HL Deb 25 February 1969 vol 299 cc1030-56

4.7 p.m.

BARONESS STOCKS rose to ask Her Majesty's Government whether tic Health Department of the Ministry of Social Services will promote an inquiry into the extent of general practitioner deputising services, with reference to their recent expansion, the quality of service, and any influence their operation may have on doctor-patient relationship. The noble Baroness said: My Lords, there is an old song which, if I remember it aright, runs something like this: I know where I'm going and I know who's going with me. I know who I love, but The de'il knows who I'll marry. If one can personify the National Health Service—or rather the general practitioner side of it, with which I am concerned this afternoon—that song might be rendered thus: I don't know where I'm going. I don't know who's going with me. I know what I want, and The de'il knows if I'll get it. What we all want of the National Health Service, what we hoped to have when it was first hammered out in 1946, is a general practitioner service free to all, giving to men, women and children in this country the services of the general practitioner based on the old doctor-patient personal relation. That is what we want. The question is: have we got it?

My Lords, since the establishment of the National Health Service two obstacles have obstructed that dream. They may have been predictable obstacles, but certainly they did not arise at the time predicted. One of them is the shortage of medical manpower, which means that the National Health general practitioners now have immensely heavy case loads—legally up to 3,500 per doctor. In fact I think that the average for England as a whole is well over 2,000 list patients. This is too much if perfunctory treatment in the surgery is to be avoided. The surprising thing is how often the treatment is not perfunctory. But sometimes it is; and it is difficult to talk freely to a doctor in the surgery when you know that a crowd of very impatient fellow-patients are champing outside, longing, it seems, for you to come out. That is an experience with which some noble Lords in this House will not be familiar, but other people are. That is one obstacle.

The other obstacle is really the inexperience of the patients. A huge number of patients, especially in working-class areas, have never been accustomed to the kind of general practitioner service with which the rich were acustomed in the old days. They do not know how to use it. Often they have rather low standards of medical practice—five minutes in the surgery and a bottle of medicine. In other cases they are over-demanding and prepared to take the view that the doctor is now their servant, paid to do what they want, and that if they send for him he has to come. This sort of attitude is often met with in patients—too often, indeed. Only yesterday I received a letter from a doctor friend of mine in which, when speaking of this, she said: The demand for doctors 'out of hours' is very seldom for a real emergency (which no doctor would object to) and has given rise to this need for the service", which I am going to describe. The letter goes on: For example, an urgent call to several doctors, to the emergency service and a hospital resulted in an elderly doctor going out to a late call to find a child with chickenpox. In the old days, in the general service to which my father as a private practitioner was accustomed, that sort of case would have been dealt with by an experienced nanny, who would have known perfectly well that in such a case you do not ring up a doctor in the middle of the night. But I am afraid that a great many emergency calls are of that nature. Those are the two obstacles to the achievement of the kind of dream that we had in 1946, and the result has been a growth of commercial emergency services for the relief of doctors.

Perhaps I may just outline how such an emergency service works, because it is strangely unfamiliar, I think, to most people in this country except those who use it and the doctors who benefit from it. A company or an individual establishes a centre with a manned telephone perpetually on call, and also engages a panel of general practitioners who are equipped with radio cars and are constantly on call. The panel must consist of qualified practitioners, though the kind of practitioner varies. In many cases, they are hospital doctors who are anxious to earn a little money in their spare time —and, heaven knows!, they need it; a number are newly arrived immigrant doctors who have not yet fitted themselves into the practitioner service or hospital service; and some are National Health doctors with very small lists and time to spare. But they all have to be suitably qualified as medical practitioners —indeed, I think they all are.

A National Health doctor in contract with the Executive Council, which is responsible for the service, is able to subscribe to one of the deputising services for certain times, certain days. He can subscribe to have his night calls taken on certain nights, his week-end calls taken for certain week-ends, his calls taken during half-holidays or whatever he wants. There is no doubt whatever that those services meet a very urgent need. It is surely quite obvious that a single-handed practitioner cannot be expected to be on call for 24 hours a day for 52 weeks in the year. He must have relief; and it is less easy than it used to be to get that sort of relief by contacting some practitioner colleague in the neighbour-hood who is prepared to stand in, because most of them are already overworked.

There are four such services now operating in London, and similar services are also operating in nearly all the big urban centres of this country. For instance, there are services of this kind in Liverpool, Manchester, Birmingham, Bristol, Glasgow, Leicester, Sheffield, Nottingham, Derby, Belfast, Coventry and Leeds. There is also a National Association of Medical Emergency Services, to which most of these services belong. I do not really know what the Association does, but I suppose it diffuses information and helps to keep up standards. A little while ago, in London, one of the commercial services got into financial difficulties, and the National Association leapt to its rescue and helped to tide it over and set it on its feet again, which was a useful job. As I say, in London there are four of these services, and they began in 1956. The first of them was thought about in 1955 but became operative only in 1956; and it was instituted as a registered company by two doctors, Dr. Solomon and Dr. Bane. At the present time, about 65 per cent. of the National Health practitioners in the Inner London area make some use, at any rate, of the deputising services.

Let me consider the advantages and the disadvantages of the system. There is obviously a very real need at the present time for some such relief, especially, obviously in the case of the single-handed practitioner. Whether it is equally necessary when there is a group practice of four or perhaps more general practitioners, I am more doubtful, because to my mind a group should be able to arrange—and very often can—a rota system in such a way that no one member of the group is continuously on call. I happen to live in a part of London which is served by just such a group, of four doctors, and they make no use at all of the deputising services. At any moment one of those doctors is on call; and, of course, they all have access—and this is important—to the medical records of the patients, which are kept at their reception headquarters. So whether such a system is necessary for groups, I do not know, but I think it must be considered.

It is true that such a system makes it easier for a doctor to live away from his surgery practice; and there are areas in London, and I have no doubt elsewhere, where no doctor wants to live, or, rather, where no doctor's wife wants to live—Stepney, Poplar or Hackney. If a doctor can arrange for his night or distant calls to be taken, and can feel that his patients are well served, then of course he can go and live in Epping, in Woodford, in Mill Hill, or in some salubrious area where he gets what he regards as better education for his children. It is a very natural feeling, with which one must sympathise. So, on the whole, it is true, I think, that the development of the commercial deputising services has been welcome to general practitioners, though the services are not of course used by all of them.

What about the attitude of the patients? May I refer to what I said about the inexperience of patients. To so many patients, certainly in East London, it is not a question of "my" doctor; it is a question of "a" doctor. One doctor is as good as another; and if they feel that there is what is generally known as "the emergency doctor" somewhere on call, that is all right. It sometimes happens that "the emergency doctor" is preferable to the doctor on whose list they happen to be, and who may be a somewhat elusive personality, as is indeed sometimes the case. There are areas in East London—Cable Street is one—where the telephone number of the local emergency service gets fairly well known and patients are apt to ring up direct—to the distress of the subscribing doctor, who finds that he has to pay for a call which he may not regard as necessary, and which perhaps is not.

On the whole the system has been popular among general practitioners in these particular areas, and is quite popular among patients. I think that probably the majority of the deputy doctors are immigrant doctors. Of course, that is not peculiar to that particular service. The system is quite popular among patients, and I have never had any experience of anything resembling race or colour prejudice against Commonwealth doctors. I am not saying that it does not exist: I am saying only that I have never come across it.

The recent reports of the Ministry of Health which I have read—I cannot pretend that I have read everything that has been published—make no mention at all of the existence and strength of the commercial deputising system. If we look at some of those valuable pamphlets issued to the public telling them how to use the National Health Service and what services are available, there again we shall not find, so far as I know, any mention of the commercial deputising services.

The only public document in which there is such mention is the Report of the sub-committee of the Standing Medical Advisory Committee on The Field of Work of the Family Doctor, under the chairmanship of Dr. Annis Gillie, which was published in 1963, before the deputising services had operated to anything like their present extent. Dr. Gillie writes in paragraphs 101 and 102: Single-handed practitioners (now only about a quarter of all established principals) often co-operate with neighbouring colleagues, usually single-handed like themselves, but in single doctor practice areas any deputising assistance may be impossible to obtain, especially during the winter. Rota systems were organised in built-up areas in the years before and after the introduction of the National Health Service. Recently, especially in Greater London, commercial emergency doctor services have become established and partially replace the rota system. This is an important phase. The weakness of this system is the deputy's lack of knowledge of the patient. Regulations introduced in October, 1962, involve further control of deputising arrangements. From 1st July, 1963, each doctor in contract is required by his Executive Council to obtain consent for employment of a deputy provided by a commercial service. I think that Dr. Gillie, who is an experienced practitioner and who has been for many years a member of the London Executive Council, put her finger on what is perhaps the main difficulty of the deputising services; that is, the lack of knowledge of the patient. When the emergency doctor (to use the current phrase) arrives, the patient is not always skilled or knowledgeable in describing a previous operation, what has been done and what has been prescribed, and it is not surprising that mistakes are sometimes made.

The Order requiring doctors under the National Health Service who use the deputising services to notify their Executive Councils of the extent to which they use those services was issued in 1962, with a covering letter to Executive Councils from the Ministry of Health. The letter says: In a few areas there are companies, firms or persons who, in return for payment to themselves, undertake to provide a deputising service to cover off-duty periods. As from the 1st July, 1963, a practitioner who wishes to use one of these deputising services will not be able to do so without the consent of the Executive Council. That is the case at the present time. A doctor who may want to use the deputis- ing services has to notify the Executive Council of the periods during which he switches his telephone to this service and of what use he makes of it, and it is the business of the Executive Council to "vet" the services and convince themselves that the panel doctors are suitably qualified and that the administration is effective.

Very soon after that, a certain amount of Press publicity was given to the services. In September, 1962, there were a number of articles in the Press. There was an article in The Times about the use of deputising services in London and a little later there was another article in The Times, indicating that the questionnaire issued by the London Executive Council had been objected to by the doctors to whom it was issued. It was regarded as inquisitorial. Perhaps it was. At any rate, it had to be modified. There was a discussion of this in the British Medical Journal in 1962. About the same time, the Medical Officer of Health for London wrote a letter to the London Executive Council on the subject, saying that there had been some delay among the deputising doctors in respect of calls for ambulances. They were not completely au fait with the proper procedure and the Medical Officer of Health quoted certain cases where things had gone wrong. But they were not very serious.

That is the system, and the reason I am asking this Question is that very little is known about the system by the general public outside the doctors who actually use it and the patients on whose behalf it is used. I should not be surprised if a number of noble Lords had heard of it now for the first time and were quite unacquainted with the way in which the deputising services work. There are a number of questions I am anxious to have answered, because here is a development which was not contemplated at all by the framers of the Act in 1946.

First, is the existing control by the Executive Councils really effective? Secondly, is there among certain doctors an over-use of the deputising services, leading perhaps in the direction of what one might call "office hours" general practice? Thirdly, how rapidly is the service growing outside London and how rapidly is it likely to grow in view of the present shortage of manpower? Fourthly, what proportion of the money —which is not enough, in my opinion—which is paid to general practitioners working under the National Health Service is in fact going through the pockets of private practitioners operating on behalf of commercial deputising services? Fifthly, is there a practicable alternative to this system? Some time ago— in 1966, I think—Dr. Bane, who was responsible for the first emergency call service in London, now the largest, issued a memorandum in which he suggested the desirability of systematising the whole scheme by taking it completely under the National Health Service. It seemed to me a very good scheme but nobody seemed to take much notice of it. Sixthly, how far, in view of the shortage of manpower and the inexperience of patients, must we abandon that dream, which many of us dreamed in 1946—certainly I did—of a general practitioner service free for everyone in the country and giving them something of the doctor-patient relationship which the well-to-do enjoyed in the years before the National Health Service was established?

These are the questions which I think should be considered and answered, because here is a development which has so far been pushed under the carpet of public consciousness, but which may profoundly affect the future of the National Health Service and our conception of what a National Health Service should be. Where are we going and who is going with us?

4.20 p.m.

LORD AMULREE

My Lords, I am very pleased that the noble Baroness, Lady Stocks, has raised this Question to-day because, as she rightly says, it is a service that not many people know about. It is one about which I think people should know something, particularly those who are interested in the work of the general practitioner, both from the point of view of the practitioner and from the point of view of the patient. After all, there are two important thing, about a general practitioner. One is that he must be readily accessible when a patient wants him (that, of course, does not apply to the general practitioner only. but to all members of the medical profession), and the second, which I believe is extremely important for the general practitioner, is that he should provide some kind of continuity of care and treatment.

But, of course, we all accept, including the noble Baroness, that no man or woman can work seven days a week 24 hours a day. What we hoped would have taken place in the Health Service was the growth of group practices and more and more partnerships, and the growth of what is quite common, certainly in London, of doctors practising by themselves but making individual arrangements with their friends or neigh-bours to cover their work upon occasions. I think the fact that a deputising service has grown up shows that some sort of service is necessary, because the various alternatives that I have put forward do not seem to have entirely filled the gap. Therefore I believe that there is a need for a deputising service. But I do not think—and I imagine that any medical person would agree—that it should turn the work of a general practitioner into an office job, working from, say, nine until five. That is why I am pleased that the noble Baroness has put this Question down.

The deputising service is one of which very few details are known. We know that it exists in London, in the Midlands and where there are large numbers of people living together. What one hopes is that the Minister, when she replies, will be able to give us some idea, with some sort of official background for what she says, of the extent to which the service is used, and whether there is some possibility of its being used more than it is to-day.

There is one final point that I should like to make, but as I have not given notice of it perhaps the noble Baroness will not be able to answer it to-day. Supposing you are a young doctor, qualified in England, before you can get on to the Medical Register you must do two Periods as a house officer in an approved hospital. In that way you do get some experience. Does the same apply to doctors coming from abroad? I think it does, but I am not quite sure, and if the noble Baroness could give me an answer to that question I should be grateful. It seems to me that we might get people coming here not of that calibre. I do not think we do, because they cannot get their names on the register unless they have done a year's work in an approved hospital. That is the question that I should like to add to those which the noble Baroness has asked.

4.34 p.m.

BARONESS SUMMERSKILL

My Lords, while I cannot agree with the implied criticism of the deputising services which I feel is embodied in my noble friend's Question, I welcome this debate, because it focuses attention on a certain aspect of our medical services which is closely related to the shortage of manpower. Far from criticising the deputising arrangements, I think we should congratulate those who have provided the overworked general practitioner with the relief to which he is fully entitled. If it were not for this deputising service, the trickle of general practitioners leaving this country, which has now become a stream, might well become a flood.

The single-handed general practitioner (my noble friend indicated that she thought there were more than she said; I think that probably one-third of the general practitioners in London are single-handed) is the only worker in the country who is expected to do a day and night shift and work on Saturdays and Sundays, at work involving great responsibility and physical strain. I should say it is work that calls for the maximum possible amount of relief and leisure. He is not long-lived. I would invite my noble friend when she is looking at the statistics to look at the obituaries in the British Medical Journal, and she will find that the general practitioner is not a long-lived individual. But doctors in the Ministry of Health, in our public services, have fixed hours —I think my noble friend called them office hours, or something like that—and in most cases six weeks' holiday, with a paid deputy.

The failure to recognise the elementary needs of the general practitioner for leisure is one reason why over 400 doctors are now emigrating each year, with the result that we have to encourage Commonwealth doctors to take their place. Last year, 500 to 600 Commonwealth doctors were added to the number already here. One can measure the change that is taking place in the country when one realises that one-third of our hospital doctors were born outside Britain. This incredible change which is taking place in our country is taking place very quietly, and we are without compunction taking doctors from Commonwealth countries where there are millions of poverty-stricken and disease ridden people. I always feel that this particular brain drain should be in the opposite direction and that doctors from the affluent countries should be going to the poverty stricken countries.

But, so far as we are concerned, even this source could dry up, and now in desperation we are sending missions to Canada and the United States to try to persuade doctors to return. Last year, 27 consented to return—probably they might have returned, anyway—out of the hundreds who have gone. This shortsighted policy is bound to fail. Doctors are responsible people who do not emigrate lightly. They have to sell their house, dispose of their practice and take their children from school before they settle in another country; and before settling, of course, they find a suitable practice in the country of their choice. It is extremely difficult to reverse this process once it is established.

The question we are talking about to-day is really the importance of adequate leisure for general practitioners. The importance of this question is recognised in the countries to which our doctors are going. May I prove my point? I have here the British Medical Journal of last Friday, February 21. There are about 10 advertisements from America, Australia, New Zealand and Canada. I should like to call the attention of your Lordships to five of them. They are beautifully phrased to appeal to the exhausted doctor in this country. Apart from giving the facilities on the premises —this was a case where they wanted only young practitioners—one of them says: And there will be ample time to indulge in extra-curricula pursuits. Then we come to Ontario: Seven weeks annual holiday and study leave. In Canada, Manitoba: One month paid vacation yearly. New Zealand: Good income available but at the same time reasonable leisure time. Canada, again: Reasonable leisure time. Fishing, hunting and plenty of sport. Western Australia: Good recreation amenities. My Lords, these advertisements were framed for the exhausted practitioners of this country. And here we are to-day talking about a deputising service, which we ought to thank Heaven for, and this deputising service alone is managing to keep a large number of doctors in this country.

I might also have read from the British Medical Journal in regard to a locum, if one can he obtained. I read that a locum demands 60 guineas a week plus accommodation generally for his family and a car. When we recently read in the papers about general practitioners getting a few pounds extra a week, I thought of the young men I know aged about 40, with three or four children, who send their children away for a holiday, and the exhausted general practitioner joins them halfway through it for a fortnight because he cannot afford 60 guineas a week for a locum.

I find the expression "doctor/patient relationship", referred to by my noble friend, difficult to understand. An emergency call in the middle of the night, which she has been talking about, is one made by a family in desperation. It is made because they are worried, and made generally because the patient looks very ill. The only emergency call that my noble friend mentioned is that for a child with chicken-pox. She said that in her day the nanny would have recognised it. We live in a country without nannies.

BARONESS STOCKS

We do.

BARONESS SUMMERSKILL

We live in a country where most women are exhausted at night because they have no domestic help during the day. We live in a country where they are nervous and apprehensive because of this. Therefore, if any individual in the middle of the night shows that lie or she is ill, whoever is in charge feels that a doctor must be called in. What that person wants is a fully qualified doctor—and I can assure my noble friend that every doctor in the deputising service is a fully qualified doctor—who can of course recognise, let us say, an acute appendix, a coronary or a pneumonia.

Neither the family nor the patient is looking for a familiar face. Neither the family nor the patient feels, "The doctor must have my record card". I have attended a number of emergencies in both Houses. It has never occurred to me to say, "I cannot look after him because I haven't seen his record card." A record card is very useful when one is examining the whole medical record of an individual, and it is nice to look back to see what happened three or four years ago; but an emergency is something which calls for immediate diagnosis from a doctor. If it is necessary for the doctor who comes to see the patient to be absolutely familiar with his record card because otherwise the patient would suffer, then I should think that the patient would expire immediately if he went to a hospital, where he would find nalf-a-dozen doctors, of all nationalities. Does anybody think that at night a consultant is called to the patients whom he may be treating during the day? Of course not. A deputy, a paid deputy, sees the patient if he is sent to a hospital: the registrar, the house physician or the house surgeon. Nobody says that the patient is suffering because the record is not there and that the patient/doctor relationship must suffer.

Most of the criticism in this connection comes from people who are sure to spend every night of their lives in a cosy, comfortable bed, undisturbed by a bell or the telephone; from people who know that for the rest of their life they will have seven or eight hours of undisturbed sleep a night. These are the critics of the "exhausted general practitioner." My noble friend said that she was brought up in a doctor's household. So was I. Still, when I hear a bell at night, for me it is the night bell of my father, who was one of these "exhausted general practitioners", who never knew the meaning of leisure or rest. When he rested it was in order somehow to gain enough strength to carry on and perform his surgeries and visits the next day.

My noble friend says that we are moving into a new time. We are moving. I am hoping that the change in our Health Service is not only a change for the patient but a change for the doctor as well. We must recognise that there are two sides of this Service: those who take the service and those who give it. I am conscious of the fact that if this deputising service were not in being the doctors, who have already revolted and are leaving our country rapidly—after we have educated them and paid for their education—would continue to do this. They will in fact continue to revolt and to leave the country unless a change is made in the attitude of the Ministry of Health.

BARONESS STOCKS

My Lords, may I interrupt my noble friend for just a moment? I have not for a moment questioned the necessity of deputising services. I have not said that they are not manned by highly qualified and perfectly well qualified people. I have merely asked whether this is the best way of securing the very necessary help that practitioners need.

BARONESS SUMMERSKILL

My Lords, I was going to deal with this point. The Ministry of Health should have done this. My noble friend has been on an important Committee all these years. Has she ever pressed for what is needed?

BARONESS STOCKS

Yes, my Lords.

BARONESS SUMMERSKILL

My Lords, I remember my noble friend criticising this service years ago in very strong terms. My noble friend has made her point. If one looks at the Order Paper, it is quite clear that my noble friend's Question is critical. She asks about the quality of service, and any influence their operation may have on doctor-patient relationship". These are the matters I am dealing with.

What has happened is that other people have come along and provided a deputising service. My noble friend keeps using the words—she has used them so often —"commercial service". It just happens that no organisation can be set up unless somebody is prepared to do the work involved. The doctors themselves take the line of least resistance and leave the country, and they have left it to somebody else to set up the service. When one refers to a "commercial service", it is a fact that these doctors who are in the deputis- ing service are of course paid. I suppose that one might say that money is commercial; but one must not keep criticising it as a commercial service in a way which is a little disparaging, because these doctors are providing a service without which the general practitioner could not function to-day. The rota system has been mentioned. The position now is such, and the shortage of doctors is so great, that even when a doctor is part of the rota system he still has not sufficient rest, and so he also becomes part of the deputising service.

I really wonder where our priorities are these days, when I read about the commotion caused in the Government about the housing of certain weird, inanimate objects in the Tate Gallery, and even a threat to take neighbouring premises used for medical work to house these artistic monstrosities. It is even suggested that a medical institution should be taken. I ask your Lordships to consider the difficulty all over the country to-day of getting accommodation for an old person. Our hospital wards are crowded; our mental hospitals are a disgrace. And yet we can get the Prime Minister, the whole Cabinet and the newspapers interested in these objects, which excite more ridicule than admiration, objects which will have long been forgotten when the neglect of the National Health Service is still remembered. So I hope the Government will make health its priority.

Finally, my Lords (and this debate is quite topical to-day), there has been a recent criticism of the work of foreign doctors and a Minister has declared that the National Health Service could not function without them. This is not a defence: it is a confession of failure. It is a measure of the failure of successive Governments to provide a medical education for boys and girls. If they had done that, and if there had been sufficient qualified medical people coming forward now, this discussion would have been superfluous, and my noble friend's criticism of the Service would not have been forthcoming.

4.52 p.m.

LORD SEGAL

My Lords, I must confess that I welcome this debate this evening somewhat less warmly than previous speakers, because I have grave doubts about the wisdom of holding a Government inquiry into this problem. This is the second time within a week that Her Majesty's Government have been asked by the noble Baroness, Lady Stocks, to promote an inquiry, and if the theory of "Never two without three" is anything to go by, one is left wondering on what subject the next request for a Government inquiry is likely to be. I can only hope that on this occasion Her Majesty's Government will reject this request for an inquiry as emphatically as they did the one last week on the subject of ritual slaughter.

My Lords, these deputising services could never have survived for so many years had they not served a definite need. As the noble Baroness, Lady Stocks, has already said, they exist not only in London but in many of our large provincial cities. From my own personal experience I have found that they are often manned by experienced, well-qualified doctors. many of them quite highly skilled. Several have degrees from Australian and New Zealand universities, and many are reading for higher medical qualifications in order to become specialists. Some deputising services are approved by the British Medical Association and have now been enrolled as members of a National Organisation of Emergency Treatment Services. They are assisted locally by professional advisory committees; medical applicants who wish to join them are carefully scrutinised and have to attend for an interview before this committee. They are always able to obtain advice on the professional and ethical aspects of their duties, and there are certain essential requirements for any doctor who wishes to enlist the services of a deputising agency.

As the noble Baroness, Lady Stocks, has already mentioned, as long ago as 1962, Circular ECN 415 was issued by the Ministry of Health (as it then was) to all doctors, reminding them that they must not only obtain the consent of the Executive Council before using these services, but also give precise details of the name and address of the deputising agency, the periods in which the deputies were employed, and whether all types of cases, including obstetric emergencies, were covered by the deputies' services. Some of these doctors are also required to give details to the deputising doctor of any emergency on which he is likely to be called out. That, I think, provides, so far as any doctor can humanly provide, a record to the deputising doctor of the history of the patient's previous illness where cases of probable emergency are known.

Nearly all the conceivable defects in the existing scheme are already accounted for. Unless the deputising doctor himself is in contract with the Executive Council, the summoning doctor is fully responsible for the professional conduct of his deputy, and is himself liable to be held responsible for any inadequacy of treatment on the part of the deputising doctor.

What, then, are the safeguards open to the patient? These are numerous. But any doctor who is called to visit a patient at night may be faced with endless complaints. He himself labours under severe handicaps. How can he prescribe on an emergency night call? The chemists shops are nearly all shut. The patient is almost entirely dependent on the few emergency drugs which the doctor may happen to carry with him at night, and these may not be the drugs required for the patient's particular illness. Occasionally the call may be quite trivial, as the noble Baroness, Lady Stocks, has mentioned. I know of a doctor who was summoned to visit a patient in the early hours of a bitterly cold morning, and arrived to find the patient sitting up in bed with a cheerful grin on his face. The doctor was greeted with the remark, "Oh yes, doctor, I had a funny feeling in my throat half an hour ago, but I am quite all right again now". Fortunately, such a case is very rare, and indeed quite exceptional. But what of the case of a patient who is seriously ill in the middle of the night? Some cases may require immediate admission to hospital, or even an immediate operation. Here the family doctor is not absolutely essential, and any skilled deputising doctor can undertake to arrange the patient's admission to hospital, without an undue strain being placed on the doctor-patient relationship. For even if the family doctor is called out and arranges the admission, the doctor-patient relationship becomes temporarily in abeyance while the patient is under the care of a hospital doctor.

So many of these night emergencies, unfortunately, have to wait for their medicines until the chemist's shop is open in the morning, and in regard to these delays in treatment the deputising doctor is in precisely the same position as the family doctor finds himself. And, as for reassurance—which is often the major part of emergency treatment at night—the patient can often feel far more reassured by an expert, fresh opinion from a well-qualified deputising doctor, than by the same old opinion of the same old doctor who may have become too familiar with his constantly recurring symptoms. So there is a great deal to be said in favour of a fresh opinion from a deputising doctor. Quite often in medicine two heads are better than one.

The variations which may occur during a night emergency call are almost infinite, and it would be quite wrong to generalise them in a debate such as this. From first to last, things must be left to the sense of duty and dedication of the doctor in attendance, whether he be the patient's own family doctor or the doctor employed by the deputising service. The general public can feel assured that the vast majority of deputising doctors will not be found lacking in their devotion to anyone who is ill, at any hour of the day or night. That is why I feel that Parliament is hardly the most suitable forum for ventilating this subject.

Sometimes a doctor, particularly after a very hard day's work—and we all know how hard most doctors are worked these days—may be dilatory in visiting his patients, especially in the bitter cold of a winter night, or in a remote country cottage that is relatively inaccessible. Rarely, there may have been a case where the doctor, whether the family doctor or the deputising doctor, may have been rude to a patient; but it is always the summoning doctor who is liable for any breach of service committed by the deputising doctor, and it is always the summoning doctor who runs the risk of being fined. In cases of any gross breach of professional conduct the patient is of course always free to lodge a complaint with the General Medical Council. Then the deputising doctor is always subject to normal medical disciplinary procedure.

But the fact remains, my Lords, that to-day the deputising services appear to fill a definite medical need. They supply a need not only for the dwindling number of doctors who are working single-handed but also for doctors working in a group practice, or in partnership, or on a medical rota where the doctor on duty is suddenly taken ill and a deputy may not always be available. I am firmly convinced that these deputising services should be left very largely as a problem for the medical profession itself to decide. The noble Baroness herself is a member of the Inner London Executive Council and also of that Council's Doctor-Deputising Arrangements Committee. Surely, with her wise counsel and able assistance, these bodies are the ones best qualified to deal with this problem.

I remain completely unconvinced that Parliament is the best place to discuss this issue any more than it is the best place to discuss the highly controversial issue of ritual slaughter. Every patient to-day has a ready means of redress and can lodge his complaint with the Executive Council or the General Medical Council. But the holding of this debate to-day might conceivably, and quite unjustifiably, be the cause of alarm and despondency among highly nervous patients, and on these grounds I feel that it is somewhat to be deprecated.

Nor could the timing of this debate have been more unfortunate. Just when the Government's Green Paper is under discussion, when the Report of the Redcliffe-Maud Committee is being awaited, when the hospitals are under fire with shortages and criticisms of their resident medical staff, surely a worse time could hardly have been chosen for further badgering the already hard-pressed general practitioner. That is why I earnestly hope that Her Majesty's Government will to-night emphatically turn down this request for an inquiry into the general practitioner deputising services.

5.3 p.m.

LORD STRATHCLYDE

My Lords, it is with a considerable amount of trepidation that I enter into this debate, which seems to have been conducted up till now by those who are experts. Far from agreeing with the noble Lord, Lord Segal, as to the undesirability of having a debate of this nature at this time, I think that any debate which takes place and which impresses on people the desirability, in fact the necessity, of taking some of the weight off the family doctor's shoulders the better it will be both for the service and for the general public. I have had certain experiences in this regard, and it is only for that reason that I intrude into this debate.

I remember on one occasion staying with a doctor, and after his wife had gone to bed we sat chatting, and then the telephone rang. He said, "I will be away about half-an-hour. Wait up for me." I waited, and the doctor came back and we chatted, and eventually we went to bed, and I slept very soundly. When I saw him in the morning he said, "During the night I very nearly committed murder". I said, "What happened?" He said, "After I left you, I was getting into my pyjamas and the telephone rang again, and on two other occasions the same thing happened. Finally at about 4 o'clock when I was getting into bed my wife woke up and looked at me with a bleary eye and said, 'Have you been out?', and that was when I very nearly committed murder." I live in the country, and my own doctor told me recently that he had been called out at 2 o'clock in the morning, very urgently that it was absolutely necessary for him to go at once. He had some miles to motor, and when he arrived at the house and asked the lady what was the matter she said, "Doctor, I cannot get to sleep". That is really quite appalling. I suggest that in ordinary simple cases people should be trained to some extent what to do. The noble Baroness who opened the debate talked about the child who had chicken pox and the nannie being there. That was all very well when we had nannies, but we do not have any nowadays. In those days, we had mothers who seemed to have been brought up with some kind of knowledge of what was wrong with their children when they started shouting in the middle of the night. I am one of eight children, and my mother never had to ring up the doctor in the middle of the night.

I think some education should be given in schools and colleges to both men and women to cope with the simple situations. There should not be any need to call out doctors unnecessarily during the night. I appreciate very well what a terrible thing it is when a child is really ill in the middle of the night and you do not know what to do about it. There comes a point when you have to call the doctor. In most cases I have run into—and we had seven children—my wife was able to say, "This can wait till the morning and we will call the doctor then". I believe that more education in regard to the simple ailments would save the doctors a very great deal of time and worry. I press, therefore, that there should be the utmost increase possible in the deputising services and also in the formation of group practices. These two things can save a very great deal of time and worry, and I am sure they will bring ever greater respect to the great profession to which the noble Baroness, Lady Summerskill, belongs.

5.7 p.m.

LORD NEWTON

My Lords, I want to intervene for only a brief moment. May I begin—although she is not with us at the moment—by offering my congratulations and good wishes to the noble Baroness, Lady Serota, in her new appointment. I cannot wish her anything better than that she should enjoy herself in that Department as much as I did a few years ago.

The noble Baroness, Lady Phillips, is faced with the very delicate problem of trying to strike a balance between the points of view of the two noble Baronesses behind her. I certainly agree with what the noble Lord, Lord Segal, said, that there is no need for an inquiry into these deputising services. I emphatically disagree when he says that this is not the sort of subject Parliament should discuss. I think it is exactly the sort of thing Parliament should discuss. The Government are responsible for the whole of the National Health Service, and at any rate in theory the Government are still responsible to Parliament. I do not see why the noble Baroness, Lady Stocks, should not ask the Question. Why should she not ask for assurance that the deputising services are adequately controlled by the Executive Councils?

LORD SEGAL

My Lords, if I may intervene, I fully agree that the noble Baroness was more than justified in putting down this Question. I did not agree that she made out a case for holding a Government inquiry into the deputising services.

LORD NEWTON

I may have done the noble Lord an injustice, and if so I apologise. But I seem to recall that he said that this debate should not have taken place at all this afternoon. I leave that for the moment. Among the other questions which the noble Baroness, Lady Stocks, asked, as I have said, were whether there is effective supervision, and the amount of use—do the Government think the amount of use is right; ought there to be more or ought there to be less, and various other questions like that.

The noble Baroness, Lady Summer-skill, put very clearly indeed, I thought, the beneficial advantages which accrue from these services, both to general practitioners and to the National Health Service as a whole. I would agree with that in general. I think everyone realises and understands, as my noble friend behind me pointed out, that nowadays all doctors—particularly, perhaps, general practitioners—are entitled to as much leisure as other people in the community to-day expect to have. At one point I thought that possibly the noble Baroness, Lady Summerskill, was pleading too much, but I can understand why that was. The noble Baroness, for obvious reasons, was particularly concerned with the position of the doctor; and, as I understood the noble Baroness, Lady Stocks, her particular interest was the patient—, and why not? The doctor/patient relationship is not just one-sided; it is really two sided, and they are equally important.

Again I think everyone would accept that when there is an emergency call— either genuine or (shall I say?) a "misinformed" emergency call—in the night one cannot expect to get one's own doctor. As the noble Baroness, Lady Summerskill, and the noble Lord, Lord Segal, said, it probably is not necessary. All you want is a good and fully trained doctor, and whether he knows your medical history or not does not really matter.

Many people would agree with the noble Baroness, Lady Stocks, that an ideal doctor/patient relationship is one of the things that a very large number of people want. I think also that many people would consider it is absolutely the backbone of the general practitioner service, and that is the reason why we cannot afford to lose the general prac- titioner service. The noble Baroness, Lady Stocks, quoted Dr. Annis Gillie, for whom I have the greatest possible respect, as saying that in so far as there are disadvantages to the deputising services it is lack of knowledge of the patient which is perhaps the biggest, or at least one of the biggest.

Finally, the noble Baroness, Lady Stocks, asked the Government whether there is an alternative to the deputising services. I shall look forward to hearing what the noble Baroness, Lady Phillips, says about that. I, myself, should have thought not, except possibly very large group practices. But there again, if we had very large group practices predominating in the service all over the country the chances of getting doctors whom one did not know and had never met before when one was really in need would be pretty high indeed; and that, to an even greater extent, I am sure, is true of large partnerships. I will not trouble the House any longer, but I must say again that I look forward to hearing the noble Baroness, Lady Phillips, preserving the balance.

5.14 p.m.

BARONESS PHILLIPS

My Lords, the noble Lord, Lord Newton, has suggested that it falls to me to preserve the balance. If I might say so at this point of time, I would not attempt to adjudicate between the merits of whether there should be a question nut or not, but would make some small attempt to make the Government's reply to the Question which my noble friend has posed. I think, as always, my noble friend Lady Summerskill put her finger on the vital point: the shortage of medical manpower. I think this was mentioned by my noble friend, Lady Stocks, herself, when she opened her Question, and again by my noble friend Lord Segal.

I know something in a personal way of the problems of the young, struggling general practitioner, and I felt very much in sympathy with the picture painted by my noble friend Lady Summerskill of the young man feeling at the end of his tether, opening a medical journal and reading of this inviting opportunity to go to Canada at four times the salary, and to get the opportunity to hunt—did I understand?—and fish. Even if not of the hunting and fishing type, I know a young doctor who said to me on the telephone one, day, "I wish I did not keep reading how exciting it would be if I went to Canada or Australia".

I think all speakers in this very short and interesting debate have agreed that the crux of the question is the shortage of medical manpower. My noble friend, Lady Stocks, put a certain number of specific questions. Her first one was whether the existing control by the Councils is really effective. If I were to take the easy line, I might say that my noble friend Lord Segal, in his remarkably expert analysis of the situation, answered this; but I would offer the reply on behalf of Her Majesty's Government that, as we have heard from several noble Lords, the family doctors in the National Health Service are obliged by their terms of service to obtain the consent of the Executive Council for their area before using a deputising service, and Councils may impose such conditions on a doctor's use of a deputising service as they consider necessary. Councils have been asked to review periodically, in the light of their experience of the service, any consents already given; and such reviews may lead to the withdrawal or restriction of existing consents. A doctor may appeal to my right honourable friend the Secretary of State for Social Services against a decision of an Executive Council refusing, restricting or withdrawing their consent to his use of a deputising service.

As my noble friend will know, my right honourable friend's Department gives detailed advice to Executive Councils on the stages they should take, including periodic requests for information, in order to satisfy themselves, before granting doctors consent to use a deputising service, that the staffing and equipment of the service will enable it to provide a satisfactory standard of service for doctors and their patients. The Department will continue to call periodically for returns from Executive Councils on the operation of deputising services in their areas. I would assure my noble friend that the information the Department has received so far from Executive Councils has suggested that Councils in the areas where deputising services operate are properly discharging their responsibility to supervise these services. These Councils include, of course, the Inner London Executive Council, to which the noble Baroness has given such valuable service for so many years and from which, to our regret, she is now retiring; and I should like to reiterate the words of the Minister in the letter he sent to my noble friend on the long service she has given in this connection.

I think she asked whether there was over-use by certain doctors. It is obviously not possible to give a straightforward answer to this. I think that she may have this information, other noble Lords will not, but in November, 1968, the Inner London Executive Council had given consent to 940 doctors to use the deputising services, out of 1,400. In other words, 65 per cent. of the doctors in the Inner London Executive Council area had been given consent to use the deputising services. Figures showing how far certain doctors have used such services are obviously not available. I am not certain that the Department, or even the Executive Council, would find it easy to obtain this information. Seven doctors of this group were given consents because of age and infirmity. Here we come back to the question of the single-handed practitioner, and I think my noble friend Lady Summerskill mentioned that there are still quite a large proportion of these in Inner London.

My noble friend also asked whether the service is growing outside London. The figure I have here is, of course, for 1967. It shows that at that time 16 services were being operated, in the areas of 40 of the 118 Executive Councils in England. I also have a note which says that we do not know of any deputising services in Wales. I am rather pleased about that, because it seems to suggest either that conditions are easier or that the Welsh, as is so often the case, are slightly ahead with their group practices or health centres.

The noble Baroness also asked what proportion of money paid to general practitioners goes into the deputising services. I am sure that she will appreciate that I cannot give her a direct answer on this point; in fact, I am not sure that anybody could give her an answer. The two noble Lords who are experienced in the medical profession and who took part in this discussion have emphasised that value for money has been the key note of the deputising services.

The noble Lord, Lord Amulree, put to me a point about overseas doctors. I am not sure that this is the complete answer, but deputising services generally are understood to require doctors whom they employ to have at least six months' experience of general practice or one year's hospital experience. This does not say whether or not they are overseas doctors, but I will see that the noble Lord has this information.

All speakers in this short debate have paid tribute to that remarkable group in our population, the general practitioners. If they are to give the best service to their patients, it must be possible for them to have adequate time for rest and relaxation. The noble Baroness, Lady Summerskill, told us a story which those of us who are older know only too well; the story of the much-loved general practitioner who literally worked himself to death. Happily, this situation need no longer apply; but it is part of any system that there must be an opportunity for these doctors to have adequate time for rest and relaxation. This implies some form of deputising arrangements, and these are often made with members of the same practice or group or with other local doctors, rather than with a deputising service. In the main, deputies will be on duty at week-ends and out of normal working hours on weekdays, and generally they will deal with medical and surgical emergencies where the need is for immediate medical attention.

Each of the professionals who has taken part in this short debate has emphasised that there is no reason for the patient or his relationship with the general practitioner to suffer, so long as the deputy who attends him provides a service efficiently run and staffed with experienced doctors. I believe that it was the late Aneurin Bevan who said that he would rather recover in a large and impersonal efficient hospital than die in a cosy, inefficient hospital. It seems to me that there is the crux of the matter. What one wants in an emergency is somebody who can deal with the situation. I would pay tribute to my noble friend Lady Summerskill, who is probably the most called upon medical practitioner within your Lordships' House. Therefore, she may well claim that her patients recover and are a tribute to her attentions in emergencies.

BARONESS SUMMERSKILL

They have all survived.

THE LORD PRIVY SEAL (LORD SHACKLETON)

There is also the noble Lord, Lord Amulree, deputising.

BARONESS PHILLIPS

Then both noble Lords can congratulate themselves. To sum up, my Lords, in my right honourable friend's view, adequate safeguards are afforded by Executive Councils' obligations and statutory powers and by the arrangements whereby they and his Department receive information on the operation of the deputising services. He does not consider that they need to be supplemented by a special inquiry, but he will keep the position under review and will consider from time to time whether further advice should be given to Executive Councils.