HL Deb 22 April 1970 vol 309 cc715-32

2.49 p.m.


rose to call attention to the Report of the Royal Commission on Medical Education; and to move for Papers. The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper. I am sure your Lordships will be sorry that the noble Lord, Lord Todd, is unable to attend today because of ill-health. He wrote to me over the weekend to say that he is progressing but his doctors will not allow him to come to Westminster.

My Lords, the Report of the Royal Commission on Medical Education was published in April, 1968. Although it gave rise to plenty of discussion, much of this was imprecise and made no headway. Indeed, as one observer commented, it seemed to produce a stunned silence. Two years have now passed, and no lead has come from Her Majesty's Government to encourage official debate on the Report in either House. But policy decisions have been announced based on the Report, and it has become apparent that at any time legislation may be introduced. It seems wrong that in such an important matter as medical education, policy decisions should be made or legislation proposed without the opportunity for open debate. This implies that the findings of the Commission are wholly acceptable to the medical profession; but that is far from so, and many criticisms, fears and reservations exist that must be respected.

In considering a document of this type, it is only human to criticise. Courtesy and expediency also demand that one must begin with an appraisal of its merits. It is a lengthy, serious and thought-provoking document compiled by 20 members of a Royal Commission, carefully chosen, and their conclusions clearly must inspire careful attention. The Report contains a number of generalisations which are based on opinion rather than on factual evidence and it is a pity that such opinions are often not logically argued. Among the recommendations that must be generally acceptable is that which aims to improve the pattern of general practice away from the one-man type of practice; from the doctor's surgery existing in isolation towards the team sharing a group practice or a health centre, with all the advantages and increased efficiency that can result. There is also the principle of improved training for general practice, by which a doctor is no longer to be thrown in at the deep end soon after qualification but will spend time in postgraduate training organised in such a way as to raise general practice to the importance and dignity it deserves. The principle is good; the details suggested are not so readily acceptable.

The plans for improved postgraduate training for the specialities are also acceptable and, in fact, conform with the plans and intentions that the Royal Colleges have already followed for several years. The recommendations for a planned increase in the numbers of doctors in training are fully acceptable from a simple consideration of the present shortage and the even greater shortage that threatens. The Commission rightly emphasise that medical education is a university responsibility and must be judged from that viewpoint. They state that the undergraduate course in medicine should be educational and that medical education should continue throughout professional life: Its object is to produce not a fully qualified doctor but an educated man who will become fully qualified by postgraduate training. Much of the Report is concerned with the medical schools of London, and the recommendations about London are some of the most controversial. Moreover, they seem to be the most unpractical and costly recommendations. From the very early days of the Commission it was widely stated that their Report would contain a deliberate attack on the London system of medical education. It is hard to say this, but the measure of prejudice against London that was widely alleged appears to be substantiated. It is assumed that the conditions in the regional provincial centres are of special merit and that a similar regional parochialism can with advantage be imposed upon London. What is good for Birmingham and Manchester and Newcastle must be good for London! Clearly there are conditions, methods of training and other features in the provincial organisation that can be applied with advantage to London. But, my Lords, we should do well to remember that London is unique and from its very size and complexity presents a special problem that will not be solved by trying to turn it into a number of smaller provincial-like centres.

The very size of London is inescapable as also is its traffic problem and the distances to be travelled between its hospitals and colleges. It is impossible to brush aside its position as a huge centre of international importance, not only in medicine. It is involved in the education of about one half of all doctors. There is also the part it plays in postgraduate training. The noble Lord, Lord Cottesloe, in a recent debate on the Green Paper, emphasised that the number of postgraduate doctors who come to London from overseas is larger than that of all the doctors trained yearly in Great Britain. Some of the detailed recommendations of the Royal Commission in regard to the London medical schools have the aura of being doctrinaire in origin and inspiration.

This problem of the handling of London is as vast and complex as London itself. The dean of one of the great London medical schools points out that the Report comments: London medical degrees rightly hold a high reputation; that the London medical schools attract entrants of high ability and that the medical graduates of the University of London obtain higher professional qualifications such as the M.R.C.P., after a shorter time than do medical graduates of other universities apart from those of Oxford and Cambridge, and that they fill a larger share of consultant posts in Great Britain. This seems scarcely criticism but high praise of the London medical schools. The Report further states: … the University of London as a whole has shown a remarkable degree of flexibility and adaptability to modern educational needs. Appendix 14 of the Report is a valuable presentation of the origin and development of the University of London. It sets out the problems that have arisen as a result of the persistence of 12 independent undergraduate medical schools. Those of us who remember the situation in the 1920s will have no difficulty in understanding the unsatisfactory state of the medical schools when they had to rely on their own financial resources. This meant great deprivation of funds for leaching, for equipment and research and for the salaries of teachers. All this was changed by the coming of grants via the University Grants Committee which enabled the schools to take a powerful forward step. Unhappily the interwar years did not see the formation of enough professorial departments to impart further strength to the schools although the number is now more satisfactory. It was hoped that the residual problem of the London medical schools could be helped by the Todd recommendations. When one considers the many solutions suggested over the last 100 years for this problem, it seems that the recommendations of this Report are not necessarily any more likely to be successful than the many previous solutions suggested.

Briefly, the Report states that the 12 medical schools are too many, that they are too small and that the total number of medical students is as big as is manageable. It recommends that the 12 schools should be paired so as to produce six medical schools. It is stated that this would permit larger scientific departments which would attract a larger staff, with consequent practical and academic advantages. It recommends also that each of the six new medical schools should be closely associated with a multi-faculty institution. Few would disagree that advantages might follow such an arrangement if it could be implemented. But many doubt the depth of the advantages that would follow such a multi-faculty association in the absence of a residential system. From the details given in the Report, all that would be achieved would be lip service to an idea: an idea that would often be only a pipe dream.

But what would pairing of the London medical schools involve? It would take too much time to consider the problems presented by each pairing. I confess that my own reaction to the plan was at first largely unfavourable. I now think that advantages can follow fusion of some of the schools, but the suggestion of a straight pairing is too pragmatic; it lacks all finesse. Such an upheaval can scarcely be handled by such a simple device, and I suggest that the details demand much more careful study. For instance why should all schools be paired? It may well be that some other arrangement might suffice. Some of the pairing seems unpractical and in nearly all cases the cost of implementation either would be so great as to be impossibly difficult or would delay pairing for many decades. If we accept the policy of thoughtful, not pragmatic fusion of certain schools, then it should be applied first to schools in which the conditions are favourable. In some the proposed pairing demands delay. But the whole exercise is so complex that it can be achieved efficiently only if great thought and discussion are given to the details. It is too complex a problem to be dealt with just by doubling up.

I must make it clear to your Lordships that you should differentiate between hospitals and their medical schools. It is not intended that the hospitals should amalgamate, although there has already been fruitful sharing of clinical effort; for example, between Guy's Hospital and King's College Hospital in neurosurgery and in psychiatry at the Maudsley Hospital. The pairing of medical schools can give rise to great difficulties from the geographical separation between hospital and medical school; the cost of building on a new site may be prohibitive. Especially difficult would be the deprivation of the close liaison that should exist between pre-clinical departments and the clinical needs of the hospital. In any pairing there is bound to be a favoured partner and a deprived partner. If the new medical school is built away from both hospitals, for instance at a multi-faculty college, both will be deprived. Already it is being suggested in one such pairing that the loss of the physics department to one partner should be corrected by a small physics department being retained or formed at the parent hospital so that its clinical needs would not suffer. This would be a complete negation of the policy enunciated by the Todd Report that pairing should permit the organisation of large and more efficient departments. It reveals an inherent weakness of pairing. Guy's and King's are suggested as a natural pair but they illustrate yet another problem.

The Todd Report remit does not include dental education but it is unrealistic to ignore the dental schools that share certain pre-clinical departments and teaching. There are five dental schools in London whose students, like the medical students, have to be provided with training in basic sciences. King's College Hospital has a dental school with an annual intake of 50 students and a new and large building. Guy's has an annual intake of 80. The medical school and the dental school at Guy's together have 1,024 students; a number already large enough by the Todd criteria to provide viable departments worthy of full academic support. Their intake of 200 students a year equals the optimum entry suggested. What is to be done in this case? Are the two dental schools to be paired as well as the medical schools; and, if so, on which site? At Guy's or at King's? Much more detailed thought is necessary to solve the many problems. No clear indication is given as to where the large sums of money are to come from for the six new medical schools.

Next are the recommendations about postgraduate hospitals, and here again we see the apparent prejudice against London. It is proposed that the small but highly specialised postgraduate hospitals of London should be merged with the undergraduate teaching hospitals. The achievements of the special hospitals in heart disease, nerve disease, lung disease et cetera have brought them worldwide fame and much credit to this country. Postgraduate students flock to the Metropolis from all parts of the world because of this success and because of the teaching the associated institutes offer. It is now suggested that they can do better work in small departments in separate undergraduate hospitals. The bare statement that they will benefit from this is just not good enough. An advantage could be the sharing of expensive laboratory, library and interdepartmental services, but this could also be achieved if the postgraduate hospitals and their institutes were combined in one or two large postgraduate centres, as has already been explored and even begun in the Chelsea scheme.

In such a scheme the postgraduate student attracted to London could gain great advantages rather than by attending small departments at individual undergraduate hospitals. It is a pity if the Pickering Report on postgraduate centres is to be rejected. The Commission do not seem aware of any difference between teaching basic education to undergraduates and training postgraduates in a specialised and highly technical discipline. The two are entirely different.

My Lords, it is also remarkable that the great achievements of the Postgraduate Medical Federation and of the Royal Postgraduate Medical School at Hammersmith during the last thirty years have been largely ignored by the Commission who seem to have been reluctant to draw on the experience and achievements of these very successful bodies. There is no evidence that any member of the Commission has firsthand knowledge of the London postgraduate hospitals and Institutes, nor that any study in depth of their work and achievements was made. All the postgraduate hospitals have important links through joint staff appointments with most of the undergraduate hospitals as well as with the University of London. There is, in fact, no isolation. The existing links could well be increased, but not if this would involve loss of administrative control and loss of individuality.

The suggestions in the Report for postgraduate education include plans for systematic training schemes and in particular for general practice. In so far as the various specialities are concerned, the recommendations of the Royal Commission are in line with the thoughts and actions of the Royal Colleges who for several years now have been concerned with organising systematic training after taking advice from the various specialities. Their plan is similar to the Commission's, that a period of general or basic postgraduate training should be followed by a period of special training after which the individual could be recognised as a trained specialist in his particular discipline and could then be registered.

Difficulties arise in connection with the recommendations for training in general practice. The plan is for all doctors, after graduation, to spend four years in general professional training and then to spend a further four years in what is called " vocational training", making eight postgraduate years in all. In the case of general practitioners, this means that it will be eight years before a doctor can become: a principal in general practice. Such a long training period gives rise to many practical problems such as rotation of posts every six months for up to four years. This could raise great difficulties in regard to married quarters and for married women doctors.

There is grave danger that this greatly increased time spent in training for general practice, eight years after qualification, will drive many doctors from Great Britain to other countries where they can obtain satisfactory employment without such a long period of waiting. It is difficult to see how these long years of training can be made compulsory. But even more important will be the effect of the conditions in general practice into which doctors will be going. Unless great improvements are made in the conditions of general practice doctors will just not be content to spend eight postgraduate years in training.

It is only fair to draw attention to the great advances that have actually been taking place in postgraduate training for general practice and so on, irrespective of the recommendations of the Commission. This is shown by the several hundred postgraduate centres formed throughout Great Britain, paid for by local funds raised for the purpose and providing libraries, lecture rooms and many valuable educational amenities.

My Lords, it is necessary now to consider the position in regard to the Royal Colleges. I suppose I should declare an interest in that I am a former President of the Royal College of Surgeons of England and am Director of one of its research departments, but I hope to show that I base my support of the" Colleges on reason and not on prejudice. A number of comments in the Report of the Royal Commission are felt to be unfairly critical of the Royal Colleges. This is especially seen in the attitude of the Commission to the higher professional examinations of the Colleges. The pass rate for the F.R.C.S. and the M.R.C.P. at each examination is about 25 per cent., and it is suggested that this is far too low and in fact constitutes an unfair barrier to specialisation. It is suggested that the pass rate should be much higher and almost automatic, being based essentially on reports of satisfactory progress from the postgraduate student's teachers. It is significant that the same pass rate is arrived at independently by the two Colleges.

My Lords, the Royal Colleges have a statutory obligation to satisfy themselves that a man who receives their higher diplomas indicating ability and fitness to become a recognised surgeon or physician is indeed properly trained. Many feel that it is not possible to do this unless a set examination of a certain standard is passed at some stage. This is especially so in regard to those who come from overseas and whose training and knowledge may be quite unproven and is often inadequate. The Commission actually state the reverse in regard to doctors from overseas. Just because a man decides that he would like to become a surgeon, or perhaps his parents may have decided that ambition for him, it is suggested that by expressing the intention and doing some work he inevitably acquires a 60, 70 or 80 per cent, chance of obtaining the appropriate higher diploma without examination. I repeat that the Colleges have a statutory obligation to satisfy themselves that the public is properly protected against an imperfectly trained or incompetent surgeon or physician. That the pass list for any one examination is only 25 per cent, does not mean that the examination is unduly harsh, nor that the percentage of candidates ultimately successful is so low.

The examinations of the Colleges are managed very fairly and are meant to select those who are sufficiently prepared to embark on a final course of postgraduate training. Once the candidates have shown that they have the basic knowledge, it is not intended that they should be required to pass yet another examination hurdle in the course of their organised vocational training period. The set examination is meant to show that they are fit to receive further training. It is difficult to understand how anyone can deny the need for an examination to test knowledge before allowing a surgeon or physician to practise on the human body: he may be lazy, unintelligent or indifferent.

A question that must be asked is: who will start the proposed reforms? Will the control of medical education be an integral part of the National Health Service, and therefore be essentially under Government control? This would be a great danger. Medical education should not be controlled by the service needs of the National Health Service. Indeed, we must remember the observation of the Royal Commission, that medical education should be a university responsibility. The Royal Colleges will be unwilling to surrender their responsibilities, which they feel they are fully capable of honouring. They will be willing to accept modifications and improvements after discussion, but will not submit to dictation. It would seem that a great deal of academic freedom is at stake, and the acceptance of the Todd Report could be the first step in the loss of academic freedom by imposed State action. Particularly important is the attempt to suppress originality or differing standards and ways of training. This threatens the recognition of excellence and encourages egalitarianism.

Of special and sinister significance is the recommendation that the present system of boards of governors of teaching hospitals in England and Wales should be discontinued and that the teaching hospitals should be brought within the framework of the Regional Hospital Boards. This is an especially unattractive and dangerous recommendation. The interposition of two or three tiers of management between the teaching hospitals and the Ministry would inevitably cause delays, hindrance and extra difficulties of management, harmful to the teaching hospitals and to the National Health Service. The recommendation is against the weight of enlightened management opinion, and the task of administering these hospitals will no longer be as attractive to hospital administrators as it is now, with the current measure of freedom and independence. Able and experienced hospital administrators are already in short supply. Improvement in medical education affects everyone, and it must be unsatisfactory to force upon the profession and the public policies and decisions that have been formulated without full discussion and agreement. Peremptory unilateral or authoritarian instructions will get us nowhere. The only recommendations in the Report that justify priority are those related to increasing the numbers of medical students, and hence the number of qualified doctors, and those recommendations related to improving the standards of general practice.

My Lords, it is not possible in a single speech to cover fully the many fundamental matters this Report raises. I leave much to following speakers, and I hope that my remarks, if critical, will not be thought disparaging of this important and thoughtprovoking Report. I beg to move for Papers.

3.14 p.m.


My Lords, it is with temerity that I stand at this Box this afternoon, greatly daring in speaking in a debate that will justify itself by the quality of informed and knowledgeable speeches we shall hear from those who are expert in this technical and controversial subject of medical education. But it is a matter which is important to us all as eventual patients. Perhaps, therefore, as one who is sometimes at the receiving end of the complete process of medical education, I may be forgiven for my audacity. I must confess that this afternoon thirtyseven years ago, when I was being married, I would have hardly believed that thirtyseven years later I should be addressing your Lordships on the subject of medical education. I feel extra gratitude to the noble Lord, Lord Brock, for affording me this unforeseen privilege and at the same time I add my regrets to his that the noble Lord, Lord Todd, is unable to be with us here today.

The Royal Commission on Medical Education was set up to: … review medical education, undergraduate and postgraduate, in Great Britain; and in the light of national needs and resources, including technical assistance overseas, to advise Her Majesty's Government on what principles future development (including its planning and coordination) should be based. It is just two years now since the Commission presented their unanimous Report. It seems to me that it was a remarkable achievement to have completed so important and technical an inquiry so expeditiously. I often think that Parliament does not sufficiently declare its gratitude to highly qualified and very busy men and women, who nevertheless make time to give of their best in public service by carrying the burden of a Royal Commission such as this. Parliament has not debated the Commission's Report at all until today and even now it is not on the initiative of the Government. Implementation of it, of course, depends largely upon what money the Chancellor of the Exchequer is prepared to provide—and I hope that he will be imaginative and realistic. Advance in medical science is now one of the highest priorities in the whole of medical care.

The Commission in their recommendations were looking forward not just to the immediate future, but as far ahead as possible, and obviously realised that many of their plans would take years to implement. Looking at the future pattern of medical care, the Commission came down in favour of general practice continuing in Britain, even though the idea of general practice seems to be disappearing in some other countries. It is thought, however, that general practitioners will in future tend to work here in larger groups and that single-handed general practitioners will gradually disappear.

The Commission were so right to envisage much closer integration between general practice and the Hospital Service and the services devoted to community medicine. This is one of the main subjects of the Government's recent Green Paper on the future of the National Health Service. Larger groups of general practitioners should work in properly organised premises, such as health centres, the Commission thought, and they should be much more closely in touch with the hospitals. The suggestion that the most widespread practice in the future will be groups of 12 or more doctors, with assistance from nurses, health visitors and other non-medical staff, needs close examination from the practical point of view. Some; of those already engaged in large group practices claim that with more than eight doctors an administrator would be needed, which would add considerably to the cost, and in spite of the efficiency of the health centres, general practitioners using them do find them expensive.

As for the future pattern of the Hospital Service, the Commission foreshadowed that the idea of the district general hospital, with seldom less than 800 beds, would be developed and that smaller hospitals would gradually disappear. While realising that a standard pattern would not necessarily be applicable in every part of the country, the Commission thought that most cities and large towns would have such a district general hospital, with perhaps a general practitioner health centre attached or near to it and close relations with other general practitioner units farther away. The new health centres would be able to furnish more help for the doctors in the way of secretarial assistance and of what are called the paramedical personnel—that is, nurses, health visitors and so on.

Unless the Government make up their minds about the future of the National Health Service soon, no more new health centres will be forthcoming. For what local authority, threatened with the loss of its responsibilities for community health, will continue to spend its ratepayers' money upon capital equipment for services which will shortly be outside its control?

Although theoretically the future pattern of the Hospital Service as envisaged by the Commission may be attractive and appropriate in large cities, what of the thousands of less sophisticated patients living away from the towns, who are surely deserving of some consideration? One cannot read the Report without suspecting that most members of the Commission were less closely in touch with these. I fancy that a great many of your Lordships live in the country. When you leave London tomorrow night and return home you may smile at the passage in the Report which speaks of modern developments that will "ease the lot" of those who live in the countryside.

Where I live, in a village just outside of a small town, we have available a splendid new district hospital 13 miles away in an industrial town which is rapidly expanding, and also an excellent local hospital, like a big cottage hospital, serving a wide country area near a small town. Where do the patients from the small town and the villages want to go? To the local hospital nearly every time. And why? Because they are greeted as friends; they know what to do and where to go; and as outpatients they spend the minimum of time in waiting to see a doctor, to be X-rayed or to receive the necessary treatment. Inevitably the big hospital, though better equipped, is much more impersonal, and there are much longer waits. All cases that need the more intensive care available in the new district hospital are sent there; but the personal desire is always to stay nearer home. And I must say that this attitude has my sympathy. After all, the Hospital Service exists for the patients, and not for the doctors, administrators or members of committees.

To come back to the subject of medical education and the would be doctor, the Commission said that candidates for a university medical course should have good "A" levels in chemistry or physical science, together with two other academic subjects chosen from the whole range available for "A" level; mathematics would be useful, and for those with inadequate science training preliminary courses at a technical college should replace the three medical courses formerly given in medical schools. In spite of the obvious and admitted potential wastage affecting women candidates through marriage, the Commission recommended that the main criterion for admission to a university medical school should be quite simply the ability of the applicant to profit from the course and to become a good doctor. This should be the criterion for admission regardless of sex, and the justifiably maligned quota system for women candidates should be abolished. The noble Baroness, Lady Summerskill, must have felt fortified when she read this.

The Commission said that the duration of the undergraduate course should continue to be five years; that it should be firmly in the hands of the university (I expect that is why the noble Baroness, Lady Phillips, is replying to the debate), and that the aim of the undergraduate course should be to produce not a finished doctor, but a broadly educated man who can become a doctor by further training. That seems to me to be the heart of the Commission's thinking: that all doctors ought to be, in addition, specialists in particular branches of medicine, and that postgraduate training, which has hitherto had an insufficient systematic basis, should be keyed to that. I am not expert enough to say whether the detailed proposals made by the Commission for implementing that are the best, or whether they could be improved upon. I know that my noble friend Lord Cottesloe is going to speak on it from his special knowledge as Chairman of the Postgraduate Hospital at Hammersmith. All I would say is that if we are to attract young men and women of high quality into the profession and to offer them prospects worthy of their abilities, we must get this postgraduate training right. We obviously need much larger numbers of young men and women to opt for medicine as a career. We must be able to offer them a training worthy of the next fifty years in the profession, and a career where ability will be rewarded and advancement will not depend so much on chance.

Of course, a crucial question is how many doctors are likely to be required in the future. If one looks at the present medical personnel available, at the expected growth of the population and at prospects of death and retirement, it seems to me certain that there is going to be a serious shortage of doctors by 1975. The Commission said that the aim should be to have a ratio of 1,800 doctors to every one million of the population by the end of the century. Part of the shortage could be alleviated by making use of the services of women doctors parttime. Many trained women doctors cannot at present work fulltime because of home responsibilities, and many of them are deterred from making the attempt by the tax position. If they are married to a doctor, or to a member of some other profession, they will be worse off financially by returning to fulltime practice, because the joint income of husband and wife will exceed £5,500 a year and therefore the wife's additional earnings will be subject to surtax as well as income tax, and her taxed earnings will be less than the extra she has to pay for work in the home which she no longer has time to do herself.

It means a lamentable waste of professionally skilled womanpower, but until Treasury Ministers are willing to recognise the unanswerable case for effecting further tax changes in this field we shall continue to waste scarce national resources. Fortunately, this is a matter which a Conservative Government are pledged to rectify. On April 14 of last year, twelve months ago, the Secretary of State for Social Services made in another place a Statement upon medical school places in which he said that the Government had completed their consideration of the recommendation of the Royal Commission about the number of doctors to be trained in our medical schools by the mid-'seventies. They accepted the main finding, that having regard to current shortages and likely future demands further provision was needed to produce a substantial increase above the number being trained at present and beyond existing plans for expansion. The target accepted as the practical figure for the annual entry of pre-clinical students was 3,700 a year by 1975—about 40 per cent. up on current figures. The Secretary of State went on to say that the plan for expansion would consist of two parts—and I quote: The first is the maximum use of existing facilities … Only when all that has been done shall we rely on new medical schools. Nevertheless, the sooner we decide to have new medical schools, the better, because it takes years to build them. Can the noble Baroness who is to reply tell us what progress has been made in existing teaching hospitals to enable us to reach the accepted target of an extra 1,000 a year intake by 1975, and what progress has been made in the development of the new medical schools which the Secretary of State referred to twelve months ago?

It costs about £10,000 to train an undergraduate medical student. Although the numbers of doctors emigrating each year are apparently difficult to estimate, it is thought that a figure of some 300 a year is about correct for the past few years, excluding those who are going to give service for a time in underdeveloped countries. That is about onesixth of the annual output from our medical schools; and these are trained doctors, going to developed countries such as the United States and Canada. It represents an investment of £3 million a year for their undergraduate training alone. Can we afford this annual drain upon our medical and financial resources? Ought not much greater trouble be taken to study the reasons for it? If it were not for the help that we receive from doctors of other countries, especially India, the British Hospital Service would have broken down long ago.

Is this a situation with which any Government can be content? Today there are over 5,000 overseas doctors filling junior posts in the Hospital Service, about half of the junior staff strength. We know that many of these overseas doctors cannot easily be spared from their own countries, except for limited periods of advanced training; and they may at any moment stop coming here either because their Governments will refuse to let them come any more, or because they may prefer to go elsewhere. But why are so many of our own younger doctors leaving this country when they are so badly needed here? Broadly, those who are emigrating are doing so in the belief that they are going to find better equipment, better working conditions and facilities, better opportunities, better earnings and a larger net income to spend on themselves and their families, because the countries to which they are going have a more intelligent and less discouraging system of direct taxation. Could the noble Baroness tell us whether the Government have any positive plans to remedy this fantastic failure to keep from emigrating across the Atlantic those whom we need in this country, our own British doctors?

My Lords, it is well known that medical education in London began long before the foundation of the University of London, and that it was substantially based upon the hospital teaching tradition of apprenticeship and practical tuition. In London there are over 200 hospitals, some of them very small, 26 boards of hospital governors and 12 separate medical schools. Is this tremendous concentration of medical schools in the capital city really sound in the present-day conditions? Many of them were founded a very long time ago when there was ample population resident around them to provide clinical material for teaching. That is not so today. Industry and offices have absorbed the space hitherto occupied by people, and this population change has presented some of the teaching hospitals with considerable difficulties. Can the noble Baroness tell us what the Government plan to do with regard to the Commission's recommendations to reduce the number of London medical schools from 12 to six? That is a question on which the noble Lord, Lord Brock, has spoken with deep feeling in the debate this afternoon. My Lords, it was the Government that appointed this Royal Commission, and it will be Government, after consultation, that will decide whether its recommendations can or cannot be implemented.

The Departments of Health and Education will have to examine the division of financial responsibility for medical education. Perhaps the noble Baroness can tell us whether this has been done and with what outcome. The sooner the present consultations are completed and the Government are ready to announce their decisions, the better it will be for everyone concerned. But I am also sure that the greatest possible wisdom will be needed in coming to any final conclusions, and for the future of this country's health and for the satisfaction to be enjoyed by the doctors of many tomorrows, let us hope that that wisdom is available in large measure.

The problems posed to us by this Royal Commission are not insoluble. This country is great enough to supply itself with all the doctors its people need, and to break loose from its present humiliating position of not managing to staff its own hospitals. There is no more honourable profession than healing the sick. But the training must be right and the career offered to a young British doctor must be reasonable, evoking his ambitions and his loyalties. Now that we have a National Health Service, all these are matters for the Government; and our part as Members of Parliament is to insist that the Government shall take decisions.