those relevant sources, what did the Willink Committee recommend? First—and this shows, despite the observation of the noble Baroness, Lady Summerskill, that we were not terrified—that there should be an immediate increase in the number of general practitioners; 625 principals should be immediately entered into practice, and that thereafter there should be 75 extra general practitioners a year to offset changes in the size and age distribution of the population.
What did it say of consultants and specialists? That there should be an increase of 160 yearly until 1965 and about 80 thereafter, and similar increases in junior staff. And despite the fact that the Association of Municipal Corporations said in evidence that no further increase was needed in the medical services of local authorities, and the British Medical Association said that no increase beyond 75 was needed, the Committee was so impressed with the significance of preventive and social medicine and its growth that it recommended 125 additional doctors in those services. In other words, the Committee recommended increases all round except where no demand was made, and there were cases in which no demand was made.
In 1960, when Lafitte and Squire published their now celebrated paper, they complained that no increase whatever was allowed for whole-time medical staff of the Medical Research Council. Let us look at the Willink Report, which I will now quote:The Medical Research Council told us they did not expect any significant increase in their own wholetime medical staff of 298 (including the public health laboratory service).1173 In order that your Lordships may be familiar with what the Committee concluded—because so far you have heard solely that it concluded there should be a reduction of 10 per cent. in the student intake—let me read what the conclusions were in the Committee's own words. They are quite brief, but they are revealing:Speculative though many of our assumptions, estimates and calculations have necessarily been …note that—speculative, because we recognised they were speculative—… we believe that certain broad conclusions emerge from them, as follows:1. Up to the present the medical schools in Great Britain have not been producing too many doctors.That was a view contrary to the widely held opinion of the medical profession.2. Up to 1961 the output from medical schools is already substantially determined by the number of students now at various stages of training. After that year, however, a reduced output will suffice. Our estimates suggest that a reduction of student intake by about one-tenth from as early a date as is practicable would meet the case.3. About 1975 an increased output of doctors is likely to be needed and the student intake would therefore require to be raised from about 1970.This forecast is, however, so speculative that it would seem prudent for there to be another review of the situation in about ten years' time.They are the conclusions of the Committee, and not solely that there should be a one-tenth reduction in the student intake.
How was that Report received? The Lancet regarded the Report as—and here I quote:an informative and shrewd analysis of what is obviously a most complex situation.These were the views which were echoed by every paper, whether it be medical or national. Even in February, 1960, when the Royal Commission on the Remuneration of Doctors and Dentists reported under Sir Harry Pilkington, this is what was said in dealing with recruitment, referring to the conclusions of the Willink Committee:The broad conclusion seems to be that the supply of candidates training as doctors is reasonably close to requirements.It said that because it did not wish to promote incentives for the medical profession in its Report on Remuneration.
1174 As your Lordships have heard, it became clearer in 1959-this was pinpointed by Lafitte and Squire in their Lancet article—that some of the Willink assumptions were being falsified by events. What were these? First, we had been told by the Government Actuary that an approximate forecast of the population increase during the next 16 years would be 4½ per cent. Actually, it turned out to be nearly 8 per cent. Even accepting that increase, as we must, if we recognise that 25 per cent. of the population of this Island is over the age of 65, which means that if there is an increase in longevity there will be the same or a greater proportion of old people, and the aged require more medical service than do those under the age of 65, it becomes abundantly clear that that, too, was a false assumption on the part of the Willink Committee.
We also found in 1959–60 that retirement from general practice in the National Health Service in 1958-which does not, of course, necessarily mean retirement from some form of private work—was more than we had anticipated. Why did we say that? May I refer not only to the evidence of the British Medical Association, which I do not propose to put before your Lordships in detail, but to what the British Medical Journal said after our Report was published giving our assessment on retirement? It said this:It may well be smaller"—referring to the number of retirements from practice in the National Health Service in 1958—than might be supposed because the pension will not be large and compensation will have declined in money values. Therefore, it must he expected that many practitioners will continue to work after 65".There was a fourth false assumption of the Willink Committee. We were told that the Services would reduce their numbers by 1962, at the end of National Service, by 1,000, and this had an appreciable effect on the conclusion we reached as to the date from which a reduced output from the medical schools would suffice to meet requirements. After this explanation I willingly accede to the noble Lord's request and concede that on the 10 per cent. reduction, the 1175 Willink Committee were wrong. But I would remind him of Swift's commentA man should never be ashamed to own he has been wrong, which is but saying, in other words, that he is wiser to-day than he was yesterday.So my head is neither bloody nor bowed.
Then what happened after the Willink Report? Was there this 10 per cent. reduction? Not at all. Let me tell your Lordships what happened in my own medical school. In 1957–58, which was the year after the Willink Committee reported, we admitted 91 medical students, which was approximately the number we admitted earlier. We have gradually increased admissions, until 1961–62 shows an increase of over 10 per cent. after the Willink Report, bringing the number to 102. May I say, in relation to two matters which have been raised, one by the noble Lady, that I agree wholly with her that the number of potential medical students is considerable. We had applications, from this country, from 969 candidates, over 300 of whom gave Liverpool as their first choice.
§ LORD TAYLOR
My Lords, may I interrupt the noble Lord just to say that I am quite delighted at what he has said; and may I say that it is quite clear that he spotted that the Willink Committee was wrong before I did, because he at once stopped his medical school from making this mistake, and they have been doing the right thing from the start.
§ LORD COHEN OF BIRKENHEAD
My Lords, the noble Lord must not jump to conclusions. Entry into the medical school is determined not by me. But I should like to emphasise to the noble Lady that we in Liverpool admit somewhere between a quarter and one-third of women, who, I am delighted to say, are among our best medical students.
§ BARONESS SUMMERSKILL
My Lords, might I ask the noble Lord whether he will consider 50 per cent. next year?
§ LORD COHEN OF BIRKENHEAD
Well, I do not want to enter into another argument with the noble Lady, but the question of wastage in medical services has to be considered.
§ BARONESS SUMMERSKILL
My Lords, on that important point, how can the noble Lord regard marriage in a woman as wastage?
§ LORD COHEN OF BIRKENHEAD
My Lords, if the noble Lady knows anything of pregnancy and the rearing of children, she will realise that inevitably there is some wastage in time; but I do not want to pursue that at the moment. I think it is regrettable that the figures for the whole country are not ascertainable. There is no source from which we can, with accuracy, find the number of medical students admitted to our schools. The reason is that some are counted twice. Some are counted when they enter into their pre-clinical course at one of the older universities, and they are counted again when they enter another school for their clinical training. But I think that in yearly comparisons they tend to cancel one another out.
It so happens, however, that so far as the Deans of medical schools are concerned, we have some evidence on this point. In the Report of the Working Party on the Medical Staffing Structure in the Hospital Service, at page 30, paragraph 93, we find that in 1958, long before Willink could have had any influence on the situation, there were 1,675 graduates from the medical schools of this country. In 1962, which is the first year when the cuts could possibly have any effect, there will be 1,691 graduates; in 1963 it is anticipated that there will be 1,719 graduates; and in 1964 there will be 1,730 graduates. So, my Lords, the Willink recommendation could not possibly have had the influence which the noble Lord earlier attributed to it on more than one occasion. We are, indeed, not going short because the Willink Committee made a recommendation. But you see, my Lords, whether the Willink Committee is right or not is not the crux of this problem.
§ LORD COHEN OF BIRKENHEAD
I only answer the attack on the Willink Committee because I think it is my duty to do so as a member of the Willink Committee. But I do not regard this as significant at all. The crux of the matter is: are there sufficient doctors? I should 1177 like to say to noble Lords who have spoken that this is far too wide a question. The question is not whether there are sufficient doctors, but whether there are sufficient doctors in general practice, in the hospital service, in the local authority service, and so forth, and whether they are properly distributed, which is a factor of profound importance. Now, my Lords, such facts as are available are extremely difficult to interpret and, if I may say so, most of them are speculative and very rapidly changing. The subject which we have been debating is fraught with prognostic difficulty and, as the British Medical Journal wrote after the publication of the Willink Committee Report, nothing short of efficient crystal gazing could give the answer.
May I deal for one moment with two factors which have changed, the situation? Both have been mentioned this afternoon, but I should like to deal with them in more quantitative detail. The first is the question of Commonwealth practitioners. In the three years, from 1956–57 to 1960, Commonwealth practitioners who were provisionally registered—and I will deal with that later—increased from 108 to 463, and so we had an extra 355 provisionally registered Commonwealth practitioners in this country. In 1956 we had 1,086 Commonwealth and foreign temporarily registered practitioners, and in 1960 we had 1,701. That is a difference of 615, but we must allow there for some duplication. That is to say, in the last few years there have become available to our hospital service about 200 doctors a year from the Commonwealth.
Lard Evans and Lord Uvedale of North End dealt with the question of emigration. Various estimates have been made and I am quite certain that they are all wrong, because I have written to the High Commissioner for Australia and he has no figures whatsoever of emigration from this country into Australia. The Ambassador of the United States, also, has no figures. But in looking through the number of those British graduates who were licensed to practise in the United States in 1959 I find there were 85, and in 1960 125, and without passing the licentiate of the State in which they propose to practise they cannot practise except in hospital. As to Canada, although I agree with the 1178 figures of the noble Lord, Lord Uvedale of North End, the fact is that whereas in 1957 there were 311 British immigrant doctors, in 1960 the number dropped to 162-about half.
Another question has been raised and not very thoroughly tackled, and that is: is the 3,500 patients maximum right? It was Lord Auckland who paid some attention to this matter. Well, the maximum is not that which it is obligatory on any doctor to accept. There must, indeed, be differences because of geography, because of age and its accompanying lack or excess of energy, and because of different degrees of diligence, zeal, skill and the like. There clearly must be differences in the number of patients which any general practitioner can have on his list, but the noble Lord and myself were members of another Committee which did, in fact, agree that 3,500 was a reasonable maximum. Let me say at once, however, that although the maximum is 3,500, the average list in this country for a principal is 2,287. I hope that what the Willink Committee recommended, which was that in urban areas there should not be an increase beyond an average of 2,500, and in rural areas not above 2,000, will as soon as possible be acceptable. But it is true that, on the whole, except for last year when there was a difference of 01 per cent., or possibly less, the number of patients on a doctor's list is going down.
Two doubts have been raised by noble Lords about the employment of some of our Commonwealth practitioners. Let me first remind your Lordships, in relation to this matter, that in regard to hospital staffing there has, indeed, been an increase in our junior hospital posts, and not simply the 15 per cent. increase in consultants which the noble Lord, Lard Uvedale of North End, mentioned. What are the doubts? The first which has been expressed is that there might be a sudden cessation of Commonwealth practitioners coming into this country, and then we should find our hospital service denuded of junior hospital staff. Well, one must concede that that could arise from some major political crisis, but otherwise it is extremely unlikely, because for decades to come—and with this I am sure the noble Lord, Lord Taylor, will agree, in spite of what he said—the demands of India, of Pakistan 1179 and so forth will never be satisfied by the facilities which they then can, themselves, provide for post-graduate training. Indeed, they come to this country because our diplomas and post-graduate degrees stand so high in prestige in those countries. If they do not come to this country for their post-graduate training they will go elsewhere, and there is some evidence that some of them are going elsewhere because they have been refused postgraduate training facilities in this country.
The second doubt which was raised was on the quality of these men, their standards of medical practice, their skill and the language difficulty. Lord Taylor suggested that perhaps we might have training and selection centres for our Commonwealth practitioners and for foreign practitioners, for them to learn and for us to exclude the utterly unsuitable. But, my Lords, this is not legal in many cases and, I would suggest, is impracticable in others. We are governed by the Medical Act, originally of 1886, and now the Consolidated Act of 1956. If we provisionally register practitioners, we have acknowledged that the standard of their degree is such that we are prepared to have reciprocity with them, so that the holders of our qualifications can practise in their countries and the holders of their qualifications can practise in our country. We could not keep these people out, even if we wished: they are registered in this country. I might add that we do not recognise all Indian medical schools, but those we do recognise we believe to be conveying a sufficient standard of medicine, surgery and midwifery to enable their practitioners to undertake practice in this country.
They are the provisionally registered. Temporary registration is given to foreign and Commonwealth graduates who are not eligible for provisional registration, and they are therefore those about whom I know the noble Lord, Lord Taylor, spoke very kindly, but whom, if I might put it frankly, he regards as not having a sufficient standard for this country. In order to get temporary registration—and I can assure the noble Lord that I am speaking with knowledge, because for several years I have been one of four people responsible for giving provisional or temporary registration to practitioners in this country—the hospital must be approved by 1180 the General Medical Council, and the appointment is made by the hospital management committee. Therefore, it is up to the hospital management committee to satisfy themselves that the applicant is suitable. I will deal with this in another aspect in a moment, and I suspect that I am going to anticipate the observation which was about to be made by the noble Lord, Lord Taylor. It is possible for hospital management committees, once they have appointed an applicant, to terminate the appointment if the doctor proves unfit for the post. I suspect the noble Lord was going to say, "Ah, yes, but what alternative has the hospital management committee? It has to have someone, and therefore it takes these people". I believe this to be true, and I shall use it later, if I may, to justify my support for an increase forthwith in the number of students admitted to our medical schools.
But even in the present situation I believe there are certain questions which we should properly ask ourselves. The first is: are we deploying our present hospital staff to the best advantage? Secondly, are some of these hospitals giving the training which a Commonwealth practitioner can expect to receive at them? The answer is, "No".
§ LORD COHEN OF BIRKENHEAD
This soon gets around, and that is why many hospitals have no applicants. I have known, in a teaching hospital, a particular firm to have no applications for its residency because it is known that the consultants of that firm do not devote the time they should to training the students under them. There is a third point: is it not a fact that many of the residential quarters in some of these smaller hospitals are unfit for human habitation? The answer is, "Yes"—and these are measures to which I believe we can even now attend. Then there is the language problem. This, of course, is a difficult one sometimes. Only a week or two ago P.E.P. published a report on Indian undergraduates in this country and said that 27 per cent. found some difficulty with the language. That is not my experience with post-graduate medical students, many of whom have, of course, been taught in English. But it is still true that some of them have difficulty, and it 1181 may well be that the employing hospitals should help with language instruction and should postpone the hospital appointment.
I have given this problem detailed consideration, because it leads to the conclusion which I have already hinted at—that there is a need for more doctors. Why? Because we do need to correct the false assumptions of the Willink Report on population trends and on the age of retirement of doctors. Secondly, we should aim at reducing the average number of patients on the doctor's list, in urban areas to 2,500 and in rural areas to 2,000. I think we have to provide also for still further expansion in our consultant and specialist hospital services. It is true that we have revised R.H.B. 48/1, and that, in new hospital building, we are going to assign 3.3 beds per thousand of the population to acute general cases instead of 5.0 per thousand; but that means a significant increase in our out-patients; it means, I think, a significant increase in domiciliary consultations properly carried out, and we shall always need more pairs of hands. This might partly be met by the suggestion that we keep our graduates in hospital for a longer period. This would not solve the problem, but it might help to solve it. I believe, also—and I say this from my experience in the Royal Society of Health—that we need more doctors of the best type in local health authority services, in our mental health services and the like. There is an increased need. But, my Lords, its degree is still speculative. I believe that our first step should be forthwith to increase our intake by approximately what the noble Lord has said—250 students each year. This would make it about 10 per cent.—that is, 10 per cent. above the Willink figures.
But I am not sure that I agree that we should implement this decision in the way in which the noble Lord has suggested. I think there are three stages of implementation. The first is to invite those medical schools who made a cut to restore it so that they have their Willink numbers—that is, their Willink numbers 1956, and not their so-called Willink numbers 1962. The second is to increase their intake, if possible, into the pre-clinical years. The noble Lord, Lord Evans, said that this is the 1182 bottleneck—and, indeed, it is. Most of the provincial universities could double their numbers of clinical students; it is in the pre-clinical years that they find difficulty. During the post-war bulge we met this, not simply by duplicating but by triplicating classes, which meant that the members of the staff could carry out no research work; all their time was occupied with reaching. I think this is bad, but I feel that in anatomy, in physiology, in biochemistry and in histology there might be a possibility of enlarging in existing universities the pre-clinical facilities. If this were done, it might well give us immediately the 250 rise for which we are all looking.
It may become necessary to establish a new medical school—one or more. I think it would be a mistake to establish it (as the noble Lord, Lord Taylor, suggested as one of his alternatives) in association with a hospital, the Central Middlesex Hospital. I think that all medical schools should be integral parts of universities—a matter which the Goodenough Committee stressed and which the General Medical Council has stressed on more than one occasion. I know many medical schools which cannot regard themselves as an integral part of a university. I would agree that if a university medical school is to be founded, it should go to one of the newer universities—Exeter, Southampton, Nottingham or Leicester. A consideration which might weigh with me, and which is illustrated in some of the figures which are available for applications for general practices would be that most doctors tend to settle in the neighbourhood of their medical school. Since the deficiency is in the north, then let us repeat that a former Minister of Health, now the Leader in another place, exhorted young men to go North when he was Minister of Health. Let us try to see that, if other things are equal, the university should be a Northern university.
I should like to emphasise again and again that we need to make the best use of our present resources, and that might well depend on the reorganisation of hospital staffing. I hope I shall not be accused of procrastination when I say that we need only 250 now; but it would be unwise to neglect the implications in this field of festina lente. The supply of doctors is a dynamic, not a 1183 static, problem. There are too many imponderables for a rigid solution. The situation might change overnight. If within the next 24 hours there were discovered a drug which would cure cancer, then there would be out of work 150 consultant radiotherapists and a considerable number of their underlings. The work of the surgeon would be considerably reduced. Again, my Lords, in these days of rapid advance, not of psychology but of the biochemistry of mental disease, of genetics, and of the chromosomal changes which are concerned with mental disease, it may be no one can tell, that we should be able to deal with the mental health of the community with a far smaller number of doctors. On the other hand, it may be that new specialties will arise, as they have done in the past, such as thoracic surgery, neuro-surgery, and the like. But what I have tried to illustrate is that this is still an uncertain situation. This is the lesson which history teaches us; and, as Santayana told us,He who neglects the lessons of history is compelled to live them again.There may be other factors which would modify the number of doctors we require. For example, it has been mentioned that political decisions in relation to the Immigration Bill might impede the flow of Commonwealth practitioners here. I do not believe that. I think the Immigration Bill, even as at present drafted, would permit the admission of Commonwealth practitioners to this country. There might well be a change in the type of practice, with greater emphasis on domiciliary practice as contrasted with hospital practice, and that certainly will be so if the provisions of the Mental Health Act, which are so dear to the hearts of my noble friend Lord Taylor and myself, are in fact implemented. And, of course, we might in the future make greater use of the professions supplementary to medicine and spare the doctor. Now, clearly, what is needed, as so many of us have said, is a regular annual review of graduates, of medical school intakes, and the like, undertaken in detail by the Health Departments, so that immediate decisions can be taken. Because, as we have heard, a decision taken to-day will affect the supply of doctors only in seven to eight years' time.
1184 My Lords, I hope the Government will view what suggestions I have made sympathetically. I share certain apprehensions with other noble Lords. Money is needed. John Webster said 300 years ago thatGold which buys health is never ill-spent",and that should indeed be the motto of the Ministry of Health. Because the saying remains as true to-day as when Disraeli uttered it in Battersea Park 80 years ago: that the health of the people is really the foundation upon which all their powers and all their happiness as a State depend.
§ 5.55 p.m.
§ LORD STONHAM
My Lords, whatever opinions your Lordships may hold about this debate, I think everyone will agree on two things. The first is that we are extremely fortunate that there has been no shortage of doctors in this debate; and secondly, that my noble friend Lord Taylor has rendered a signal service to your Lordships' House, and I think to the country, in raising this Motion. I thought that his case, marshalled in 30 minutes, was so packed with convincing figures and information as to be unanswerable, and the whole course of the debate appeared fully to support his contention, until we heard the noble Lord, Lord Cohen of Birkenhead, although he, too, came through at long last and supported my noble friend. We also had what I found of extreme value, a gallant and spirited defence of the Willink Committee Report, which made it perfectly clear to me for the first time that the Willink Committee did not in fact recommend that there should be fewer doctors. Indeed, it said that there should be more G.P.'s, more doctors in local authority services, and others; and that was in the teeth, as it were, of distinguished medical opinion at the time.
In fact, the recommendation was made in the face of information which was incorrect, and of one or two pardonable false assumptions. We know that the Willink Committee in fact recommended, not a decrease but an increase in the number of doctors, and that it proposed that that increase should be provided by decreasing the number of students by 10 per cent. round about 1960. Now we all have that perfectly 1185 clear, and I think the noble Lord, Lord Cohen of Birkenhead, will say that our misunderstandings were reasonable, because it is remarkable that they should recommend that there should be more doctors, and that we would get those extra doctors by having fewer students.
My Lords, I was interested in the whole of the noble Lord's speech, but particularly with his concluding references. I do not want to misquote him, but I think that he said that the gold that is spent on health can never be wasted—
§ LORD STONHAM
—or words to that effect. That was the main theme which I wish to pursue, because Mr. Powell, the Minister of Health, on the 18th of last month, made a speech to the Conference of Chairmen of Hospital Management Committees, in which that was his theme. He said, in effect, that the spur to efficiency in hospital service, which in business is supplied by the profit motive, is stringency; and stringency, he said, is the mother of efficiency. In other words, he was perhaps saying that necessity is the mother of invention. In developing this theme, Mr. Powell urged the group chairmen to get more and more from a given quantum of resources, far more real service and far more real care out of a given number of personnel. I think that is what we should all want to do.
To illustrate his meaning, the Minister said that when he went round the hospitals and was shown devices to cut out misuse of nursing time, he hadsweetly observed what a wonderful thing the shortage of nurses is, and how we could not get on without it.Then he bluntly told us that since the quantum, financial and human, was not going to alter very dramatically, we should direct our minds to what can be clone with the available. He urged us, finally, to regard the Ministry as a sort of clearing house of the corporate experience of the Hospital Service and asked us to suggest improvements.
In picking up some of the points which have been raised by noble Lords during this debate—that is precisely what I propose to do—first I would say, providing it is not reduced to an 1186 absurdity, so that we are asked to dispense not only with the straw but also with clay for making our hospital bricks, that I fully support the Minister's thesis. Indeed, it will be within your Lordships' recollection that that was my own theme —value for money—in the debate on hospitals which I had the honour to initiate some time ago, although I regret that as yet there is no evidence that the suggestions made at that time have been heeded, let alone implemented.
I would assume that the Minister would say about the shortage of doctors, as with nurses, "How could we get on without it?" Even if all the suggestions which have been made during this debate were immediately implemented, it is perfectly clear that it is going to be some seven or ten years before there can be any material difference in the number of British trained doctors. How are we going to provide an efficient and safe hospital service while exporting British doctors at the rate of about 600 a year (I am not going to quarrel about the number) and importing between 700 and 800 overseas doctors, mainly, by the way, from under-developed countries like India and Pakistan, who surely can very ill afford to lose them? I would say that there could scarcely be a better opportunity for trying out the Minister's dictum that stringency is the mother of efficiency, particularly as the situation is getting ever more stringent.
I am not going to quote a lot of figures, hut, as I am only the second non-doctor to speak in this debate I think that it is reasonable to say how it appears to one who has the voluntary responsibility of meeting the stringency and trying to do the best he can with the human quantum which is available. Just consider the position, not in a rural area and not in the Provinces, but in my group of five hospitals right in the heart of London. Our establishment of registrars, housemen and senior house officers is 42. In fact, we have 41 doctors. That is very good; we are up to establishment. Of that 41, 22 are from overseas. That, again, is roughly in line with the figure of 55 per cent. quoted for the Provinces. So, "not to worry"—not yet. But we have had an astonishing experience during the last two months—I am not going back even a year ago but will deal with the situation as it is now in October and November. We advertised to fill 1187 actual and impending vacancies which very rapidly arise in the junior medical staff. I will just give your Lordships the bald facts.
My noble friend Lord Taylor mentioned that the post of medical registrar was a "plum" post. In one hospital last month we advertised the post of medical registrar. For that "plum" we had thirty-two applications, twenty-six from overseas and only six from British applicants. In the same hospital, during the same month, we advertised the posts of house surgeon and there were forty-two applications; anæsthetic registrar, three applications; gynæcological registrar, ten applications; surgical registrar, sixteen applications—a total of seventy applications and not one single application from a British doctor. Every single one came from overseas. And this, I would say, is a fairly good hospital, certainly one going on under the ten-year plan, with over 300 beds and some very good consultants on the staff. It is not a hospital slum.
Take another hospital in the same group—anesthetic registrar, three applications, none British; house surgeon, thirty-nine applications, two British; house physician, thirty-nine applications, one British. These are the most recent figures, and if that trend continues I say that it is a reasonable assumption that in eighteen months or two years there will not be a single British doctor in these hospitals in those grades. I do not mind where they are trained—I hardly need tell your Lordships my views on that—provided they can give efficient service, but there are important differences between filling gaps in the nursing ranks with girls from the Commonwealth and satisfying the doctor shortage with men and women from the same source.
If the girls who come to us from Africa, the West Indies or Asia have an insufficient command of the written and spoken work or have other educational deficiencies, we see that they either go to classes or provide classes for them, so that these drawbacks are overcome before they start their student nursing training. The results are magnificent. Last week I was present at one hospital when fifteen certificates were presented to fifteen nurses who had satis- 1188 fied the examiners after three years' training. Of these, eight were coloured —about fifty-fifty—but out of the twelve prizes, eight were won by coloured girls, including the first and second. That was an absolutely magnificent result, a remarkable triumph for the girls, the teaching staff and the hospitals, and provides the answer to a whole lot of problems and to a lot of ignorant calumnies, but it was achieved by careful and devoted training and practical work under supervision all the time.
But, as my noble friend Lord Taylor made so clear, there is no such training for young overseas doctors, either educational or medical. The great strength of our medical training system is that our young men do a great deal of practical work under supervision, and those who come over here for post-graduate work, in my lay and humble submission, have not had the practical work. Certainly they do not evince the practical experience which is so necessary. They are pitchforked into posts of responsibility and danger, for which all too many are ill-prepared. The noble Lord, Lord Cohen of Birkenhead, said that my noble friend's suggestion, which I was also going to make, is illegal and impractical.
§ LORD COHEN OF BIRKENHEAD
My Lords, the first part of it is illegal and the second part, I submit, is impractical.
§ LORD STONHAM
I am happy not to misquote the noble Lord. He admitted, though, that it is possible for hospital medical committees to limit their employment. That is not the answer. What alternative have we? I would submit that this is one of the matters in which the Ministry must help us to find a way. If it is the case that these young doctors must be registered with us in this way, we must have an opportunity of paying them while they are being trained in certain essentials. I think that it would be thoroughly disgraceful and completely unjustifiable, simply because we lack doctors, to thrust an untrained, in the practical sense, doctor on to an un-suspecting number of people. I, for one, should be completely unwilling to do such a thing, if I were aware of it, and I am afraid that I have to admit 1189 that I am becoming aware of this danger. I would say, then, that in so far as the legality of it is concerned, we must find a way; and it is up to the Minister to consult with those who can advise him on this subject and then give us, who have the job of dealing with these things in the field, as it were, the power to get over this difficulty.
There are many difficulties which arise from the employment of overseas doctors. As has been said, they not only frequently have an insufficient command of the English language, which creates difficulty between doctor and patient and doctor and staff, but they are unfamiliar with the Cockney or provincial idiom. It is not only virtually impossible for them to understand the patient in many cases, but equally impossible for the patient to understand them.
§ LORD COHEN OF BIRKENHEAD
My Lords, may I interrupt the noble Lord for one moment? There are doctors trained in medical schools in the North of England who are quite unable to understand some of the dialects in this country.
§ LORD STONHAM
They appear in the course of years to have overcome the difficulty. I would assure the noble Lord that I have never had any difficulty in understanding him, just as apparently at this moment he has not had any difficulty with regard to my Cockney accent. But this leads to problems and dangers, for example, in taking the case histories of new patients, normally one of the functions of the resident doctors. And their command of the written word is not always sufficient to enable them to prepare case summaries giving concise and accurate information to the G.P.s.
Then there are the varying social standards in the countries of origin. This factor causes friction in doctor-patient and doctor-staff relationship. Some awkwardness arises in resident quarters, because many of these doctors are naturally from different national groups, and if there are sufficient of them in a hospital they tend to form that group and in off-duty times to speak their own language. When they are in the majority, the British doctor feels isolated; and when you get beyond a certain point it is difficult to recruit British doctors. This situation is common to hospitals in my group and applies to many quite good 1190 hospitals throughout the country. It is a source of anxiety to consultants and to the administrative staff; we are all very uneasy about the trend and fearful of what may happen.
This leads me to say again that the average patient who has no knowledge of the staffing problems of hospitals accepts the need for training of overseas doctors here. But it is bewildering to him when he sees that the overwhelming majority come from that source, and he must find it difficult to have complete confidence in a doctor whom he himself does not understand, however good that doctor may be. Therefore, I would submit that the first and most important thing to be done is to devise some way of having short courses in the written and spoken word. That is one way to help remove the differences of the way of life, if you like, between us and them, and to help them. This is not to suggest that their life is not as good as, or even better than, ours, but merely that it is different, and it creates a difficulty that we have to remove and helps to make them more efficient doctors, able to carry out the Minister's policy, which, as I have already said, I support.
The point is this. These young doctors, all untried, often start work in the casualty department, and the casualty officer is a most important person. He must be, or should be, a good diagnostician. But how can he be if he has had so little practical experience? If he is in doubt, and plays safe by calling on his consultant, he risks a telling off if his chief decides that the call was unnecessary, and this means a black mark from the very man from whom later on he will want a recommendation. So the next time he takes a chance, and he may be lucky. But the point is that the patient may be unlucky. I do not blame the young doctor; but we shall be blameworthy if we allow this sort of system to continue.
There is no doubt that the low quality of this vital casualty work is a major cause of concern throughout the hospital service. The Observer, in its inquiry recently, "What is wrong with the Health Service?" published on November 12, a graph showing how efficiency varies in different casualty departments. The comparison was of six hospitals which include two acute teaching hospitals and a special 1191 hospital. I do not know the names of these six hospitals, but I hope the Minister does, because one at least, on that evidence, should be closed; it must be more like a slaughterhouse than a hospital. For 23,000 casualty attendances, according to the review in the Observer, there is said to be no consultant supervision and no interest shown by the medical committee. It was marked nil for equipment, patient comfort, control of infection and appreciation of the sepsis problem, and there was no interest in rehabilitation or in prevention and follow up.
An acute teaching hospital is the next one, and for 63,000 attendances it had nil appreciation of the sepsis problem and was deficient to a major extent in most of the other criteria. I would submit that that hospital should cease to teach if it cannot quickly overcome these medical defects. The only satisfactory feature, from the point of view of the review by the Observer, was the 100 per cent. quality of the sister in charge—even in the very bad hospitals it was 100 per cent. for the sister in charge; and in most cases the quality of the casualty officer was high. But I submit that the other major deficiences which were revealed would not exist if the consultants were doing their job properly. In a good hospital it is the consultant's energy, devotion and initiative which permeates the whole service. His example, supervision, instruction and advice can transform the work of all but the dullest of new young doctors; and his persistence can win new equipment from even the most reluctant of regional boards. There are many such consultants in the National Health Service.
I would re-emphasise that the National Health Service, and certainly the hospital service, is not under attack in this debate; it has no case to answer on the service. We are concentrating on the one point. As the President of the Royal College of Physicians made clear in a recent letter to the Guardian, there is no case against the Health Service on this issue. But there are many first-class consultants who exercise a wonderfully stimulating influence. They spend long, frustrating, unpaid hours in committee; they are the ever-worrying backbone of ale medical side of our hospitals. But, 1192 unfortunately, there are also the other kind. There are the people who never appear at committees unless they have a personal axe to grind; who deliberately over-insure and waste beds for very questionable reasons; who browbeat those of their juniors who try to carry out group instructions and assist the emergency bed service; the consultants who come an hour late to their clinics and airily explain that they have had to see a patient at another hospital. We cannot check these things. It is impossible for the keenest group chairman to follow Mr. Powell's advice and get more real service from his personnel if he cannot in some way bring these gentry to book. Nobody wants or expects—it would be utterly absurd—that a man reaching the top, or at the top, of his profession, drawing a salary, perhaps, in some cases of nearly £8,000 a year, should punch a clock, and things like that. He is on his professional honour.
What do we do if honour is lacking? There is virtually nothing practical that I or any other group chairman can do. You can appeal to the regional board and if the case is bad enough, after they have gone tremblingly through all the legal possibilities and are absolutely certain that the case is very bad, they can submit it to a committee which is heavily over-weighted with distinguished medical men, all of them distinguished public servants of the very top class. They themselves are confronted with the fact that, if they are convinced that the case is proved and if they then take the action, it would mean that the consultant in question probably would not get other employment. So they say, "Well, he has had a very good talking to; this will not happen again". And nothing is done. It is not good enough. I know the consultants are seconded to various groups on a sessional basis and if all goes well the region has nothing more to do with him.
I suggest to the Minister of Health that he should give the strongest possible consideration to giving hospital management committees the power to make direct contracts with consultants. In my view, it would be the quickest way of getting more real service from our personnel. I know that the noble Lord, Lord Cohen of Birkenhead, and my 1193 noble friend Lord Taylor have made a number of extremely important suggestions, some of which depend upon investigation. I would submit to the Minister, that, where suitable—and that covers a wide range of subjects—the investigation should not be from within his own Department, because I do not think there are sufficient numbers of personnel to deal with it. In any case, they stand very close to the job, and it cannot be left to our own first-class, but all too few, work study teams. I would submit that a more detached expert assessment would be invaluable, the kind of job, for example, which in some fields, indeed the hospital field, has already been done by some of the members of the Management Consultants' Association. It must be a top-level expert job.
We need to tear aside the veil from some of our medical taboos. It needs courage and determination which, fortunately, the Minister has shown that he possesses in full measure. I would suggest that he directs them to some of the suggestions made in this debate. He may, ere long, be able to say with some approach to accuracy that, "we could not get on without the shortage of doctors".
§ LORD FERRIER
My Lords, before the noble Lord, Lord Newton, rises to his feet, I think it is proper to point out that conditions in Scotland differ some-what from the conditions in the rest of Great Britain. I think it is safe to say that, so far as Scotland is concerned, doctors form a significant part of Scotland's most important export—namely, men. As regards doctors from overseas, the situation there is clearly disclosed in Table VI on page 89 of the Working Party's Report. These figures go to confirm what I believe to be the case: that there is not the same shortage of doctors in Scotland as there is in many parts of the South.
§ 6.25 p.m.
§ LORD NEWTON
My Lords, whenever it is necessary to do so, your Lordships' House can always draw upon a wealth of expert medical knowledge, and this has been proved once again this afternoon. So I begin by thanking the learned doctors who have contributed to our debate, even though most of them 1194 have now gone. All of them ganged up against me, with the exception, and most important exception of course, of the noble Lord, Lord Cohen of Birkenhead. I am extremely grateful to him, not only for the great help which he gave to me by what he said, but also for the moral support with which he has fortified me to face my trial. I should also like to thank the noble Lords, Lord Beveridge, Lord Auckland, and Lord Stonham, for ensuring, by their contributions, that I am not the only layman to speak this afternoon.
The subject we have been debating, when stripped of any overtones, is technical and complicated, although, perhaps, not quite as complicated as the mind of the Russians, upon which my noble friend Lord Taylor demonstrated on Sunday that he is such a notable authority. In terms of the national interest, not all technical subjects are important, but this one undoubtedly is. On the other hand, it is not a subject upon which Party politics have any bearing, and there has been no such bearing in this debate. However, some of your Lordships have made fairly severe criticisms of Her Majesty's Government. I welcome this challenge without hesitation, but in replying to the debate I shall be as objective as I can and, I hope, not too long. Lt will be my endeavour, if not to silence the critics—perhaps it is always too much to expect to do that—at leak to satisfy them. I must, however, say at once that I do not consider that there is anything in the present situation which reflects discredit upon the stewardship of my right honourable friend. Nor do I wish it to be thought that I associate myself with what I may call the mood of alarm and despondency which has at times crept in this afternoon.
The noble Lord, Lord Taylor, supported his main argument with evidence obtained by personal inquiries, he told us, from all over the country. He did not, and I recognise that he could not, disclose his sources, and because of that obviously I cannot comment upon that evidence. If he thinks that any of it ought to be separately investigated by my right honourable friend, I hope he will let me know. I imagine that it was open to the noble Lord's sources to give 1195 evidence to the Platt Working Committee on the Medical Staffing Structure. Perhaps they did.
§ LORD NEWTON
My Lords, I am sure that is a very good thing. But if they did, and if subsequently matters within their purview changed in their opinion for the worse, it was of course open to them to inform my right honourable friend, and, indeed, it was open to them to approach him even if they did not give evidence to the Working Party.
The noble Lord referred among other things, to a shortage, or a coming shortage, of consultants. The facts, as I understand them, are that in general medicine and surgery there are still a number of senior registrars who have completed their training and who have not yet secured consultant positions. There are, however, certain fields in which new developments in medical knowledge or techniques have resulted in unforeseen demands for more consultants. Until senior registrars in these specialties can be trained—a process which takes about four years—to the point of being qualified to compete for consultant posts there is bound to be difficulty in meeting the demand, and this would be so even if there were a superfluity of doctors entering the profession to-day. It takes fifteen years at least from the time they enter as students to train doctors to the point at which they can become consultants. Consultants being appointed now were already embarked, or about to embark, upon their senior registrar training when the Willink Committee reported. They started to train as students in 1948 or before.
Some senior registrar jobs are less attractive than others, of course, and for that reason they may not be filled so easily, but the Platt Report has recommended ways of improving the organisation of senior registrar posts and the guidance of senior registrar training. It is true, as has been emphasised so much this afternoon, that the supply of doctors generally over the next five to seven years is already determined. But whatever the position becomes will depend on other factors besides sheer numerical strength. For example, the reorganisation of hospital medical staff- 1196 ing following the Platt Report should make a valuable contribution.
My Lords, the main employers of doctors are the hospital service and the general practitioner service. We have had a good deal of statistical information this afternoon and I do not want to burden your Lordships with a lot more, but I feel I ought to give just one or two figures to the House. To take Great Britain as a whole, the number of whole-time equivalents (to use what to a layman is ghastly jargon) who were employed in hospitals in 1956 was 18,537. In 1960, the number had risen to 20,148, an increase of about 9 per cent. In the general practitioner service the number employed in 1956 was 22,551, and in 1960 it was 23,291. In England and Wales 1959 was the only year of the five in which the percentage increase for the population was greater, and then only slightly, than the percentage increase in the number of general practitioners. This was due to the exceptional circumstances of the tenth birthday of the superannuation scheme. In Scotland, the percentage increase in general practitioners exceeded the percentage increase in population in each of the five years. I just mention these statistical facts in order to put the main question before us to-day in proper perspective. There are also in this country some 2,500 doctors wholly or predominantly employed by local authorities, but their numbers, I understand, vary little from year to year.
Not much has been said by any of your Lordships to-day about doctors' pay. As your Lordships know, of course, the recommendations of the Royal Commission were accepted by the Government and implemented, but I was interested to hear the obiter dicta of the noble Lord, Lord Taylor, on the subject of doctors' pay when he spoke a fortnight ago in the debate on Technical and Scientific Manpower, and I had it here ready to quote to him. Any major revisions of pay will fall to be recommended by the review body, which has not yet been set up, but about which my right honourable friend hopes to make an announcement shortly. The Royal Commission envisaged that the review body would go into action at relatively infrequent intervals; it mentioned three years as a usual minimum, and, of course, it is less than two years 1197 since the Royal Commission reported. I will also mention that the Royal Commission appreciated that peripheral hospitals, those in unattractive areas, about which we have heard so much today, have difficulty in recruiting junior staff and they recommended the special allowance of up to £100 a year. This the Government accepted and so did the profession. So far, 623 posts have been approved for grants. In all but 11 cases payment dates from September 1 of this year.
I understood the noble Lord, Lord Taylor, to be rather disparaging about this recommendation and its implementation, but what I would just say to him is that as payments started to fall to be made only from September 1 this year, it is rather early for anyone to assess the general effect of the scheme.
§ LORD TAYLOR
My Lords, I am very sorry I did not make myself clear, but what I said was this. You pay a lot of posts £100 a year or more when there are only x doctors in circulation, as it were. You do not increase the supply of doctors, you merely reduce the supply somewhere else. That is what I said. I think that it is a completely fallacious and ridiculous exercise to allow vacancies in hospitals to push up prices. It is exactly opposite to the wage freeze; and to attract people to other places is exactly what the Government tell us not to do. You shove up the money by £100 a year and reduce the numbers of those in the profession. There are no more doctors coming through.
§ LORD NEWTON
My Lords, if I misunderstood the noble Lord, I am sorry. We are concerned to-day not only with the number of doctors but with their distribution, and many of your Lordships have said that the distribution is nothing like as good as it ought to be. I would add in this connection, since the noble Lord referred in his speech to the problem of Sheffield, that the Sheffield Board has been informed that my right honourable friend would approve of the grant of allowance for 50 posts. So far the Board have applied for 34.
The noble Baroness, Lady Summer-skill, returned to the theme which she stressed during the debate on the Address, that of women students. The 1198 number of women students taken into medical schools is entirely a matter for universities, and not one which either the Government or the University Grants Committee can influence. So far as London schools are concerned, only a small number of women were admitted before 1948, except to the school of the Royal Free Hospital, which admitted no men. In 1948, London schools got together and met quite informally, and an agreement was reached that the schools in general should take something of the order of 15 per cent. of women, and that the Royal Free school should take the same percentage of men. This is not to detract in any way from the genera] position that the questions as to individuals admitted and the proportion of men to women rest wholly with the universities. But figures recently received from the University Grants Committee indicate that in 1960–61 about a quarter of the medical students entering pre-clinical training in Great Britain were women. This also applies to the London schools as a group where the output during the same year showed the same proportion. Perhaps I might also say that there is certainly no discrimination against women practised by my right honourable friend's Department, and, indeed, this afternoon I have four advisers in the Officials' Box of whom two are women, so what could be fairer than that?
§ LORD STONHAM
My Lords, has the noble Lord, among the figures he obviously has before him, the figures for the percentage of women students at St. Thomas's Hospital? I am told that only one girl applicant in 40 is accepted, and I should like to know what figures he has.
§ LORD NEWTON
My Lords, I have not any figures for St. Thomas's, but if I can find them I will let the noble Lord have them.
I turn now to the main question before us, and I must begin by reminding your Lordships, as indeed did the noble Lord, Lord Evans, and even more graphically the noble Lord, Lord Cohen of Birkenhead, that in the years before 1955 anxiety was felt in the medical profession that too many young doctors were being produced in relation to the places that would be open to them. I was in another place at that time and I can remember to 1199 this day representations on those lines which were made to me as a Member of Parliament. Because these things were so, the Willink Committee was set up, as the noble Lord, Lord Cohen of Birkenhead, said. The Committee reported in 1957. It concluded that there had been no over-production of doctors up to the time it reported, but it recommended an immediate reduction in the intake of pre-clinical students from Great Britain of about 10 per cent. This recommendation by this distinguished Committee was commended by the Government to the universities. My Lords, what else could they have done? I have made researches and I can find no record of any criticism of this decision of the Government in either House of Parliament. The noble Lord, Lord Taylor, was not at that time a Member of either House, but the noble Lord, Lord Stonham, was and so was the noble Baroness, and it is my recollection, though I may be wrong, that the noble Baroness was then the shadow Minister of Health.
§ LORD STONHAM
My Lords, it was probably because my noble friend was not a Member of either House that the thing went wrong.
§ LORD NEWTON
On the other hand, as the noble Lord, Lord Cohen of Birkenhead, has told us, there were articles in the British Medical Journal and the Lancet which indicated broad approval of the Report, to put it no higher. I have not been able to find any contemporary comment which questions the validity of the Willink calculation beyond pointing out, as the Committee itself did, the uncertainty of many of its assumptions. It was later that doubts were expressed about the numbers of doctors available. Suggestions were made that the Willink Committee had under-estimated the demand and that a shortage might be developing—for in-stance, the article by Professors Lafitte and Squire, which has been mentioned by several of your Lordships.
Accordingly, the Government decided to review the data and calculations of the Willink Report, and this decision was announced in another place on February 8 this year. This review has just been completed, and I am able to tell your Lordships that the Government are satisfied that the prospective demand for 1200 medical services would justify a rise in the university intake of pre-clinical students from Great Britain of 10 per cent. above the level recommended by the Willink Committee. This was a figure of 1,760. I might mention in passing that the comparable intake figure in July this year was 1,788.
My right honourable friend, the Chief Secretary to the Treasury, has asked the University Grants Committee to consider with the universities the implications of the Government's conclusion. This being so, it would be premature for me to say more about numbers and capacity of medical schools than that I find it hard to imagine that the Government would be able to approve of the very large increase for which the noble Lord. Lord Taylor, called.
Consideration of all the factors has convinced the Government that it would not be realistic to attempt to replace the many figures used by the Willink Committee by other figures which might give an unwarranted appearance of equal precision. It is clear from the work which has been done that there are many uncertainties. Some are bound to remain. Others will be clarified only by the further research which is being undertaken. For example, it is realised that the assumption of a population increase of 4 per cent. up to 1971 used by the Willink Committee should now be replaced by a figure of 7 per cent.; but this estimate may need to be adjusted as time goes on. Information about the migration of doctors, both into and out of the country, is at the moment lacking. In our free country importunate questioning by officials is rightly kept to the minimum. Again, figures for losses—I will not say wastage—particularly of young women doctors early in their careers, are not accurately known. Here, too, past and present experience are not necessarily certain guides for the future.
Steps are being taken to improve the quantity of statistical information so far as this is reasonably possible. Nevertheless, uncertainties will remain. The solution does not lie in attempting to make firm estimates at wide intervals in time, but rather in constantly watching the figures, including those of output from the medical schools. This the Government intend to do. I am hopeful that the noble Lord. Lord Taylor, will approve of this approach in view of his wise 1201 observations about statistical exercises in the debate about Technical and Scientific Manpower a fortnight ago.
I turn again to the hospital service. The number of medical staff employed has been rising steadily—by about 9 per cent., as I said earlier—over the past five years. The Plan Working Party earlier this year drew attention to a shortage of doctors in the junior grades and to the large number of foreign graduates. It also made recommendations covering the whole of medical staffing in hospitals, recommendations about, for instance, the responsibility for patient-care and the organisation of training for consultant posts. The main principles of the Platt Report have been accepted by the Government and the medical profession and its recommendations will be acted upon. One of the most important is that there should be a review of medical staffing in hospitals. Circulars will shortly be issued to hospital boards about both this and the other recommendations. My right honourable friend envisages that the review will cover not only immediate circumstances but also the needs of the next few years. Until this review is completed it is not possible to say what changes may be necessary.
The noble Lord, Lord Taylor, and many others of your Lordships discussed the question of doctors from overseas. It is the case that over one-third of the posts in the middle and lower grades were, in March, 1960, occupied by doctors born outside this country. It is no doubt true that sometimes some of these doctors have difficulty with the language, with which they are not completely familiar. But I cannot say too emphatically that it really would be quite unjust to exaggerate criticisms of this sort. The Platt Committee went so far as to say:Without the 3,628 doctors from overseas—a large number of whom are in this country for a short time only—there would obviously be a breakdown of staffing below the senior registrar grade … We hope that many young doctors will continue to come to this country for post-graduate training and that the hospital service will continue to provide suitable places for them …We must not forget the value of these doctors to whom we have obligations. We must not ignore that, and I got the feeling this afternoon that that was present in the minds of noble Lords.
§ LORD STONHAM
My Lords, certainly I did not intend any such interpretation and I do not think it was intended. Of course we depend upon them, and they do a wonderful job. All the remarks I heard were directed to the object of making them more effective.
§ LORD NEWTON
Well, I listened to the speeches as well as the noble Lord, Lord Stonham. Obviously, there are dangers in excessive reliance upon doctors from abroad, particularly those whose command of English is indifferent. But it is the Government's hope that doctors from the Commonwealth and elsewhere will continue to make their valuable contribution to the hospital service.
The noble Lord, Lord Taylor made the interesting suggestion that there should be special training and indoctrination centres for these doctors from the Commonwealth. But this suggestion ignores the fact that regional hospital boards, hospital management committees and boards of governors have complete discretion in their appointments. To insert a training school of the sort the noble Lord envisaged between one group of fully registered medical practitioners and their potential employers would be a slur not only upon the qualifications and training that these people obtained in their home countries, but also upon their prospective employers, who are expected to exercise informed discretion over the persons they appoint, and to ensure that after appointment any necessary supervision is given.
The Platt Report recommends that young hospital doctors should be encouraged to stay longer in hospital. This will help to ease the staffing difficulties at the junior levels. But it has a wider purpose. It links up with the recommendation that these doctors, most of whom will later go out into general practice, should be given experience in hospitals which will fit them still better for their careers in general practice, and that suitably qualified general practitioners should play a more active part in the hospital service. This is a recommendation which can be implemented only gradually, but when one examines the problem of the future of the general practitioner one cannot doubt that a closer relationship between the hospitals and the general practitioner is as necessary as it is desirable. Even in areas 1203 where the average general practitioner's list is high there may well be some doctors with smaller lists who would be able to take on part-time hospital work and could do so without over-burdening themselves. Already there are signs that general practitioners are seeking part-time hospital posts in some parts of the country. The experience of the Birmingham region, where no fewer than one general practitioner out of every four has a part-time appointment in a hospital, shows that, despite the demands of general practice, more assistance can be expected from this quarter.
I come now to the general medical service, and I would emphasise again that the number of doctors providing these services continues to increase each year. Up to 1958 the increase in the number of general practitioners in England and Wales was proportionately much greater than the increase in population. In 1959, as I have said, for the first time the percentage increase in the number of such doctors was less than the percentage increase in population, and I have explained why this was so. The position has since recovered. In 1960 the average number of patients on a doctor's list was 2,287, about 150 lower than it was in 1952, the first year for which comparable figures are available.
The increased openings for doctors in all fields are reflected in the reduced competition for advertised vacant single-handed practices. In the mid-1950's vacant practices in England and Wales attracted on the average over 40 applicants and it was not uncommon for more than 100 doctors to apply for a popular vacancy. In those years some young doctors found it very hard to enter general practice. In the last two years the average number of applicants for vacancies has been 18. Substantial vacant practices in pleasant areas still attract large numbers of applicants. It is the less popular parts of the country, mainly industrial areas in the North of England and Wales, which have experienced difficulty. On the average, practices in the South of England will receive 24 applicants for each vacancy compared with 10 in the North of England and Wales. It is, however, necessary to keep this matter in proportion. During 1961 6 vacant practices 1204 had to be re-advertised before an appointment was made, but in every case the vacancy was in fact then filled, though in one case the vacancy had to be re-advertised twice—this was in the North of England. In the other 5 cases, one re-advertisement was sufficient despite the fact that all the practices concerned had lists of below average size and three of them were very small.
The problem of improving the distribution of doctors is very much in the mind of the Government and it is of particular concern to the Medical Practices Committee which was constituted by the National Health Service Act. Neither my right honourable friend nor the Medical Practices Committee have power to direct doctors to particular areas, but the Medical Practices Committee do have power to refuse a doctor's application to take part in the general medical services in an area where the number of doctors undertaking to provide these services is already adequate. The Committee publish lists of areas which are designated as needing more doctors and where initial practice allowances are payable. They also publish lists of areas where admission is restricted and is normally refused. Over the rest of the country individual applications are considered on their merits.
I do not wish to belittle the difficulties of those parts of the country which are still short of doctors, but the very great improvement already brought about in the distribution of doctors is illustrated by the fact that in 1952 over half of the population of the country lived in areas designated as needing more doctors. In 1960 areas still needing more doctors contained only one fifth of the population of the country.
As your Lordships are aware, one of the measures taken to encourage doctors to set up in practice in areas designated as needing more general practitioners was the payment of initial practice allowances. At January 1 this year, the amount of these allowances was increased and they can now be paid for a maximum of four years instead of for only three years as previously. It is too soon to judge the effect of these changes.
Many different reasons lead doctors to prefer to practise in one part of the country rather than another. For 1205 example, the climate and character of the area greatly affect its chances of attracting doctors, but such factors are not subject to alteration or influence by Government action. However, the question whether there are any new measures which could be taken to alleviate the present difficulties of those areas which are least well supplied with general practitioners is shortly to be discussed between my right honourable friend's Department, the Medical Practices Committee and the General Medical Services Committee. The recommendation of the Management Committee of the Executive Councils Association, which was referred to by the noble Baroness, will be included among the matters to be discussed.
To sum up what I have been trying to say, the Government are fully aware that the number of doctors requires to be watched in the interest of the Health Service. They consider, however, that it would be rash to provide at infrequent intervals, as in the past, categorical estimates of exactly what the disposition of and need for doctors will be at distant future dates. Instead they propose to keep evidence of demand and supply under continuing review, and to try to maintain a flexibility of approach to the problem which has not hitherto been achieved.
Inevitably, we have for most of the time this afternoon been discussing doctors as though they were numerical entities. It would not be right for me to sit down without saying something about them as human beings. The standards of medicine in this country have been, and continue to be, widely renowned. The medical profession has for long been held in esteem by the public. Originally this esteem was, I fancy, related to the doctors' empirical concern with the mysticisms of life and death. In recent years public knowledge of and interest in medical matters has increased, stimulated by various media including the television screen which regularly lays the mysteries bare. The appreciation of the man in the street for his doctor has consequently been heightened by a stronger sense of participation in the work that the doctor does and the kind of life he leads. For the first time patients, and that means most of us, are beginning to comprehend 1206 fully the dedicated commitment of the doctor to his job, a commitment which, even if it most properly has its moments of gay relief, goes on remorselessly throughout the twenty-four hours.
My Lords, new therapeutic measures, advances in the technical field, and changing attitudes have brought ever more benefit to all of us. At the same time, these factors have tended to intensify the responsibilities, never light, which have to be borne by the profession. These responsibilities are accepted without question. Our obligation to the doctor, who in his day-to-day work (which is by no means always as full of variety and glamour as "Emergency —Ward 10" may suggest) is always ready to put the interests of another before his own, and is never unwilling to shoulder the burden placed upon him, should not go unacknowledged on an occasion such as this in your Lordships' House.
§ 7.2 p.m.
§ LORD TAYLOR
My Lords, first of all I want to say "Thank you" to all the noble Lords who have taken part and have supported the proposition which I placed before your Lordships, particularly my noble friend, Lord Cohen of Birkenhead. I must say he hit me a few shrewd blows which I thoroughly deserved, but how jolly fine it was to find his coming out in the end and saying that Willink was wrong! That is what we hoped he would do, but it is more than the noble Lord, Lord Newton, had the courage to do.
My Lords, I feel that we have had a thoroughly unsatisfactory reply. The noble Lord, Lord Newton, did his best with his brief and it was a very fine effort, but really I have completely failed to convince the Minister and the Government that this is a problem. What are we told? We are told, "Oh, it is going to be all right. We are going to put back 10 per cent. on the Willink figures." I do not know what that means, and I wonder whether the noble Lord, Lord Newton, knows. I explained that the number of medical students was cut before the Willink Committee reported, and that the total cut which occurred was a cut of 10 per cent. Although the 1207 Willink Committee recommended it, it was not done on their recommendation; it was done before, so far as we are able to ascertain.
As the noble Lord, Lord Cohen of Birkenhead, said, these figures are imprecise because of double-counting. He is absolutely right. We have had a 10 per cent. increase of population, we have had a 7 per cent. increase of doctors, and we have had a decrease in medical students. This is insanity, my Lords; this is absolutely mad. I am at a complete loss to understand why Her Majesty's Government have not appreciated what they have done—or what they have let happen, because I am sure that they have not done it deliberately. None of us realised what was happening, but now their eyes must be opened. I have done my best to open them and I will continue to do this. There is the fact that we have had to have 3,500 Indian and Pakistani doctors in our hospitals. They are not here for postgraduate training—do not believe it, my Lords!; they are here to provide pairs of hands in the rottenest, worst hospitals in the country, because there is nobody else to do it. The jobs are there waiting for them to come and get them and be paid while gaining experience. There is no nonsense about teaching in these places. Oh, no!
Now we say: do something about it. Do two things: first of all, get a proper estimate of the number of medical students we need in proportion to the population. Then have regard to the fact that you have increased the number of specialists from 4,500 to 7,000, or whatever figure it is and that you must have more doctors. Surely, we are going to make our contribution to overseas as well. I hope we are. I think my noble friend Lord Cohen of Birkenhead was very minimal when he said 200 to 300 more a year. I think it is probably more like 400 to 500 a year that we ought to have to meet this deficiency which is with us now and will go on for the next seven years, and will be worse at the end of seven years.
Then there was the noble Lord's attitude to this question of training these Indian and Pakistani doctors who come. I just think that we are not playing fair by them.
§ LORD TAYLOR
We are putting them into these thoroughly unsatisfactory hospitals where, as the noble Lord, Lord Cohen of Birkenhead, said, the conditions are very often so bad for the residents that you cannot expect Englishmen to work there. That is a terrible state of affairs. We must give them a fair deal, and I am not suggesting any legal changes at all. I may be suggesting something that is impractical, but then I often do, and I often find that it is not impractical when it is tried. I am not suggesting any legal changes. I am saying: let some of the regional boards, themselves, run these training schools. Let them see all applicants for posts who have to go through the training schools and then, if there are people who are completely unsuitable, they will not be appointed. That is all. This seems to me the common sense way of doing it, and I cannot see any objection to this on any moral, practical or other grounds, except, of course, that it would cost some money—and I have no doubt that that is most abhorrent to the Government: the thought that the National Health Service will cost them some more money. But you cannot go on doing it on the cheap. You have to pay the proper price for what you want.
The noble Lord, Lord Newton, said that there is difficulty over the new specialities; that that is where the weakness is. Of course, he is absolutely wrongly informed. It is in the oldest of old specialities, the anæsthetist, the ear, nose and throat surgeons, and the casualty department—the oldest of all hospital departments—where the shortages are now. That is where there is a failure of consultants to come forward; and, of course, you must have a pressure of consultants. My noble friend, Lord Stonham, was absolutely right and the Minister was absolutely right in their basic philosophy. You must have a pressure to produce a stringency of jobs in relation to the number of doctors. If you have stringency of jobs in relation to the number of doctors, then you will get the anæsthetists and the other people going, and willingly going, to the less attractive hospitals to work; but so long as there are too few doctors, of course they will go to the pleasant places. Of 1209 course they will take the pick of the jobs, and the periphery and the worst places will suffer. My Lords, I failed to get it across to the Government and I should, like, therefore, not to withdraw my Motion, but to ask your Lordships to carry it.
§ On Question, Motion for Papers negatived.