MEDICAL EDUCATION: THE TODD REPORT

HL Deb 22 April 1970 vol 309 cc735-820

3.40 p.m.

Debate resumed.

LORD AMULREE

My Lords, we now turn from the troubles in the Caribbean to the troubles and problems here. But I do not think that the troubles to which I am going to refer and which I found in this Report are anything like as serious as the troubles we have just been talking about. When I first read the Report when it came out, and when I read it again last week, I thought there was very little in it with which I did not, broadly speaking, agree. There are, of course, one or two points on which I should like to ask questions and one or two points on which one wants to be a little critical.

If I may comment briefly on some of these, I should like to begin by saying that I am pleased to find that the Report attaches a great deal of importance to the work of the general practitioner and to proper training for the general practitioner, so that he can have the same amount of postgraduate training as somebody going into one of the recognised special branches of medicine. I thought that that was rather supported by what the Commission say: that the majority of the doctors becoming principals in general practice do not take up their job until they are aged thirty or more, whereas most of them have done their first preregistration job by the time they are twentysix so that they have been doing five or six years of some kind of postgraduate training, whether it is in hospital or whether in working as an assistant in general practice before becoming a senior member in general practice. So I am not very worried about the amount of time it is going to take before somebody can become a principal in general practice.

I thought that two points were important about the work of the general practitioner in the future and what he is going to do in his training. It is an important recommendation that he should do some work with the local authority and do some work in the occupational health service. For a very long time—the situation is not as bad as it was—there has been a certain hostility between the local authority medical services and the general practitioner medical services; and I am sure that a great deal of this hostility occurred because people did not know what the other service was. Therefore, it is a very good recommendation that general practitioners should know something about the work of the local authority.

In passing, I should like to say why I think there has now been a great change in the attitude. Recently we were debating the Green Paper about the importance of getting rid of the tripartite system in the National Health Service, and I ventured then to say to your Lordships that where good will was existing between the various branches of the tripartite system—the general practitioners, the local authority and the hospital services—there was remarkably little difficulty; a certain amount of administrative extravagance might arise, but from the personal point of view there is very little difficulty at all. I also said that, supposing there were not good will between them, I did not think we could make good will in Parliament. I should now like to emphasise what I said then.

The second point I would touch on is the steps taken to increase the number of doctors in the country. As the noble Baroness, Lady Brooke of Ystradfellte, has said, there is going to be a big shortage in the near future. There is no need to go into the causes of that. We know that more people are growing old and therefore more people will need care. Another point is quite important and will arise on the Bill we shall be discussing next week. It is that more people are disabled, either with congenital conditions or with conditions they have acquired, who not so very long ago would have died when they were young or first injured or contracted their illness. What is occurring now? They are not dying; their lives are being preserved, but a number of them are not going to be fully normal and independent people; they will have some kind of dependence and will need some kind of medical care which would not have been required formerly. These factors are among the various reasons for the increased need.

A very interesting letter appeared in The Times about four days ago from young doctors at King's College Hospital, in which they explained quite categorically and well that when they joined medicine, as indeed applies to all of us, they knew that they were going to be on call for most of the 24 hours. What they were saying was wrong, and what they did not approve of, was that the Ministry (or I suppose I should now call it "the Department") says that a normal working week for them should be 90 hours and that for more than that they should be paid overtime; whereas, as they pointed out quite firmly, that really would not do any good from the point of view of their becoming too tired to deal with patients properly. What was needed was more young doctors in hospitals so that one should not have a position in which, with the complications of medicine, doctors were having to work longer than they reasonably could. It does not matter whether they are paid extra or not; additional payment is not going to make any difference to their competence when they are tired.

The first comment I should like to make on the shortage of doctors—and I am sure the noble Baroness, Lady Summerskill, will agree with me here—is to ask: why do we not have more women doctors? It seemed to me totally absurd when I read in the Commission's Report that the number of women medical students admitted represents only 24 per cent. of the total—not more than that! I am told that the number who apply is only 26 per cent., but I am sure (and again I feel the noble Baroness will agree with me here) that the reason for that is that women are not encouraged to apply by their schools because it is known that they cannot get in. Therefore, it is felt, why go and knock at a door which seems permanently shut? There are an enormous number of women doctors in foreign countries. I think there are up to 75 per cent. in the Soviet Union, and I cannot think why we cannot do more in this connection. Here I should like to quote again—because I think the more we quote it, the better it goes down— what the noble Baroness, Lady Brooke, has already referred to: The main criterion for admission to a university medical course should be the ability of the applicant to profit from the course and become a good doctor. I am sorry to repeat the same words as the noble Baroness quoted, but it is important to emphasise that point from the Royal Commission's Report.

We need more new medical schools. One might ask, "Can you not expand the existing ones?" I do not think, with the present system of training we have in this country—which is not done by demonstrations in great lecture theatres but more by intimate ward rounds with students and professors, which I am sure is a far better way of teaching medicine —that we can expand the schools much. But why does it take so long to get a new school founded? We have been talking about Nottingham and Southampton for years and years; I cannot remember when I first heard them spoken about, and I believe they are just about to start or perhaps have now started. But we are going to lose a certain amount of good material and good opportunity. Why could a school not be founded immediately at Durham? Durham was one of the oldest medical degrees in the country. It has gone now because Newcastle has become an independent university, but there is the nucleus of a setup at Durham now and it seems a pity not to use it.

If I may go across the Border into Scotland, there is another example. There is the University of St. Andrews, which for a long time sent students for their clinical work to Dundee. Now that Dundee has become an independent University, the authorities have told the University of St. Andrews that Dundee cannot take their clinical students and they must go to Manchester. That may sound all very well on paper, but, as is pointed out in the Report of the Royal Commission, the sharp difference between pre-clinical and clinical students is gradually going to fade away and their more pre-clinical teachers are working with clinical material, and vice versa, and obviously the two sides of the training are going to be integrated. So what is going to happen to poor St. Andrews if they have to walk across the road to Manchester, which is quite a long way away, whereas at Dundee they can really walk across the road, which is much simpler, now that the Tay Road Bridge is built? So it seems that much could be done to help those places which are now giving medical degrees, to continue to give them.

I should like to say a word about the number of doctors who emigrate abroad. The thing which is always extremely difficult to find out is whether they go abroad permanently or only for one or two years. I always encouraged young men and young women who were working with me to go to America or Canada for one or two years if they get the opportunity. The vast majority come back again, and I think a good deal one hears about the emigration of doctors is due to people going abroad temporarily. It is extremely difficult to find out the exact position, although I do not know why it should be so.

There are just one or two small points I should like to raise. In paragraph 475, the Report says: a teaching hospital, …. should provide medical services for a local community as well as for a selected group of patients. The hospital where I worked, University College Hospital, was the first to become a district hospital, and that must have been eight or nine years ago. The effect has been excellent. There has been no falling off of interest and one feels that one is doing the job right in the middle of the area. I hope that movement will spread. Indeed, I think it has spread to one or two other places. Of course it may be partly due to the fact that University College Hospital was the first in London to start to train medical students and not to treat the sick poor. There may be something in that; I am not quite sure.

I was interested to see the suggestion that the teaching hospitals and the non-teaching hospitals should be more or less merged and that one should not have the great separation between the boards of governors and the Regional Boards. That system has worked perfectly well in Scotland. They have four Regional Boards and at the top of each Regional Board is the teaching hospital. I do not want to bring too much down from Scotland to England, but I cannot see why if it works in Scotland it should not work down here in England. I think, too, that boards of governors have a certain amount of financial difficulty because, large and grand though they are, they have not the same financial resources at their disposal as a Regional Board has. Therefore they find it rather more difficult to obtain big sums of money if they suddenly require them.

Another point is that the Report recommends that there should be more married quarters for young married staff working in hospitals. That is quite right. People get married today very much younger than they did twenty, thirty or forty years ago. One may say, "Well, it is foolish to get married", but we cannot stop them. One sees the difficulty, because when a young man or woman is doing his or her first job there is not much money to support a family. It makes it difficult for them, and I believe that if they cannot live with their wife in the first few years of marriage it may well encourage people not to be too keen to stay in England. That is because, first, they naturally want to live together, and secondly because it is much more expensive for them to run two homes. So I hope that that recommendation in the Report will be put into practice.

Then a point is made, with which I am sure everybody would agree, about giving help to the developing countries; but the question is, what kind of help do they require? It always seems to me that one of the difficulties is that they do not have to go through the process that we went through a long time ago, of starting off by getting good sewerage and water supplies, and so on. They want to get their first-class research medical schools going right from the start, and the environmental work, on which all health really depends, takes second place. Therefore when dealing with the developing countries one has to be careful to know what is the best thing for them.

I apologise for speaking at such length, but there is one further point that I should like to raise. Somewhere in the Report it is said that environmental hygiene will get more and more into the hands of technically qualified people and not people with public health experience. It has always been a source of anxiety to me that the Ministry of Housing and Local Government has no medical staff. In my younger days, when that Ministry was combined with the Ministry of Health and I was one of its medical staff, we had some say on such matters as water supplies, housing, and so on. Now the medical people have no say at all. It may be said that there has been no difficulty, because the foundations were well laid and things have carried on under the momentum started in the nineteenth and twentieth centuries; but it seems to me to be rather alarming that it should get more and more technical and less and less professional. That is something we should try to stop now, although I am not sure whether we can do so.

I am interested to see what the Report has to say about vocational and specialist training. I do not want to go into that aspect because the noble Lord, Lord Cohen of Birkenhead, will be talking about it: it is something he knows much more about than I do. But I am pleased to see that the Royal Commission look upon such training with a kindly eye and do not feel that it may lead to a certain inflexibility and rigidity. That was what one rather feared when one first heard about it. But having read the Report, and knowing the views of the noble Lord, Lord Cohen of Birkenhead, I realise that such apprehensions were not based on anything very solid.

My Lords, that is all I want to say about the Report, except to give it a general welcome. The only general comment I can make is that it is a little too idealistic and perfect; and whether all the recommendations can be implemented at the present time I am not quite sure. I wonder whether it is not a very long-term project. However, that does not mean that the Report should not be regarded as being a worthy document which has been brought out by such an eminent body of people.

3.59 p.m.

THE LORD BISHOP OF LEICESTER

My Lords, I stand, with the noble Baroness, Lady Brooke, as a diffident speaker as a layman in these matters, but I do not think any of us need be too diffident. I was looking at the list of members of the Commission, and the second name I saw was that of the noble Lord, Lord Platt; and I remembered that only a week or two ago he was using the columns of The Times to enlighten the nation as to the exact value of the Old Testament, of which I understood he took a poor view. So there is evidently some overlapping of spheres of influence in these days. I also saw the name of Dr. Carstairs, who I think a short time ago was in much demand as an adviser to the youth of England on matters of sexual morality. So perhaps a mere Bishop can have a few opinions about this very important and valuable Report.

I do have some slight personal interest, by the pure coincidence that my own college at Cambridge was Gonville and Caius, which was always associated with medical education; and the noble Lord, Lord Stamp, and I sat for several years at dinner under the portraits of John Caius and Sir Clifford Allbutt and other famous figures in medical history. Many of our friends were medicals, and one of the diversions was for non-medicals to be taken by medicals into the anatomy laboratory in order to be shown what wonderful sangfroid they had in their daily work.

I was also interested in the extraordinarily striking parallels between the problems which the medical profession are facing in matters of recruitment and training and those which the Church is facing. I notice exactly the same impatience among the students, if I can use that word, with anything other than something immediately and strictly relevant; a great impatience with all the normal traditional objective, factual learning which we have been accustomed to take as the basis of our education. I notice the question of early marriage, to which the noble Lord, Lord Amulree has referred; I notice the attempt to combine teaching hospitals; and I can only warn the medical profession that if they have as much trouble over this as we have had over combining of theological colleges they are in for a lively time.

I notice that there is going to be, if we are not careful, a shortage of 11,000 doctors by 1975. If there had been a similar shortage of clergy by that time this would have been headlined as "End of religion in sight", but I do not imagine anyone thinks that this means the end of medical learning. We hope not. I hope, incidentally, that among the new medical schools there will not only be the one at Durham which has been mentioned but also the one at Leicester, which I feel holds great promise. I had the privilege of blessing the postgraduate Institute, which we already have, on the day it was opened, and I hope that perhaps the noble Baroness may be able to tell us that our prayers are likely to be answered and that the medical school will soon be established there.

Coming to the Report itself, I think that, as a layman, I should say that its immediate value is in bringing this sub- ject vividly before the country, because it is something in which the whole community is concerned. It is fair to say, I think, that it needs popularising if it is to be the subject of general debate in the community as a whole. The Report is rather a difficult document. It says on page 231 that the Commission's treatment of the subject has been brief and selective. All I can say is, "If that is really the case, may I be spared from reading a Report that is full and comprehensive!" I notice (this is of course a matter of one's own ignorance) that the use of the words "undergraduate" and "postgraduate" is specialised to medical readers. Anybody who has been mixed up with medical education at Oxford or Cambridge thinks of the moment of university graduation as the actual marginal over which one has to pass. But one soon learns that this is used here in a special sense, in relation to medical qualification.

I was surprised when I read the section on "General Professional Training" to find that this has nothing to do with the training required in order to become a doctor, but refers to the training to which doctors had to submit, or were asked to submit, even after doing one year of qualified medical service. I am not at all happy about the way in which, in all our professions, we are extending the word "training" to cover such a wide variety of phases of experience. I cannot help feeling that there is something not very apt about describing a man who has already had six years of training in the ordinary sense and is going through a period of another two or three years as a "trainee". It does not seem to me a very good word to use for him. And if it should be overheard by the patients I should think they would be somewhat concerned—and quite wrongly so, of course, because the word is being used in a highly specialised sense.

I should therefore like to see a more popular version of this Report—possibly a Green Paper or something of that kind —not only because medical education concerns the whole community, in the sense that almost everybody requires medical care at some time or other, but because the visual and tactual props, the aids which are used in education for this purpose, are living persons, and they are at their most vulnerable when they are ill, and sometimes very worried. I think that this alone makes the whole question of medical education something that cannot be left entirely in the hands of those who are professionally concerned with it.

There is a certain amount of anxiety in the country as a whole as to whether the doctors during their intern year are overworked. This point has been touched upon by the noble Lord, Lord Amulree. There is the anxiety lest these men and women should be really so tired or strained that they are unable to give the best service to their patients. This is a matter that needs to be approached with a certain amount of care, because some allowance must be made for the enthusiasm of youth, and for the pleasure and satisfaction they feel at being able at last to do the job for which they have been preparing for a long time. We must make it clear that, if any kind of legal restraint is put upon them, it is only in their interest, and the interest of the patients.

The question then moves on to what happens to the man or woman after his or her intern year. Broadly speaking, the answer given in this Report is that from then onwards everybody shall be a specialist. It is rather like the situation in A lice in Wonderland: everyone has won and everybody gets a prize. One welcomes that, in so far as it brings out the point that general practice can be, and indeed is, a specialism. I have to say this to my own clergy, who themselves nowadays get impatient because they feel that they are jacks-of-all-trades and masters of none; and I say that your generalism is your specialism.

One notices a certain amount of bluff in that attitude, and I do not think one should disguise from oneself the fact that, particularly in the early stages of any great profession, there are bound to be some who set their eyes on the highest goals. I do not believe that you can finally satisfy that and can damp down ambition by saying that everybody is going to be a specialist. I think that, even if the division between consultant, registrar and general practitioner is abandoned, you will then have a new kind of sorting out as people within these different groups of specialist make their way forward.

The last matter on which I would say just a word is one that perhaps comes a little nearer to the kind of interests which we on these Benches are, I suppose, meant to represent: I refer to the whole question of the authority attaching to the medical profession in matters wider than purely medical concerns. The Report contains two most interesting paragraphs about this matter. The first is paragraph 29, and I think I will delay your Lordships by reading a few words. Towards the end of the paragraph these words appear: The leadership which the doctor often has to exercise has sometimes in the past appeared to be based on the assumption of a charismatic authority which has already ceased to be convincing and in the future will be completely inappropriate. The basis of the doctor's leadership will be his superior knowledge of the central facts of the clinical situation, his ability to exercise a decisive influence on the patient's illness, and his capacity to guide and coordinate the work of others whose cooperation is essential. In other words, so far as that paragraph is concerned there is as definite a retreat as possible from what, in theological language, is called "charismatic authority". There is a retreat into the purely technical medical side of the work.

Paragraph 260 returns to the subject. Here, it looks as though the other school of thought have a little more to say, because there is a quotation taken from the evidence, that, the doctor is still considered to be an 'oracle' and the student should recognise the responsibility this entails. The rest of the paragraph says that that is all nonsense, and that the doctor should not recognise any responsibility or authority outside the strictly limited field of his medical specialism. But the paragraph goes on to say that of course he must have a general authority which will be sufficient to impart to him a personal philosophy which will enable him to deal with special and difficult questions— matters of moral and social controversy … abortion, drug addiction and artificial prolongation of life"— and so on. I welcome the fact that this matter is clearly seen as a problem. I welcome the fact that it is proposed to give education in what are called the behavioural sciences, sociology and psychology, quite apart from psychiatry. I think all this is to the good.

I cannot actually quarrel with the formal statements of the Report. I do not think it would be right to expect all doctors nowadays, in the present state of society, to become general advisers, pastors and teachers in matters outside their qualification. But I want to go on to say that I believe there always will be some doctors who will want to take a wider view of their work and responsibility than the purely technical, and I do not think we want to say anything to discourage them. I think we must remember that still by far the larger number of our people leave school at quite an early age and, to put it at the very lowest level, the doctor has had seven or more years of further education. He ought to have something to contribute to those less fortunate than himself in that matter.

Further, it will take a long time before England forgets the image of the family doctor. It is all very well to say that this is quite outdated, that there are going to be new health centres, that one's illness will be reckoned up on a computer, and all the rest of it. For a long time to come the doctor is going to be a person who is given special respect. May I give one example of that? A doctor goes into a court of law and gives evidence. Immediate attention is given to him. Do not tell me that this is purely a matter of his technical education. He is a doctor; he stands for something in the life of the country. We do not want to discourage that too much, although we must face the practical facts.

I welcome the paragraph on sex. I think that it is a most sensible and objective paragraph. It points out that young medical students may themselves need help in coming to grips with their own problems of personal relationships. I think this is necessary. Perhaps I may give a small example. I have heard of cases of young medical students at dances asking nurses for privileges which at any rate I should think were not those that they should ask for, and where, when told by the young nurse that she could not sleep with him after the dance, her partner has actually left her standing on the dance floor. This is not a matter about which we need to be concerned here in its detailed, ethical aspects. We can all have our own views about that. The point I want to make is that to the young nurse the young medical student is more than a young man; he is a man who, at her age and level, represents a profession which in her mind is worthy of the greatest respect and attention. Therefore, it is most important that young male medical students should have this thought in mind, and should acquire an attitude of responsibility early on. I hope that they will be trained in hospitals where there is a recognition of the wider aspects of pastoral and physical care than those of a purely medical and material kind. I hope that they will find it customary for the chaplains to be treated as partners and colleagues in the general service of the patient.

I end with a quotation from Leonardo da Vinci which I think is not irrelevant. In one of his notebooks he said this: You know that medicines when well used restore health to the sick. They will be well used when the doctor, together with his understanding of their nature, shall understand also what man is and what life is.

4.20 p.m.

LORD EVANS OF HUNGERSHALL

My Lords, I hope I may be treated still with a moderate degree of indulgence, for I have not ventured to address your Lordships' House since I made a maiden speech. This has not been due to indolence, but I am trying to exercise the modest, but not unuseful, virtue of listening to other speeches, a virtue which, if I may say so, cannot be overexploited even in your Lordships' House. I have found on so many occasions that the wealth of distinction and experience available to your Lordships is such that any comments that I might make would be redundant. I will quote a recent example. On March 10 we had a debate on the Green Paper on the National Health Service. On that occasion the noble Lord, Lord Cottesloe, and the noble Lord, Lord Cobbold, spoke with such authority and such effect that really to attempt to add anything to what they said would have been useless. Indeed, they spoke with such effect that the noble Baroness, Lady Serota, was able, at the end of the debate, to announce the appointment of a Committee that I am confident will solve a number of problems that came up during that debate. It would be very gratifying if such a result could be reached at the end of our discussions this afternoon.

We are again this afternoon placed in a situation where there is a mass of expert opinion and knowledge. Indeed, had I had the privilege of reading the speech of the noble Lord, Lord Brock, before I prepared my own notes, I do not think I should have had very much to say. In consequence, I shall be very brief. I can only claim, as a layman, that I have been a governor of one or two of the major teaching hospitals for over thirty years, and I am very unhappy, as is the noble Lord, Lord Brock, about the conclusions of the Report about the London teaching hospitals. However, I should like to express my admiration for the Report as a whole and our indebtedness to the noble Lord, Lord Todd. I am sure that we all feel a great sadness that the noble Lord, Lord Todd, cannot be with us this afternoon. He is a very old friend, and I happen to know how much energy and labour he put into this Report.

All of your Lordships interested in this question have emphasised that so far as the United Kingdom is concerned the great advances in medicine have been made in Scotland and in London. I am not sure that Scotland was mentioned even by the noble Lord, Lord Brock, or by the noble Baroness, but, as I sit here on these Benches I become increasingly aware of Scotland. After all, one must be just, and it was in Scotland that the first great advances were made, and after that in London. It is true that the Report does pay some tribute to this, as the noble Lord, Lord Brock, emphasised, but I do not think that it pays an adequate tribute to the part that London must continue to play if we are to have an advancing place in medicine. Without a solution of the London problem there can be no adequate advance; that is, a solution of the complex problem of the London teaching hospitals, the postgraduate institutions, the great libraries, and of course the Royal Colleges. For ten years and more the London teaching hospitals have been hampered even in their normal development from lack of funds, as the noble Lord, Lord Brock, has already emphasised.

It could be urged that the Report of the noble Lord, Lord Todd, innocently, but no less effectively, is just a charter for the provincial hospitals and medical schools. It is to this issue that I should like to confine the few remarks that I shall make. They are all centred on paragraph 438 of the Report—the noble Lord, Lord Brock, outlined this in detail —and concern the plan of taking the 12 major teaching colleges in London and reducing them to six. I am not speaking this afternoon—I do not think it would be proper—on behalf of any of the teaching hospitals. I have no contact with any of them. I have naturally consulted some of them so that my remarks should be a little more informed than they would otherwise be. Indeed, I find that many of my medical friends do not agree with what I am saying this afternoon; they are fare more optimistic than I am. There is a charming, innocent optimism about medical people, which may be dangerous to the lay public. Some of them are so naive that once they have their steering committees and the like going they cannot distinguish the difference between stating the solution to a problem and the actual solution itself.

Your Lordships will recall that the intention of the noble Lord, Lord Todd, and his colleagues was to bring together into closer unity these major teaching hospitals and medical schools. On academic grounds, or professional grounds, I am sure that that is all admirable; but when will it happen? There is a question here far wider than that considered by the Royal Commission; it is the whole relationship of Royal Commissions to practical action. The noble Lord, Lord Todd, as indeed I think the noble Baroness, Lady Brooke of Ystradfellte, suggested, was given general terms of reference, a mandate for him and his colleagues to explore the problem of medical education—not about research, but I will not deal with that—and make the most desirable conclusions. They were given no suggestion of what finance would be available. This is not a political issue I am making—no one on these Benches need apologise for what they have done to help medical education—it is the general issue that they were given no suggestion about what finance was available, or what practical support there could be. That is the situation in which one Royal Commission after another finds itself, and they go away and produce these wonderful proposals which waste the time of distinguished men for years without any practical results. What would happen if I.C.I. Limited or Marks and Spencer put forward plans in the same way? There would be mild complaints from those who are immediately concerned.

I think the first issue is that of funds. If we take the recommendation of the Report of the noble Lord, Lord Todd, about the London medical schools, we are faced with the fact that the funds are not available. Neither this Government nor any other Government, by any magic of surmise or any hypothetical finance, could ever produce the funds that are necessary to implement the proposals which are here made. The second matter is not one of finance; it is deeper. The Report of the noble Lord, Lord Todd, seems to treat London as if it were a piece of plasticine; the sort of thing that one can remodel at will. If you try to put some of these proposals into practice you will have to buy sites. But the University Grants Committee is never allowed to buy sites at other than the district valuer's price, which means that it can never buy a site in London at all. So that charmingly to say, "We will move from here to here in London" is completely and absolutely meaningless.

The paragraph in the Report that has worried me most—and I am sorry to be dealing with only the paragraphs about which I am unhappy—is paragraph 488. As it is very brief I will venture to quote it. It says: We recommend that general responsibility for the implementation of all aspects of the complete plan for London should be placed in the hands of a Committee for Medical Education in London which should be appointed by the Secretary of State for Education and Science in consultation with the Minister of Health. The Committee should include representatives of the University of London, the University Grants Committee"— which has so little money— and the hospital authorities; it should also include independent members, one of whom should be chairman. Then there is this final sentence: The Committee should remain in being long enough to ensure that, in future developments, short-term convenience is not allowed to nullify long-term planning. All members of the Committee must be endowed with longevity beyond Methuselah if they are going to achieve that result. If the Todd recommendations are to be put forward, then, purely on the basis of sites, my own estimate— and I shall not be here to find it confounded—would be at least 20, 30 or possibly 40 years.

As regards the Royal Free Hospital, their immediate short-term plans are being ruined; they have been held up by this Report. There is also the more difficult relationship of King's and Guy's. On the other hand, I am quite prepared to admit, as I think the noble Lord, Lord Brock, did in his opening speech, that there is much to be done about the London medical schools. I have wondered whether, as the debate on March 10 ended with a suggestion that there should be some discussion of these proposals, with which the noble Baroness, Lady Serota, agreed, such a discussion could come about. For if these proposals stand, nothing will happen. If compromise proposals come about, which realise that London cannot be changed overnight, and if somebody would travel by public transport from one of these places to another—which I gather no member of Lord Todd's Commission did—or would even travel by car, which takes a little longer, then it would be realised how much of the time of clinical and pre-clinical teachers would be taken in travelling across London when they were not engaged on steering committees.

4.34 p.m.

LORD COTTESLOE

My Lords, this is a monumental Report by a Commission which included men of extreme distinction. We must all deplore the illness that prevents the noble Lord, Lord Todd, from being with us this afternoon while we discuss the Report's far-reaching recommendations — recommendations which rest on idealistic aims; recommendations so far-reaching that they have been criticised, not this afternoon, but widely, as going much beyond the Commission's terms of reference. They certainly do; but I do not myself feel any ground for complaint on that score.

I propose to confine my remarks to the applications of the Report to the Metropolitan area, with which the University of London is concerned, and for the most part to matters of postgraduate medical education with which I have been privileged, and I may say very proud, to be concerned as a layman for the last quarter of a century, for ten years as Chairman of the Royal Postgraduate Medical School at Hammersmith, and latterly as Chairman for the last ten years and more of that school of the University known as the British Postgraduate Medical Federation, a school that comprises the Postgraduate Medical School and the institutes attached to the London specialist postgraduate hospitals.

The Report is informed by idealistic aims, but also also by some questionable assumptions. What may be best as a matter of pure theory is not always in practice best in the limited and imperfect world that surrounds us. The ideal setup in London, as the Principal of the University remarked in his Report for 1968–69, … now becomes one multi-faculty institution, a pair of twinned undergraduate medical schools with an average of at least two postgraduate medical institutes, and a general teaching hospital incorporating two specialist hospitals alongside. Whether such a vast and heterogeneous aggregation as that is really, in terms of practical human affairs, the ideal is, I think, very much open to question, but for purposes of planning development at the present time it is, in any case, utterly impracticable, as the Principal went on to point out and as, indeed, the noble Lord, Lord Evans of Hungershall, has said this afternoon. In an earlier Report for 1967–68 the Principal related that the Chairman of the Commission before whom he was giving evidence … paid me one of the greatest compliments I have ever received in my life by calling me the 'apostle of the practicable'. I do not think that was intended as a compliment.

Of course it is right to work towards an ideal, but it is more fruitful to approach it by a process of constructive evolution built on what is found to work well in the world as it already exists. In the two years since the Report of the Royal Commission was issued the uncertainties and problems resulting from the lack of balance in its recommendations between the ideal and the practicable have had a most severely depressing effect on the morale of a large proportion of those concerned and have caused a great deflection of thought and of effort that have been most harmful to their teaching work.

So far as the twinning of under-graduate medical schools in London is concerned, there is a great diversity. There are, I think, three pairs that seem practicable and relatively straightforward; that between Bart's and the London, in association with Queen Mary College; that between University College Hospital and the Royal Free, in association with University College; and that between Westminster and St. Thomas's, in association with King's College through the development of a biomedical centre for which a site appears to be available. This last present a tremendous academic opportunity that ought not to be frustrated by any inhibitions about the linking of boroughs joined by bridges across the river, for purposes of the Health Service reorganisation. In peace time a river is no longer a tank obstacle. But, my Lords, if these developments, which seem to be practicable in the reasonably near future, are to go forward at all, the policy decisions and the provision of the capital finance needed must be treated as a matter of urgency; for the opportunity must be seized to secure the necessary sites, and morale must not be allowed to evaporate as a result of delays into hopelessness. I hope that the Minister may be able to tell us what is proposed to be done about these particular pairings.

I must now turn to the postgraduate medical work of the University of London. The Report of the Royal Commission says a good deal about postgraduate education and training. Chapter 3 discusses the subject for 44 pages and in paragraph 178 proposes the setting up of a Central Council for Postgraduate Medical Education and Training in Great Britain—a proposal on which action is already being taken. Then, in Chapter 9 there is a section on postgraduate medical education in London, with specific proposals. Paragraphs 559 to 565 discuss postgraduate students from overseas; and Appendix 14 gives an account of the creation of the Postgraduate Medical School at Hammersmith Hospital in 1935 and of the British Postgraduate Medical Federation, as an outcome of the Goodenough Report, in 1945—and a table on page 302 gives its constituents.

There is thus a great mass of material on postgraduate medical education in the Report. But, my Lords, there are two very surprising omissions. In the first place, there is no attempt to differentiate between two entirely different kinds of postgraduate medical training: first, the further training of general practitioners all over the country, for the most part in regional hospitals, which is a purely domestic affair; and, secondly, the intensive training in depth of specialists, consultants and, most important, teachers, as it is carried on by the University of London in the Royal Postgraduate Medical School and the Institutes of the Federation—a unique national and international service to which, I was so glad and grateful to see, the noble Lord, Lord Platt, paid a generous tribute in our recent debate on the Green Paper. My Lords, those two kinds of postgraduate medical education of course overlap, but they are two quite different things, and in any comprehensive discussion of postgraduate medical education in this country the distinction between them is of great importance.

The noble Lord, Lord Brock, has drawn attention to the second and even more surprising omission from this mass of material. It is that, although the Report gives an account of the creation of the British Postgraduate Medical Federation in 1945, it leaves it there. The Report entirely ignores its development in the last quarter of a century, under the inspired direction of that great teacher and administrator, Sir Francis Fraser, and, since his death, of Sir James Paterson Ross and the present director, Sir John MacMichael. No one reading the Report of the Royal Commission would for one moment imagine that the development and progress of the Postgraduate Medical Federation, its school and its institutes is the outstanding success story in the history of medical education in Britain in the twentieth century. But so it is; and to set the record right I must give your Lordships a few facts and figures.

There is no indication in the Report of the scale of the pioneer work done by the University of London in meeting the domestic requirement, the further training of general practitioners in the metropolitan regions through the courses arranged by the Federation. Starting from scratch, without much help or encouragement, the Federation arranged in 1948–49 for 56 such courses, which were attended by 856 practitioners. Twenty years later, the demand for these courses had grown so greatly that the Federation arranged in 1968–69 for 325 courses, which were attended by 10,087 practitioners. Of course, this figure of 10,087 includes the same general practitioner attending, occasionally, more than one course in the year; but if your Lordships will compare that figure of more than 10,000, in the metropolitan regions alone, with the total number of general practitioners in practice in the whole of England, which is less than 20,000, I think you will realise that the scale and the value of the pioneer work done by the Federation in this field is remarkable and dramatic. But it is not mentioned at all in the Report.

On the other front, the intensive training in depth of specialists, consultants and teachers in the Postgraduate Medical School and the specialist Institutes of the Federation—the national and the international field—the tale is, I think, even more remarkable. But no-one reading the Report could for a moment imagine the scale of that work or its growth. Again, I must give your Lordships a few figures. In 1949, there were 10 professors in the Federation—6 at the Postgraduate Medical School and 4 in the Institutes. Twenty years later, in 1969, there were 77 professors in the Federation—23 in the Postgraduate Medical School and 54 in the Institutes.

So much for teachers, my Lords. What about students—and they are all, of course, qualified doctors. In 1958–59, the number of students was 2,182. Ten years later, in 1968–69, it was almost double—4,154. Of these 4,154 doctors enrolled last year, less than half came from within the United Kingdom. More than half—2,141, to be precise—came from overseas, literally from all over the world: from 30 Commonwealth countries and British dependencies (did your Lordships know there were so many?), and from no fewer than 61 foreign countries. They came, in fact, from every country in the world. For many years Nicaragua was the sole exception—I have not the slightest idea why—but last year a doctor from Nicaragua turned up to complete the tally.

As I told your Lordships when we discussed the Green Paper, and as the noble Lord, Lord Brock, has said this afternoon (but it is worth repeating), more doctors come to London from overseas for training as consultants in the School and the Institutes of the Federation than the total output of new octors from all the medical schools in the United Kingdom. In a single city on the other side of the world, the city of Melbourne, there were as long ago as 1960 no fewer than 50 medical teachers who had received training at the Royal Postgraduate Medical School at Hammersmith. The work done by the University of London through the School and the Institute of the Federation in fact fertilises and pervades the practice of medicine throughout the world.

Of all this, which redounds to the great credit of the nation, there is no mention whatever in the Report we are discussing. There is, in paragraph 453, a rather grudging acceptance of the Royal Postgraduate Medical School and Hammersmith Hospital, faute de mieux, "for the present". There is a suggestion that the word "British" in the title of the Federation is a misnomer. I doubt whether your Lordships, having regard to the international service given by the Federation, will be disposed to agree with that; and in paragraph 563 there is an indication—no more than that— that perhaps overseas doctors ought on the whole to seek their postgraduate training at home.

What does the Report propose, to remedy what the Commission appear to regard as this sorry state of affairs? In the domestic field, it proposes that the work in which, in the Metropolitan regions, the Federation has achieved such notable pioneering success (albeit still not developed to its full potential) should be taken over by regional committees under the Central Council. My Lords, it is, in the Metropolitan regions, the province of the University of London, and for its continued development it seems to me that it should so continue, administered by the Federation and financed by the Department.

Secondly, the Report recommends a special organisation to coordinate London's special facilities and an overseas advisory office. These already exist in the Federation, which coordinates the resources for postgraduate training in London and advises each year 6,000 overseas doctors, giving a highly efficient service of which the Royal Commission seemed to be totally unaware. And, thirdly, so far as the Royal Postgraduate Medical School and the specialist institutes of the Federation are concerned— well, the Report would let the School go on although they do not approve of it in principle. But as the noble Lord, Lord Brock, pointed out, they would dismember the Federation by the absorption of its specialist institutes piecemeal into the twinned undergraduate schools and their specialist hospitals into the undergraduate teaching hospitals.

It must, I think, be clear to your Lordships from what I have said that such a process would break up and destroy a valuable organisation and its works without replacing it with anything that would be able effectively to continue that work. The Federation and its constitutent parts make no sort of claim to perfection, but they must be allowed to continue their work, to develop and improve it by a process of evolution. Of the Royal Postgraduate Medical School I have spoken already. As a postgraduate school providing the medical services of a general hospital, it is unique. In my view the School should continue its associations with the Institutes of Obstetrics and Gynaecology and of Child Health particularly; and the hospital, Hammersmith Hospital, together with the new Charing Cross Undergraduate Teaching Hospital at Fulham, should be university general hospitals in an area extending Westwards from Hammersmith and perhaps including Ealing, Hounslow and Hillingdon. Every effort should be made to find space (Wormwood Scrubs Prison fills the role of Naboth's Vineyard in this case) for expanding Hammersmith Hospital and the School; for their present site is so intolerably constricted as to stifle development and handicap efficiency. The School should also be associated with Imperial College with which it has already forged some links.

The specialist Institutes of the Federation are a mixed bag. large and small, strong and not so strong. In some cases a merging of two or more would be advantageous and practicable. But certainly all, or almost all, should retain their identity and should continue to be administered by the Federation as a School of the University of London. The Institutes of Psychiatry and the Maudsley Hospital, with their remarkable concentration of talent and their special experience in neuropathology, in psycho- logy, in psychopharmacology, in social and in forensic psychiatry are unique; and this concentration must not be dispersed. They already have the close links with King's. College Hospital and Medical School that are necessary to the health of their work.

The Institute of Child Health at Great Ormond Street and the Institute of Neurology on the adjacent site in Queen's Square, work in close conjunction with each other and should so continue. I may say that the idea that Great Ormond Street deflects money and talent and so weakens doctor training in child health is quite fallacious; on the contrary, it adds knowledge and skill to the whole London medical scene; and if the paediatric departments of the undergraduate schools are small, this I think certainly is due more to the smaller child population of Inner London than to Great Ormond Street which draws on a wider area.

My Lords, let us hold on to the peaks of achievement and not allow egalitarianism to flatten them down. Similar considerations aply to Moorfields and the Institute of Opthalmology which have a unique standing in their own field, of which I spoke in more detail in our discussion on the Green Paper. It is envisaged that the Heart Hospital will in the not very distant future move to Brompton when the Institutes of Cardiology and Chest Diseases would form a natural merger as a Cardio-Thoracic Institute. With this, the Institute of Cancer Research nearby may be linked. They would no doubt be associated with the re-sited Charing Cross Hospital and School. The Institute of Dermatology and the Institute of Orthopaedics might be closely associated with, though not incorporated into, the Middlesex Hospital Medical School as also perhaps the Institute of Dental Surgery at the Eastman.

My Lords, I do not think I need attempt to put forward a complete blueprint on this occasion—indeed I have already spoken far too long. But your Lordships will see the general pattern that, as it seems to me, should enable this great work of postgraduate teaching to go forward and to develop as it ought. I hope that the noble Baroness when she comes to reply may be able to tell us that some such arrangement that I have outlined will be considered, rather than the sweeping and destructive proposals put forward by the Royal Commission in respect of the postgraduate medical institutions of the University of London.

5.0 p.m.

LORD STAMP

My Lords, I should like to join with other noble Lords in thanking the noble Lord, Lord Brock, for initiating this debate. Since the Report of the Royal Commission on Medical Education was published it has, of course, been the subject of prolonged discussion and deep concern to all who are engaged in medical teaching throughout the country; and to some, anxious about its many implications, it was beginning to look as though discussion of it in Parliament might never come. I am sure that everyone, whatever reservations he or she may have about specific points, would like to thank all those who have made this Report possible. Whatever other results it is destined to achieve, it has already succeeded in making medical men in every hospital and university think about the future of their profession and about the best methods of meeting the needs of coming generations, both in this country and others for which we have responsibilities.

The Report, of course, covers a very wide field, and one cannot hope to comment on more than a very small part of it. I propose therefore to concentrate mainly on certain aspects of its findings with which I have been more intimately concerned in connection with postgraduate medical teaching, in which I have been engaged for over thirty years at the Royal Postgraduate Medical School, particularly in relation to the training of doctors from overseas, and also as a pathologist. In so doing I hope to underline some of the points that have been made by the noble Lord, Lord Brock, and by the noble Lord, Lord Cottesloe.

I am naturally particularly interested in the recommendations of the Report as they affect my School and the British Postgraduate Medical Federation of which it is such an important part. I must say that it has come as a shock, particularly to those who have been working for so many years helping to build up this internationally famous School, to learn that apparently the whole concept of an institute dedicated exclusively to the postgraduate teaching of doctors from this country and overseas has been a mistake, and that postgraduate medical education should essentially be carried on alongside undergraduate training. Such a fundamental reversal of the findings of the Athlone Commission and the Goodenough Committee—with which the Ministry of Health and the University Grants Committee policy has been fully in line—can be justified only by the most compelling of arguments, which are certainly not brought out in the Report.

The support that the Royal Postgraduate Medical School received in its recent building appeal from countries all over the world, including no fewer than twelve Commonwealth countries, and even the People's Republic of Burma, is further evidence of the worldwide esteem in which it is held and the contribution it has made to international medicine. As the noble Lord, Lord Cottesloe, has said, there are literally scores of ex-members of the staff and ex-students holding Chairs and senior teaching posts in universities in this country and throughout the world.

The lack of recognition in the Report of the part that the School is playing as a training ground for teachers, and also of research workers, for this country and overseas is therefore somewhat difficult to understand, particularly as the training of more medical teachers is vital if the envisaged expansion of our medical schools is to be implemented. Postgraduate medical training is expensive and it would be most unfortunate if an institute founded specifically for this purpose were to suffer as a result of diversion and dilution of resources available for the purpose, as seems implicit in the Report.

One wonders whether the Commission, in recommending this fundamental change of policy, affecting as it does in particular postgraduate medical teaching in London, have paid sufficient attention to the unique position which London has, in the extent to which it is able to cover the whole spectrum of postgraduate medicine, compared with other university cities, and the great advantages to be gained by coordinating postgraduate teaching in one unified organisation. I wonder also whether, when the Commission make this recommendation, the opinions of the students themselves have been adequately canvassed—surely a sine qua non nowadays. I believe that most doctors seeking postgraduate teaching training would rather go to an institute devoted specifically to this purpose than to medical schools, however eminent, where, with the present urgent need to train more doctors, emphasis must inevitably be placed on teaching at the pre-registration level.

This is not to say that a postgraduate institution might not gain by closer collaboration with undergraduate medical schools, or, for that matter, with nonmedical multiscience institutes, both in teaching and research, such as that being fostered between the Royal Postgraduate Medical School and Imperial College, as the noble Lord, Lord Cottesloe, has already said. It is essential, though, that the identity and distinctiveness of the postgraduate teaching institutes should be fully safeguarded. The fears that have been expressed in many quarters, that if the specialist institutes were to be linked with large undergraduate medical school complexes in the way suggested they would eventually become completely absorbed, are in my view only too likely to be justified. There is the further likelihood that if specialist postgraduate training is too closely associated with undergraduate teaching the latter will tend to become unbalanced.

My Lords, I still believe that the concept of the grouping of the special hospitals and institutes in the Postgraduate Federation is the right one, whatever the Report may say, particularly if one or more of these groups could be located geographically in fairly close proximity to the Royal Postgraduate Medical School. The mutual advantages would be enormous. And here I find my ideas slightly different from those of the noble Lord, Lord Cottesloe. The acquisition of the land involved is of course a major problem, but I do not believe that all the possibilities have been exhausted. It would mean, though, that such planning must be regarded from a national point of view, to which all departmental and local interests should, if necessary, be subordinated. After all, as has already been mentioned, Wormwood Scrubs prison (which is next door to the school) is due to be rebuilt somewhere else eventually—and one would hope sooner rather than later—and, as the Report stresses, developments in postgraduate medical education must be regarded from a long-term point of view. If the proper priorities could be established, not only within Government Departments but also between them and the Treasury, the problem might be solved.

If this principle were accepted, a start might be made immediately on the rebuilding that is most urgently required. For example, I understand that a plot of land, off Wood Lane and overlooking Wormwood Scrubs, within a stone's throw of Hammersmith Hospital, is up for sale by the local authority. It is just under an acre, and the price asked is over £400,000. This, of course, is quite unrealistic for the purpose and, as between Government Departments, so between them and local authorities, it seems to me that cooperation in establishing priorities in the national interest is essential. There are also many acres of surplus railway land in the neighbourhood which are likely to be available in the near future; some of which, though I agree by no means all, might be suitable if a means of access were provided.

My Lords, I have made this point in several quarters before, but I feel that I must make it again in your Lordships' House. The concept of what would be a unique complex of postgraduate medical institutes, both general and specialist, to serve as a focus for postgraduate medicine for the benefit not only of our country but of the world is, I am convinced, a most forward-looking and imaginative one, and would appeal to more than one philanthropist—a not unimportant consideration. In my view it will be a tragedy if this possibility is not considered further. If the will were there, I am sure that a way could be found.

Considering further the recommendations of the Royal Commission, the extent to which postgraduate teaching can be carried out alongside pre-registration training must to some extent depend on the branch of medicine concerned. In my own subject of pathology, for example, the organisation of fulltime formal courses which are such an important part of postgraduate training, with the special laboratories and the large number of specialist teachers that are involved, would be quite out of place, and indeed impossible in undergraduate medical schools in London or the Provinces, with their already heavy load of teaching and demands on space. In any case, the most economic way of utilising financial resources for the purpose must be to concentrate such training in one or two centres. In this subject also there will always be a very heavy demand for training from students from overseas. This brings me to the recommendation of the Report that, in general, professional postgraduate training in medicine is best done in the student's own country. In coming to this conclusion, I feel that it gives insufficient consideration to all the factors involved.

It seems to me that the balance is very much in favour in giving such training to doctors destined to work overseas, and in particular in developing countries, primarily in this country, especially if they are to become medical teachers; and in view of the magnitude of the problems involved this must be the main aim in helping these countries raise their health standards. Here they can learn how to teach. Here perhaps they can undertake research under skilled direction, working for a higher degree, essential training and qualification for wouldbe medical professors. Here they can meet with doctors from many other countries and not only discuss medical matters but broaden their horizons in other fields. Here they can learn the higher standards of medical practice and laboratory diagnosis. It may be asked: "Of what use is this, if they are going back to relatively primitive conditions? If and when they do go back, they will be profoundly dissatisfied." I can only say, from talking to many of our ex-students, that they do not feel this way. They regard the year or so spent in this country as one of the outstanding and most rewarding of their lives and would not have missed it for the world.

One argument put forward by the Report in favour of giving postgraduate training to doctors from developing countries in their own country is that they will meet with many indigenous diseases not found in this country. But the provision of this specialised training must be of secondary importance compared with the need to give the best possible general postgraduate training, such as can be obtained in this country, particularly to those destined themselves to become teachers; and wherever possible such specialised training as they require should come afterwards. In any case, it must depend on adequate numbers of highly qualified medical teachers being available in these countries, and there is a great shortage of these. According to the Report, in Appendix 12, paragraph 11, some 200 British medical teachers are urgently required; and with the present shortage at home this need is most unlikely to be met in the foreseeable future.

The secondment of teaching staff from our medical schools, for long or short periods, must involve the provision of additional staff, in view of the heavy teaching load all these schools have at the present time, and this implies financial considerations. Moreover, such posts are not always easy to fill, as they may interfere with current research and even with the chances of promotion on the academic ladder. I believe that the training in this country of postgraduate students from developing countries is the most practicable and also the most economical way of helping them to raise their health standards. The whole subject is of course bound up with the wider problem of how best we can give aid to the developing countries, to which I referred recently in the debate in your Lordships' House on the Green Paper on the Health Service. The financing of the training of these doctors is not only the responsibility of the Department of Health, the universities or the British Council, but even more that of the Ministry of Overseas Development, as is suggested in paragraph 462 of the Report, though this refers specifically only to their training at the Institute of Basic Medical Sciences. There seems to be a very strong case for a greater allocation to be made to the Ministry of Overseas Development, not only for the training of medical teachers for the developing countries but also specifically for adequate facilities for the use of their teaching work when they return. Surely this is a form of "aid with strings" to which no one could take exception.

Turning to the major terms of reference of the Committee—namely, to review the need for doctors in this country and to consider how this need can be met—I propose to restrict myself to the training of pathologists. Of this, the Report says: Pathology plays an important part in postgraduate training in many branches of Medicine and the facilities and staffing of many Pathology Laboratories must be improved if they are to make their proper contribution to professional training. This need to train more pathologists is generally recognised and is likely to become all the greater when the Department of Health plans for setting up regional laboratories have been implemented.

One of the difficulties experienced by those who wish to make a career in pathology is that these medical graduates, as the Report brings out, should have had at least one year's experience in clinical medicine before being accepted for training in this subject. This, in our experience, should be followed by two years in hospital laboratories before they can be accepted for training in formal courses of instruction, which, as I have said, are such a valuable part of the training in the subject. At this stage of their career, the great majority find it impossible to meet out of their own pockets the living and tuition expenses of such courses. Nor, if they are employed as paid junior hospital pathologists, can they obtain the time off for the purpose. The only exception to this, so far as this country is concerned, are those relatively few who are seconded from the Services. The supply of fully-trained pathologists in this country can never be fully met until there is an adequate system of grants to students to meet their needs during this training period.

With postgraduate students coming from overseas, the position is very different. The Governments, the British Council, the Colombo Plan or the World Health Organisation usually meet all their expenses while they are in this country, and as a result there is a long queue of those wishing to attend our fulltime courses, which last for one year. As one example, I may quote from a letter I received a few weeks ago from the Cultural Counsellor of the Saudi Arabian Embassy: We very much hope that Dr. (So-and-So) can be allotted a place, as the Saudi Arabian Government attaches great importance to the postgraduate training of its own nationals in this country. Nor is the demand, great as it is, confined to the less well developed coun- tries. The Director General of Health for the Commonwealth of Australia also recently wrote to me as Chairman of the Departments of Pathology, requesting that the two places we reserve for their trainees should be increased to three or four out of the 24 postgraduates that we now usually take. All the expenses of those they sponsor are met by their Government.

Those concerned with postgraduate medical teaching in pathology are naturally most anxious to meet the needs of this country as well as others, but the lack of financial aid to our students is a serious inhibiting factor. In so far as the British Council and some other sponsoring bodies are financed by the British Government, it seems a little odd that equivalent support is so hard to obtain for our own nationals. It is interesting to note that overseas countries, almost without exception, attach much greater importance to formal fulltime courses in pathology than does this country. They are not even mentioned in the Report. Perhaps it is only those who have attended such courses who are fully able to appreciate their value.

In conclusion, I should like to turn to a very different subject, to one aspect of medical education with which I have not been personally involved though it has close links with my own subject of pathology and is of considerable concern to some of my friends and colleagues. I refer to training in forensic medicine. This is not mentioned in the Report, apart from one passing reference to forensic psychiatry. Yet the subject is one of enormous importance, in the interests of the patient, the doctor and the State. Teaching in it in general is hopelessly inadequate, particularly in some universities in England. Not only are there few lectures in forensic medicine during the whole period of clinical training but the student is never examined in the subject. In Scotland, though, it has always been taken much more seriously and is regarded as an essential part of medical training.

The term "forensic medicine" or "legal medicine", a better term, covers a very wide field. One of the most obviously important aspects is in the assistance that the forensic pathologist may give in the detection of crime—a subject that is on everyone's mind nowadays—tout this cannot be of any value without the preliminary observations of the ordinary doctor, who in many cases sees and suspects it first. It is for this reason that the anxieties that Professor Camps expressed recently about the training and future supply of forensic pathologists, who are the backbone of those who teach, are very pertinent, and they have not been allayed by the answer given when the subject was raised by the noble Lord, Lord Derwent, in your Lordships' House a few weeks ago. One can only hope that the Report of the Broderick Committee, due to be published this summer after five years of waiting, will adequately reflect the seriousness of the situation and the steps that must be taken to remedy it.

To those most in a position to know, there is an urgent need for one or more Medico-legal Institutes, such as they have in practically every country on the Continent, or a National Forensic Pathology Service, perhaps based on the universities, where undergraduate and postgraduate training would be given and which would provide regional centres and an adequate career structure. Failing this, fewer and fewer will take up the subject, either to teach or to practise. The teacher will be less well trained, and lack that enthusiasm that is so essential if the subject is not to be boring to the student, as it so often is made to appear nowadays. Fewer students will therefore be attracted into this branch of medicine, and the vicious circle will continue. Those who do take up the practice of forensic pathology will also be less well trained, and whatever those who feel that the situation is being exaggerated may say, this must have serious consequences in the war against crime.

But forensic pathology is only one aspect of a much wider problem. Legal medicine is becoming of increasing importance throughout the whole field of the Health Service. It includes knowledge of the problems and issues involved in legislation on abortion and drugs, to take but two of several medico-legal issues of national concern. Instruction on the legal and ethical aspects of doctor-patient relationships might well avoid increasing complaints and claims against a doctor or hospital, in which the Department of Health, as employer, must be intimately concerned. Forensic pathology includes also the training of a doctor as a medical witness in court in cases of accident, assault or rape. Lack of such training has often resulted in an inexperienced doctor, called as a professional witness, failing when his testimony and opinion might have been of vital importance.

Recent and impending legislation lays even greater stress on the argument for including blood grouping in disputed paternity as part of the subject. Then there is the problem of certification of death. On the accuracy of this depend all our vital statistics, not only national, but international; and so, too, may the discovery of industrial, environmental and pharmacological hazards. All these fall within the scope of legal medicine. So, too, does the appreciation of the right of the industrial worker or the victim of a road accident to compensation for which their legal advisers must have advice. A more mundane subject is the decision as to when a person is dead— for none of us would appreciate waking up in a refrigerator!

Research is also an important aspect of forensic medicine. Topical subjects are cot deaths and battered babies. Other fields wide open are drug addiction and the side effects of drugs and poison. There is also the need for organised training in forensic psychiatry, a knowledge of which is not limited to assessing the responsibility of a criminal for his actions. It is essential to guide most doctors through the intricacies of the Mental Health Act.

One does not therefore have to be a pathologist, or even a doctor, to feel a deep sense of anxiety at the lack of emphasis placed on legal medicine in the present training of a doctor both at the undergraduate and the specialist postgraduate level, and, even more, that apparently its importance is not being recognised in the structure of medical education of the future. There must be a reason why the Royal Commission on Medical Education in their Report fail even to comment on the evidence put before them by official bodies, such as the British Academy of Forensic Sciences, who represent the considered opinions of law, science and medicine, the Medical Defence Union and Medical Protection Society, but, on the face of it, this seems inexplicable.

While there is much to criticise in the Report, there is also much that one can wholeheartedly support, and it contains a tremendous amount of valuable information. Whatever else it may or may not accomplish, and even though many of its far-reaching recommendations may have to be deferred for financial reasons, it has, at least, as I have said, made everyone concerned in medical teaching think about the future of their profession, and how best they can collaborate with others in teaching and research, even if their views do not entirely agree with those of the Royal Commission. The Report which is the subject of today's debate will, I believe, prove a landmark in the history of medicine in our country.

5.27 p.m.

BARONESS SUMMERSKILL

My Lords, undoubtedly this Report is of the utmost importance because, whatever decisions are made regarding the recommendations it contains, they will inevitably change the whole structure of medical education for the next few decades. I am glad to see that the right reverend Prelate the Bishop of Leicester has come back into the Chamber, because I was struck by the comment he made when he said: "Let us recognise now that this will change a certain institution. The health centre is very desirable, of course, but we shall say farewell to the family doctor". That is of importance. Families have been brought up with the doctor's house at the corner of the road, and in certain respects they are often moulded, as the children in the vicarage and the manse are moulded, in a certain way. This change of approach will mean an end to that kind of life. As I happen to be one of them, I feel quite sad to think that the old Victorian corner house that we all recognise as the doctor's family home will disappear.

I should like to say something about the format of this Report. It is a very big Report—almost a tome, I feel, because it is so closely written—of nearly 400 pages, and I was surprised to find that it did not contain a summary of recommendations. This is of great importance. What is the good of all these eminent men (incidentally, I note that they were mostly men) sitting all these years, and then finally putting their great thoughts on paper, when it is presented in such a way that the people throughout the country who should read it, the doctors, who are overworked and exhausted, physically and mentally, look at it and say, "I really cannot tackle it." This really is a reflection on the Commission. If I may dare say so. it shows a lack of common sense. What has happened is that the British Medical Association have felt that the first thing they should do is to provide a summary of the recommendations, in order that this document shall be thoroughly studied by the people whom it concerns.

I am very glad that the noble Lord who has just spoken said quite bluntly that he was simply going to talk about pathologists and the training of pathologists. I propose to devote most of my remarks to Chapter 5 of the Report, on Selection and Preparation for the Medical Course, and to talk about the medical training of women. However, I cannot forbear to comment on the suggested extension of training. Again, while I am reluctant to criticise these eminent gentleman, surely this is completely unrealistic. Much of this Report presented very good, sound thinking, but some of it makes me feel that their feet were not quite on the ground.

How can we encourage the recruits to medicine whom we so desperately need when they are to be given so many years of training? Women will almost say, "I cannot get married and have my children early because I shall still be studying." I think the noble Lord, Lord Amulree, mentioned this aspect. He said that if this training was so long we must get down to providing married accommodation before we did anything else, in order that the students themselves should be accommodated.

When I mentioned general practice just now I meant to say that I find it difficult to understand, having regard to the fact that 90 per cent. of illness is dealt with within the ambit of general practice, why a general practitioner was not chosen to serve on the Committee.

LORD PLATT

My Lords, may I intervene? Dr. Parry was on the Committee. He was a general practitioner.

BARONESS SUMMERSKILL

Perhaps that is one, my Lords, just as there was one woman. My point is that 90 per cent. of the work—indeed very often the first diagnosis—is made by the general practitioner. It seems to me that these eminent gentlemen, with their brilliant qualifications, should have recognised that they ought to have co-opted on to the Commission general practitioners who are closely in touch with the needs of the people.

I believe that the concept of a rigid or compulsory programme of general professional training will not prove attractive. It is no good our presenting a structure for medical education if the potential students resent it; if they do not offer themselves, and say simply, "Well, I will go to some other profession." I should have thought there should be more flexibility between the various training schemes, so that doctors are not inhibited from moving from one branch of medicine to another. I recognise that financial success in medicine, as in other professions, depends upon an individual's going up the professional ladder, and that to change course in the middle must generally be related to a willingness to accept lower earnings. This fact must be taken into account when this particular plan is being made.

Now I come to Chapter 5, and women. The noble Baroness, Lady Brooke, mentioned this aspect in her speech, and I am glad that the noble Lord, Lord Amulree, also raised the matter. I have raised it time after time. It would be quite absurd if, in a debate on medical education, I failed to make my point once more, and perhaps amplified it in such a way that I might persuade the Government, after many, many years, to take some action. It seems to me that in considering medical education it is of the first importance to ensure that the most suitable students are forthcoming. On that I think we are all agreed. The need for more doctors is not in dispute. We hear today about young men and women working 90 hours a week, and then a generous Government say that they are going to pay them overtime over 90 hours. It seems scarcely possible that such conditions can exist in our "Great" Britain. The need for more doctors is quite desperate. They are working in this way because very often there is nobody else to take their place.

In paragraph 358 of the Report, dealing with migration, there are some figures. I do not like figures, but these are very important. In this paragraph it is assumed that over the next ten years there will be annually an outflow of 430 doctors —300 to developed countries and 130 to developing countries—and an intake of 250. The annual net loss will thus be 180 doctors. According to the Report, we expect a continuing steady inflow of doctors from Ireland and the older Commonwealth countries for permanent employment in Britain. Why are we relying on this source of supply? I have said time after time how can we keep on taking, let us say, doctors from Pakistan to look after us while they are desperately needed in their own countries? In the hospitals North of the Wash, 50 per cent. of the doctors come from countries where their services are needed by people who are in greater medical and surgical need than we are. I repeat, why should we go on relying on this source of supply? I should like to know why we are failing to use the very fine student material in our own country which can be found in the sixth forms of our girls schools. They are there.

Before I develop my theme, I must again express surprise at the composition of the Royal Commission, which contains only one woman doctor. We cannot blame the Commission, for the Government decided on their composition; they chose one woman doctor and one general practitioner. Does this indicate that in some places the same prejudice exists as one is led to believe by seeing the low figures of women engaged in our hospitals? There is no doubt about the potential medical ability of our girls, and I ask noble Lords to look at the Report. It says that between 1955 and 1965 the proportion of pupils who gained A level passes in all the main science subjects rose considerably more for girls than boys. And to follow the noble Lord, Lord Amulree, who talked about girls not liking to come forward because they were told that there was no room for them, may I quote from the Report, which says: Headmistresses believe that many of their best pupils do not apply (often it seems on the advice of their teachers) and that many girls whose capacities and inclinations are fitted to a career in medicine do not take the relevant science subjects in the sixth form because they believe that admission to a medical school will not be open to them on merit alone. This is, of course, a fact which was not denied by the University Grants Committee when I took a delegation containing headmistresses and women doctors to them to ask them to use their influence to increase the percentage of women in our hospitals.

Although it has been said by some noble Lords that the Commission think as I do on this subject, I regret that when one reads paragraph 302 one gets the impression that the Commission are attempting to bolster up the present position. That paragraph reads: The high proportion of women now accepted in some British medical schools is an indication that the admission of women raises in itself few or no serious problems. This statement is certainly not supported by an examination of the percentages of women admitted to many medical schools.

It will be recalled that the Goodenough Committee over twenty years ago recommended—and if this recommendation had been acted upon there would have been no shortage of doctors in this country— that a substantial proportion of students at all medical schools should be women. The University Grants Committee stipulated that the proportion should not fall below 15 per cent. That was twenty years ago. I have just received the lists from many of our hospitals. The latest figures in 1970 reveal that Cambridge takes 13.8 per cent. of women; Guy's, London and Baft's all take approximately 14 per cent.; St. Thomas's takes 15 per cent.; King's College takes 18 per cent.; then Westminster, University College, St. George's and Middlesex become very generous, with 19 per cent. I listened to my noble colleague Lord Brock just now describing the activities in London and the London University and he really could find nothing wrong at all. He probably has forgotten just how they treat women. The reputation of the London hospitals with regard to the education of women is disgraceful— absolutely disgraceful!—and is something for which the noble Lord, Lord Brock, should blush.

Is this discrimination made because women have failed in medicine? Have they made bad doctors? Not a bit of it! Women are sought after; women surgeons have long lists of people who want them to operate on them. There is no question: they have made good doctors. And may I tell the House, in case it may think I am being subjective on this subject, what the Commission say about them? They say: The work of women medical students is widely acknowledged to be better on average than that of men students though this may simply reflect more stringent selection. The reference to "more stringent selection" bears out the headmistresses' contention that girls are deterred from choosing medicine as a career because merit alone will not determine their chances before a selection committee. Later, I am glad to see, the Commission rally to the cause of women, and say: We think that the imposition of an arbitrary upper limit on the numbers of women admitted to the medical course would have the most unfortunate consequences for medicine ". These are very welcome expressions of appreciation and I am sorry to say that the Commission then do not follow them up. They make no attempt to challenge those who are imposing "an arbitrary upper limit" in medical schools and thereby discriminating against able girls. As I have said, it is significant that only one woman doctor was chosen to serve on the Commission. It seems that the "arbitrary upper limit" of women doctors on the Commission was one.

I feel that this policy of discrimination against potential women medical students contravenes the Sex Disqualification Removal Act 1919. In February, two months ago, I put down a Question asking the Government whether this was not so. The Sex Disqualification Removal Act says: A person shall not be disqualified by sex or marriage from the exercise of any public function or from being appointed to or holding any civil or judicial office or post or from entering or assuming or carrying on any civil profession or vocation or for admission to any incorporated society. On February 19 I asked the Government whether medical schools, which limit the admission of women students to a small percentage of the total intake, are contravening the Sex Disqualification Removal Act 1919. My noble friend Lady Phillips, who is to wind up, was given the unpleasant job, as usual, of answering. I must confess that in this House I am surprised to see how much work the women have to do, how detailed it is, and how often how very unpleasant some of it is. My noble friend said: …it is not for Her Majesty's Government to construe the law. Moreover, I am advised that if there were any contravention of the Sex Disqualification Removal Act 1919 it would not be for Her Majesty's Government to enforce the law, and that the remedy would be by way of civil injunction by any woman aggrieved."—[OFFICIAL REPORT; col. 1286.] Surely it would not be contended that, by failing to admit suitably qualified women students, the medical schools are either preventing women from entering the civil profession of medicine or are refusing to admit women to an incorporated society. I have been advised, just as my noble friend was, that action can be taken only by a person aggrieved because her own rights were being infringed. How old is an aggrieved person in this case? An aggrieved person is a girl of 17 or 18. She is probably a brilliant child who has been working very hard; shy, exhausted, a little introverted, longing to become a doctor— knowing very well that she has been turned down because of her sex. And we are told that this is the individual who will have to take action! My Lords, where is our law? Where is its compassion? Of course I have tried to find this girl; I have got in touch with headmistresses. They know; I know; but how can we expect a child of this kind to apply for an injunction?

So here we are today, short of doctors, shamelessly taking Pakistani doctors and doctors from all over the world, from sick, miserable, inarticulate people— shamelessly! Yet here we have a brilliant source of supply but we are allowing convention, prejudice, discrimination, to be used against these girls. I ask the House to join with me and with others who are pressing for this position to be changed. I want to ask the Government whether they will not now decide to stop medical schools, particularly the London medical schools, from contravening those important provisions of the Sex Disqualification Removal Act 1919.

5.47 p.m.

LORD COHEN OF BIRKENHEAD

My Lords, I propose to confine myself to one relatively small but I think important aspect of the Royal Commission's Report. It is dealt with in the phrase which the noble Baroness, Lady Brooke of Ystradfellte, omitted from the terms of reference which she quoted. That phrase is: having regard to the statutory functions of the General Medical Council and the current review by that Council of recent changes in the undergraduate curriculum". That review had been undertaken by the General Medical Council and their recommendations were published in 1967. I do not propose to discuss the details of those recommendations, but if the right reverend Prelate the Bishop of Leicester, or the noble Lord, Lord Stamp, would care to look at them they would see that the recommendations of the General Medical Council cover their doubts about ethics and legal medicine.

May I say, as President of the General Medical Council, that the Royal Commission's Report departs in no way from the general philosophy of medical education which the recommendations of the General Medical Council set out. The General Medical Council are not of course concerned; they have no statutory mandate for dealing with many of those matters under the umbrella of the Royal Commission. But the essential philosophy is that it is no longer possible in present conditions to regard the undergraduate education and the pre-registration years as sufficient to produce a qualified doctor who lawfully may practise independently. That is a view which was held by practically all, if not all, of those who gave evidence to certainly the General Medical Council; and I think it can be said that it was the view expressed by the British Medical Association, who wrote that: We would stress that the undergraduate course and immediate post-qualification time is only the initial period of instruction in a continuing education. It should be followed by planned vocational training for all branches of medicine, including general practice. It was not the first time that a committee of the British Medical Association had expressed that view, and it was a committee almost entirely composed of general practitioners, for in 1948 a committee of the British Medical Council wrote this: General practice is a special form of practice which must be founded on general basic principles and appropriate postgraduate study. In the committee's view, the undergraduate medical course should be primarily concerned with the training in those basic principles of medicine which are a necessary foundation for all forms of medical practice. Certainly there is strong and cogent advocacy in the Report of the Royal Commission why it should be so, and indeed there has now been established a central council which will advise on the provision for postgraduate medical education.

Then there comes the question: if there is special vocational training, how are those who have successfully attained the standards which are necessary for a vocational training to be recognised? The answer which the Royal Commission gave was that there should be a register of specialties. Since then there has been a misconception, and indeed considerable inaccuracies have been uttered about the nature of a specialty register. Only a day or two ago an important committee said that specialty registration is premature, if not superfluous. May I then put forward why, in the view of the General Medical Council as in the view of the Royal Commission, there should be specialist registration.

It may be recalled that the first profession to have a register was the medical profession, and that was in fact established by the Medical Act 1858. The Preamble to that Act gives an indication of why registration is not only desirable but indeed necessary. The Preamble reads thus: Whereas it is expedient that Persons requiring Medical Aid should be enabled to distinguish qualified from unqualified Practitioners: Be it therefore enacted … and so forth. Clearly this has a twofold purpose. It is to safeguard the public so that the public may be able to see from the register who is qualified and who is not qualified, because I should explain that in this country, as distinct from many others, anyone may practice medicine. It is true that certain restrictions are placed upon non-registered medical pracitioners: for example, they cannot work in the National Health Service; they cannot sign statutory certificates; they cannot prescribe certain drugs; they cannot perform midwifery—they cannot, in fact, do many things which the registered medical practitioner may do. So there are those special privileges, including, I might add, that the registered practitioner may sue for fees. No unregistered medical practitioner may so do.

The idea of the specialist register is that it shall in the same way identify those persons who have reached standards of skill and experience which show that they are fully competent to exercise independent judgment and responsibility in practising in that special field. Until now the only way in which that was determined was by the appointment of a doctor as a consultant to a hospital. The average age for the appointment of a consultant is about 37, so for 12 to 14 years after qualifying—sometimes much longer—the doctor waits for a consultant appointment, and if it is not attained there is discontent. I believe that this is one of the factors leading to the "brain drain". Therefore the specialist register will provide the earliest public recognition of the fact that a man has successfully cleared the hurdle of specialty training, and I trust that from that many fruitful consequences will flow, some of which I mentioned at an earlier date in your Lordships' House.

I am not suggesting, of course, that specialist registration should be in any way restrictive. There is no reason why a gynaecologist should not remove a gall bladder; there is no reason why a general practitioner, sufficiently competent, should not do an appendectomy; but the fact is that the public has information, and it is indicated to the public who has reached the standards required for specialist registration. If there is to be specialist registration it seems to me abundantly clear that there should be one body responsible for that registration, through acceptable machinery which shall be determined after full consultation, and the functions of that body would be to determine the minimally acceptable standards to be reached in a specialty, and also to determine which specialties justify registration.

Clearly one of the reasons why there must be one body and not many is that it is necessary to determine a harmonisation of standards as between the specialties. It clearly would be absurd, for example, for surgery to allow 25 per cent. of candidates for any specialty examination to pass whereas the standards of dermatology would allow 90 per cent. of the candidates to pass. Therefore the General Medical Council—and I think this is true also of the Royal Commission—would suggest that all those who were chosen to start the specialty training should, except for very few, reach the standards required for specialty training.

The other point is that any body, whether it be a university, or a college, in this country or overseas, which can demonstrate that its degree or diploma or certificate guarantees that that standard of proficiency has been reached, should have that diploma or degree accepted for registration. In other words there should not be a single portal of entry to the specialist register. Already many universities are giving degrees which would be of specialist standard. I can think in my own University of Liverpool of the mastership of orthopaedic surgery; in the University of London the mastership in philosophy, in psychiatry. Membership of the Royal College of Pathology, for example, already indicates a standard which would justify specialisation. But that is not true, of course, nor do the Colleges of Physicians and Surgeons suggest that it is true, of the membership of the Royal College of Physicians or the Fellowship of the Royal College of Surgeons, which are regarded as indicating that their holders have reached a stage at which they are now capable of profiting from higher specialist training.

I would remind your Lordships that specialist registers are already in being in the United States of America, in Australia, in South Africa, in New Zealand, in all the countries of the European Economic Community—and that last point is important, because if we enter the Common Market, under the Treaty of Rome there is a mutual recognition of qualifications, and we shall be at a serious disadvantage if the E.E.C. countries have the specialist register and we do not.

Who should maintain the register? Here again I should like to quote quite briefly from the Royal Commission's Report, paragraph 158: The time has now come, in our view, for the establishment, on similar lines "— similar lines being those similar to the primary qualification— of a system of vocational registration as the necessary complement to a proper system of professional training; we recommend that the General Council should be the vocational registration authority. And in paragraph 185: We have already indicated that in our view the General Medical Council should assume a function in postgraduate education and training similar in principle to that which it now efficiently discharges in the undergraduate sphere. Finally, the last two sentences, indeed the penultimate sentence, will give the necessary indication. In paragraph 185, the Commission say: We have every reason to expect that the Council would approach postgraduate education with the flexibility and broadness of purpose that have characterised its approach to undergraduate medical education in the past ten years or so. Perhaps I ought to remind your Lordships that in another place on July 24, 1969, the Secretary of State said this: The Government intend to introduce the necessary legislation as soon as possible to enable the General Medical Council to maintain specialist registration. I do not propose at this stage to discuss in detail how the General Medical Council arrives at its recommendations. It does so by taking evidence from those bodies which give medical qualifications; and it then prepares a report which goes back to those bodies and, subsequently, to the Council itself for deliberation. And, as a former President of the General Medical Council has said: Our recommendations are the expression of a concordat amicably reached, not an ordinance which is issued by an external authority. Some are suggesting that the universities and the colleges should, without reference to any centrally recommended standards, issue certificates marking the end point of a training devised by themselves, and that the General Medical Council should accept these for specialist registration. I should, I think, make it clear to your Lordships that the General Medical Council does not regard as appropriate that it should be called upon to accept for registration the names of those who have satisfied other bodies not answerable to the public, and for whose standards of training, including facilities for training and examination, the General Medical Council has had no responsibility, and that this should apply retrospectively if specialist registration is postponed; that is to say, if it does so at the moment, and later specialist registration comes in and is placed under the aegis of the General Medical Council, the General Medical Council would then not accept the certificates which had been given earlier and over which it had no responsibility whatsoever.

If the Government decide that specialist registration should be still further postponed, or that it should be the responsibility of a body or bodies other than the General Medical Council, I think there are two additional grounds on which we could reasonably say that that would be less than the best. The first is that no other body than the General Medical Council is free from medico-political activities, and indeed pressures, and no other body has the wide territorial responsibilities that the General Medical Council now has. But perhaps even more important is the point which was made a little earlier in a rather different way: that medical education can no longer be divided into neat compartments labelled "pre-clinical", "clinical" "undergraduate" or "postgraduate".

The Royal Commission emphasised, and rightly, the increasingly scientific basis of medicine, and suggested how the undergraduate curriculum might be adapted to meet this situation. They recommended that there should be no change in the average length of the medical course—five years, plus one pre-registration year—but that in the undergraduate course there should be greater emphasis on the medical sciences; and if this is carried out then there will be less time for clinical instruction. To my own knowledge, these recommendations have been sympathetically received, and many universities would wish to implement them. But they realise that, as the law now stands, they have to produce not only young men and women with a sound knowledge of basic medical sciences, but also doctors who, after a year's pre-registration training, are lawfully entitled to set up in independent medical practice. Most medical teachers agree that they cannot therefore easily reduce the clinical content of the undergraduate course and thus provide the time for the urgently needed improvement in scientific studies.

Perhaps I might add that in the undergraduate course great care is taken to emphasise the ethical implications of medicine, and the treatment of patients as human beings. When I was a clinical teacher I not infrequently reminded students of some words written well over a century ago by one of England's greatest poets. He then said, when science was advancing rapidly: True it is that nature hides her treasures less and less. Man now presides in power where once he trembled in his weakness; Science advances with gigantic strides. But are we aught enriched in love and meekness? I told them that if they were to be doctors they must give a resounding affirmative in answer to Wordsworth's question.

May I, then, in conclusion say, lest I have given a somewhat pessimistic view of the specialist registration, that the consultations between the General Medical Council, on the one hand, and universities, colleges and other medical licensing bodies of the British Medical Association on the other—consultations which are concerned with the implementation of the Royal Commission's proposals on specialist training and registration—are still in progress.

6.10 p.m.

LORD ANNAN

My Lords, the Royal Commission devoted a whole chapter to medical education in London, and although I am sure that as a member of the University of London I ought to declare an interest, I hope that your Lordships will be kind enough to judge whether what I have to say is perhaps a matter of national importance, rather than one merely of personal loyalty to my own institution. There is a very simple reason why this should be so. The medical schools in the University of London teach 40 per cent. of medical students in the country. Whatever happens in the next 30 years London will continue to be by far the largest single trainer of doctors, and also the national centre of postgraduate studies and all forms of medical research. If London medicine flags, then the standards of British medicine will fall. Here may I say how indebted I am to Lord Brock and Lord Evans for having used the broad brush to paint the London picture, and if I indulge in petit point embroidery and go into some matters of detail, perhaps 1 may be forgiven.

I am sure we shall all agree that the Royal Commission were right to stress that there are too many medical schools in London. I welcome the Commission's recommendation, and so do my colleagues, that these schools need to be integrated with the pre-clinical departments of London colleges which teach subjects such as biochemistry, physiology, pharmacology and anatomy. But I have to add that at first sight these marriages are going to be pretty costly—we reckon at least £4 million apiece. And although the noble Lord, Lord Cottesloe, was absolutely right in saying that probably there are only three starters in the immediate future, nevertheless this might suggest that a quite sizable bill is coming along.

Each complex needing a sum of this order has to buy a large enough site for this new faculty, or school of medical science, and to build upon it. There will also then have to be on that site the facilities to bring together the pre-clinical and the postclinical students and teachers, and also the research elements in the school. But, looked at in another way, I think that these marriages will not be all that expensive: first, because the Todd Report is certainly not a Casanova Charter—there will be no divorce in this case—and, secondly, because the present medical schools have lasted for over 100 years and we can discount the cost over that period of time for these new schools of medical science. I might at this point say to Lady Summerskill that I blush, as she asked me to do. I do not know, having been so acquainted only recently with the medical schools, why the lack of women students should be so marked. I have my suspicions, but I will not voice them. And, as I have blushed, and although I noted that Lord Brock's withers were completely unwrung, I think I had better leave it to him to make any reply, should it be necessary.

I think this "twinning" of schools, and their connection with the London colleges, will be good for medicine. Will it be good for universities as a whole? Clearly, these sums cannot be found from the present allocation of the Department of Education and Science to the University Grants Committee. But I am sure that no one has really imagined that the Todd Report could be implemented without additional expense. For the past ten years the civic universities outside London, new and old, have received the lion's share of the U.G.C. capital grants —and quite right, too, because it was more economic to expand higher education out in the Provinces than in London. But after such a lean decade London University hopes it will be acknowledged that expansion in London is a necessary condition of expanding medical education. In the case of the Todd Report the major expenditure I believe, should be in London, if there are to be not only more doctors but better doctors.

This "twinning" of medical schools (which in London we hope does not mean the "twinning" of hospitals) is, I think, an admirable solution to the problem of medical education in London. What I am about to say, I hasten to add, is my own personal judgment, and is in no way the judgment of my colleagues, but I want to make it clear that I rather agree with the noble Baroness, Lady Brooke, who asked whether it was still necessary to have as many hospitals and medical schools in London as existed, for example, at the beginning of this century. I ask whether, in the next century, there will be sufficient patients in the centre of London for all the hospitals that are there now. I wonder whether the very strong loyalties which the medical profession has towards these great institutions, whose history in many cases goes back for many years, and also their strong links with the University of London, did not restrain the Commissioners in their Report from taking an even harder look than has already been done, at the question of whether there is a need for so many hospitals with teaching schools in the central area. I should like to make it plain to the noble Baroness, Lady Phillips, that in regard to my own institution (again, I am expressing a personal view) I should welcome triplets rather than twins, and I am quite prepared to have them, because in our case this would mean that that great hospital, the Middlesex, could also come into the Royal Free /University College Hospital Scheme, with University College.

I wonder whether the noble Lord, Lord Brooke, would bear this interpolation which I am going to make to the noble Baroness, Lady Brooke, because in her speech she said one thing that I feel was rather unfair to the Government. The noble Baroness condemned the Government for their failure to pay doctors and to equip hospitals well enough, and she argued that there was a great waste of the money spent on medical education, because so many doctors emigrated as a result of the lack of Governmental care in this whole question of medical education and the payment of doctors. The first thing I would say on this point is that this is not the fault particularly of this present Government. It is a situation that has continued ever since 1945, during which time we have certainly seen a marked increase in emigration by doctors.

And on this point I would ask the noble Baroness whether she would prefer to see the medical profession and the doctors of this country respected, as they are, everywhere, and many doctors loved in our own National Health Service, or the situation in the United States, to which so many of these doctors emigrate, where doctors are loathed and the medical profession reviled because of their bitter opposition to medi-care: a state of affairs that has resulted in a situation in which not only the lower-paid classes, but also the vast middle class of America, dread falling ill, because they feel that they will be ruined by the exorbitant fees charged by doctors and by the astronomical hospital costs which no private insurance scheme can possibly hope to meet. I think that this is of relevance to the question of whether we should educate doctors merely so that they may emigrate.

Another item of expenditure ought to be mentioned. The Todd Report recommends that the training of a doctor, which now takes six years, should take nine years. One of these years would be after clinical training had been completed and before registration; and the succeeding last three years would be spent as a registered doctor, but working in a hospital if the doctor wished to be regarded as qualified for certain posts in the future. I am afraid that I must tell your Lordships that these proposals have received something considerably less than a warm welcome from medical students. It is not so much that they object to lengthening the course, but that they fear the very low pay which they receive in pre-registration year will not be substantially increased after registration. They look on the proposal as an attempt to strengthen the Health Service "on the cheap". So I hope that, as soon as possible, putative scales of pay will be published for these last three years of qualification, so that these fears can be allayed.

May I draw your Lordships' attention to one other matter of concern in the University of London? We all want hospitals to be good hospitals, but some of the hospitals have to be "more equal than others". It seems to me that you are bound to draw a distinction between what used to be called a "teaching hospital," and other hospitals. What special privileges must a teaching hospital have? I do not think it can be disputed that it must have a more generous level of staffing on the clinical and diagnostic side and in the laboratories than there is in other hospitals. For one thing, it has to include basic sciences within its orbit, as well as biomedical and pre-clinical subjects. For another, the staff, or a large part of it, must have time not only for care of patients but for teaching and for research and for the heavy burden of administration that I am afraid goes with these activities. We have heard a reference to the overwork of doctors in teaching hospitals, which I am sure is true, and it is not really a good enough guide to see a staff/student ratio of one to four and think that this is an enormously lavish way of staffing. First of all, I think that crude staff/student ratios do not tell the whole story; and, secondly, one has to go into the hospitals to see the burden which is put on the great teachers and researchers in the teaching hospitals.

Then again, the Faculty of Medicine in which the medical school will exist, and the teaching hospital itself, ought to retain the right to appoint its own staff. This means that all medical staff of consultant grade, as well as fulltime clinical academic staff, should be appointed in future by the associated medical school. I wonder, therefore, whether it would not be wise to set up academic appointments boards with external university advisers upon them to make appointments.

I hope it does not sound pedantic, and possibly alarming, to hear this emphasis on academic standards being applied in appointments. I expect that most people would think that every important hospital post needs doctors with practical experience rather than theoreticians. But it cannot be repeated too often that the care of patients, which is the prime concern of all hospitals, is only one of the concerns of a teaching hospital. Our teaching hospitals are the places where the research takes place which is going to improve the care of patients in the future. That is why teaching hospitals should remain free to take patients from all over the country if their illness is one with which that particular hospital is specially equipped to deal. That is why if a choice has to be made on the head of a department (say the department of pediatrics), between a man who is popular with staff and with patients and who has given long and devoted service to the hospital, and a woman who also has an excellent record in patient care but, in addition, has published some very useful papers which could result in more effective treatment of patients, then the woman doctor ought to be appointed. That is sometimes a difficult point to get over.

Finally, my Lords, there is the administrative structure which was set out in the Green Paper. I do not know any administrative structure which is more complicated than that of medicine and health. Directly life and death come into question it appears that you have to double or treble the number of committees needed in any other field. I find this very paradoxical. I must say that anything which I add on this point I add with great diffidence, because I am really very ignorant of the medical administrative structure. Until now the success of the London medical schools, which depends on the high standard of their associated teaching hospitals, has owed a good deal to their being administered by boards of governors. In the new deal, London University's teaching hospitals and the special postgraduate hospitals will require some supplementary finance. Could not this be done through an earmarked grant for medicine through the University?

The reason I ask that is as follows. The structure of the new Area Health Authorities contains some rather worrying features. In the Green Paper they seem—and I want to repeat, they only seem—to have been set up without any regard for medical education and research. Among those 90 Authorities, quite a number will, in fact, be responsible for teaching hospitals. Now I am not criticising the Green Paper on this point. Nor have the universities been turned down on this matter, because the Green Paper sets out only the broad administrative structure. Yet I venture to suggest that when the details are spelled out in some subsequent paper, more protection for teaching and research will be needed than appears at present. In the present Green Paper the only time medical education gets a look in is on the Regional Committees.

Again. I am not for one moment suggesting that the universities ought to be represented more strongly on the Area Health Authority Board. There are already too many pressure groups struggling to be represented on these Boards. I rather doubt, too, whether to set up a parallel committee structure on the academic side would help very much. But I do suggest that a way must be found to earmark money for teaching and research so that they are not dependent for finance upon the Area Board, which inevitably will put patient care as its highest priority. Furthermore, the medical schools and the postgraduate institutes will need some form of government. Could this be provided by basing it on the committees of management of existing medical schools or postgraduate institutes? These committees could be expanded so that they became a locally responsible executive controlling authority with financial control, answerable to the Area Health Authority for matters concerning provision of health service in the area. But could this controlling authority also be made directly responsible to the University of London for matters concerning staffing, teaching, research and development? I am not asking the noble Baroness to give me answers to these questions, but if she would draw these matters to the attention of her right honourable friends I should be greatly obliged.

6.27 p.m.

LADY RUTHVEN OF FREELAND

My Lords, I should like to echo the words of my noble friend Lady Brooke of Ystradfellte, and say that it is with great temerity that I venture to address your Lordships on this extremely specialised subject of medical education. As your Lordships will appreciate, I have no real knowledge of this subject, but I was for 17 years a member of the board of governors of a London teaching hospital, and for 13 years I have been, and still am, a member of the board of governors of a postgraduate teaching hospital. I have also read the Report of the Royal Commission and heard it discussed by many eminent members of those two boards, and have been allowed to see some of the papers they have written on the subject. It is on those grounds that I venture to make a few remarks on the Royal Commission Report.

I have been rather carried away by the last speaker, the noble Lord, Lord Annan, because he spoke on a subject about which I should love to speak; that is, the Green Paper, because I think it comes into this debate very closely. However, I dare not do so, and I think I must stick to the brief, which is the Todd Report. There are many good points in this Report, but I agree with the noble Lord, Lord Evans of Hungershall, that the Report is too idealistic and not always very practical. It is going to cost an awful lot of money, and I wonder where that money is coming from. I would also say that it is rather out of date. One example of that is that it suggests that teaching hospitals should take on the role of a district hospital, whereas, as the noble Lord, Lord Amulree, said, a great many teaching hospitals have already done that and have been doing it for many years.

The Report also seems to be rather vague and undecided in its views as to whether teaching hospitals should go under the regional boards—or area boards as they are now to be called—in the same way as in Scotland, or whether the pattern which has been planned for Nottingham and Southampton should be the one to be followed. It seems to me, as an amateur, that it would be more reasonable to wait until the full implications of Nottingham and Southampton are realised before proposing such drastic changes from the present method of administrating teaching hospitals.

There seem to be so many different proposals for administrative reorganisa tion and I feel convinced, as the noble Lord, Lord Annan, said, that there are many things which teaching hospitals will wish to retain. I think they will want to retain, if possible, some personal form of committee or governing body. They will want to have very close and intimate links with their medical schools. I am sure that they will want to have separate and adequate finance, both revenue and capital, rather than have a doling out from the area boards. I am also sure that they will want to control their own endowment funds which they have used so much in the past, both in research and in rebuilding. I am certain, too, that they will want to employ their own staff and, while very happy to provide district services, will wish to retain the right to admit patients irrespective of their locality of origin.

I am afraid that I cannot quite agree with the noble Lord, Lord Amulree, that the Todd Report takes adequate account of the distinction between general continuing postgraduate medical training and the specialist postgraduate medical education provided by such hospitals as the Hospital for Sick Children in Great Ormond Street, the Hospital for Nervous Diseases in Queen's Square, the Bethlem/ Maudsley and the Royal Postgraduate Medical School at Hammersmith, each in conjunction with its own Institute. The Report does not sufficiently acknowledge the work of these specialist postgraduate teaching hospitals in London, or the British Postgraduate Medical Federation. There is practically no mention of it at all, as has been said so frequently by the speakers who preceded me.

Again, as I have already said, it also fails to distinguish sufficiently between the continuing postgraduate professional vocational training in the general sense, and the highly specialised postgraduate education provided in the London postgraduate hospitals. The former is really the responsibility of the Health Service throughout the country. The latter requires a concentration of special knowledge, skill, equipment and research which can be found only in university centres devoted to these specialised subjects.

Here I should like to put before your Lordships the example of the Bethlem/ Maudsley Hospital and Institute of Psychiatry. This is the largest institution for psychiatry in the Western World. It has the largest output of specialised teachers and research workers. Not only does it produce specialists, but, more important, it produces the teachers of the future in psychiatry and allied fields. Already they are linked with King's and Guy's, and have a district position; and they are also starting to train nurses for community work in their neighbourhood.

The national and international role of the London postgraduate specialist hospitals can be illustrated, as has already been mentioned by my noble friend Lord Cottesloe, by the fact that the number of overseas doctors coming to London each year to obtain postgraduate experience and training, who are looked after by the Postgraduate Medical Federation, exceeds the total annual output of new doctors from all medical schools in the United Kingdom. This cannot be over-emphasised.

Eminent critics of the Todd Report, such as Sir John McMichael and Dr. Avery Jones, have drawn attention to the enormous dimensions of overseas demand and the considerable part which the London postgraduate teaching hospitals and their Institutes play in meeting this demand. To quote Sir John McMichael, he said: The Postgraduate Medical Federation in London has blazed a trail in this direction and played a full role, although this is scarcely acknowledged in the Todd Report. And Dr. Avery Jones said: The postgraduate centres in London have developed as in no other city in the world, and form a national asset of which we should be very proud. I was very worried by the proposals in the Report for these big university centres and big combinations of teaching hospitals—the " twinning " which is, perhaps, going to be better than one expected. But I feel it is going to cost an enormous amount of money, and I only hope that the standards of teaching, research and even treatment will not be lowered by this combination. I am glad to hear that the hospitals themselves are to retain their own identity, even though their schools and pre-clinical schools may be joined together. Of course, as my noble friend Lord Cottesloe said, every postgraduate hospital will not necessarily have to be treated in exactly the same way. Some of the smaller ones may wish to redevelop in closer proximity to an undergraduate hospital and medical school. But in the interests of progress in all fields of medicine, such hospitals as centres of concentrated effort on specialities, however they may develop in the future, must retain their individuality, a large measure of independence and the closest links with their institutes.

In my view, it is essential that the larger postgraduate hospitals and their Institutes should retain their individual governing bodies and control of their endowments, which, after all, were given by generous donors to the hospitals in question. Much of the success of these postgraduate hospitals and Institutes has, I think, been due to their having personal and dedicated boards of governors, independent enough to obtain and deploy resources sufficiently large to meet the ever changing and expanding needs of their Institutes and hospitals. It is therefore very important that the Institutes of these hospitals should also retain their separate committees of management, and that they should be closely linked with the hospitals' boards of governors. It would be a tragedy if, as a result of the recommendations of the Todd Report —some of which have already been discarded—such alterations should be made that the Institutes, so long the admiration and envy of medicine throughout the world should be handicapped in carrying on the purposes for which they have been built up.

6.37 p.m.

LORD SEGAL

My Lords, I think it is sometimes forgotten that the Report of the Royal Commission on Medical Education appeared after three years of intensive work by one of the most distinguished and high-powered Royal Commissions ever appointed by any Government. I say this allowing for the possible omissions which have already been mentioned, although at this late stage I do not wish to be diverted by any war of the sexes. Two of the leading figures on that Commission are Members of your Lordships' House, and we must all be grateful to the noble Lord, Lord Brock, the most distinguished cardiac surgeon of his generation and one who has spent a lifetime of service in medical education, for initiating this debate.

Unfortunately, with a profession so independent and so fiercely individualistic as the medical profession, the Report seems to have met a fate which it hardly deserved. When it first appeared grave doubts from all quarters cast a gloomy shadow over its future. And the question was asked: If this thoughtful and painstaking Report is not to be plunged into one of those pigeonholes which are specially reserved for Reports of Royal Commissions, who will initiate 'the reforms that it advocates? Were the Royal Colleges to make a start and adjust themselves to changed conditions? Was the General Medical Council to give a lead to the profession and set machinery in motion to implement the recommendations?

Clearly, these recommendations also called for Government action. If the Government have been somewhat dragging their feet, can this inaction be justified by the plea that the medical profession itself was divided among its own members? Of course that is true, but the fact remains that the medical profession has never been united in the past, is not united at the present time and can see little hope of being united in the future. Perhaps that is one of the glories of medicine: that differences of opinion, on administrative as well as academic matters, are widely accepted and very freely discussed.

Meanwhile, some of the problems pointed out by the Todd Report may grow more and more intractable with the passage of time. The Royal Commission expressed the hope—and I quote: … that action will follow swiftly on the publication of our Report … Some of our recommendations will require changes in legislation to make them fully effective. We hope that these changes will not be long delayed … That is on page 232. Two years have since elapsed, and I would ask the Government now: what changes have since been effected? When is the necessary legislation expected to come before Parliament? Rugged individualism in any profession is all very well, but it can create problems from the patients' point of view. If we are to maintain all our hospitals at the high level of efficiency of our London teaching hospitals and keep abreast of modern scientific and technological developments in medicine, some action cannot be any longer delayed. We may have to pay a heavy price, both in terms of money and in terms of human values, if these problems are neglected, and if some of our great voluntary hospitals are allowed to cling to their time-honoured traditions and to remain outside the stream of modern technological advances.

There is no time at this late stage of the debate to deal with many of the Royal Commission's recommendations. Many of the earlier chapters, such as those on the future pattern of medical care and on postgraduate education and training, verge on the platitudinous, and have found general acceptance. But I should like to comment on some of the administrative changes proposed. If we are to achieve an annual intake of 5,000 students into our medical schools in the next twenty years, half at least will be trained in the provincial centres. I believe that the recommendations, of the Royal Commission for the future of the medical schools in the Provinces have generally been warmly welcomed. Cambridge as an undergraduate clinical school, Nottingham and Southampton as new medical schools, and especially the extension of existing facilities in Leeds and Sheffield—all these should now develop apace, so that the target figure of 2,500 annual intake should be attainable during the next few years.

But it is when we come to the future of the London medical schools, as has been mentioned by other speakers, that bitter controversy has arisen. All our great London hospitals are to retain their separate identities: it is only their medical schools which are asked to undergo a radical change. But what is the point of reducing the existing medical schools from twelve: to six and merely pairing them off? Is there anything specially sacrosanct about the number six? If two schools amalgamate, such as London and Bart's, or Middlesex and St. Mary's, or Charing Cross and Westminster, there is bound to be some rivalry among their staffs, even if their rivalry on the rugger field may disappear. Questions of prestige, of precedence: and of personal status are almost bound to arise and to create difficult working conditions, at least in the short term. And even greater difficulties are bound to arise in linking the new groupings with six multi-faculty colleges of London University. The six designated colleges are: Queen Mary's, University College, Bedford College, the Imperial College of Science, new buildings in place of the old King's College, and a projected and entirely new college for Tooting or Guildford, or somewhere in the wilds of Surrey. At present, the links of the medical schools with most of these colleges are of the slenderest and in some cases are almost nonexistent. And the building of any new colleges for pre-clinical studies, rather than the extension of existing colleges, would be a sheer waste of public money in these difficult days.

I would suggest that if there is merit in six groupings, there might also be merit in four groupings, or even three. I throw this out merely as a suggestion, because it is very easy to demolish the case for amalgamation, as the noble Lord, Lord Brock, has to some extent done. But why not combine the medical schools of London Hospital and Bart's with Universitly College Hospital and the Royal Free Hospital into one large eastern group for the purpose of pre-clinical education; or Middlesex and St. Mary's with Westminster and Charing Cross, at Fulham, into one large western group, again for the purpose of pre-clinical education; and, equally, Guy's and King's College Hospital with St. Thomas's and St. George's, at Tooting, into one large southern group? It appears that the Royal Commission has been somewhat unsure of itself in its London amalgamation proposals—and I agree with Lord Brock that the clinical teaching is far better left as it is today, unless the teaching hospitals themselves decide otherwise.

These larger pre-clinical groupings could bring about enormous advantages in administration and in the saving of public money. Students would have a much freer choice of their future teaching hospital, as they now all enjoy at Oxford and Cambridge. They would have far wider contacts in their pre-clinical years, and would be not only better trained but better educated in the fullest sense of the term. With these wider pre-clinical amalgamations, personal rivalries and questions of prestige among the teaching staffs would be minimised; and there is also likely to be some measure of safety in greater numbers. Our small specialised hospitals could be more readily available for postgraduate teaching, and could be made more attractive to the far larger number of graduates who wish to specialise. And the saving of public money would be enormous, especially in obviating the need for building new pre-clinical colleges. But most important of all would be the wider pooling of existing resources, the increased efficiency of the larger units, and the economies that could be achieved in the purchase of new and more up-to-date equipment.

These problems of pre-clinical education are tremendously important, not only in attracting greater numbers but in ensuring the highest quality of our medical students; and I sometimes feel sorry for the young medical student who has to go right through the whole of his five, six or seven years of medical training always in constant company with the same fellow students in one particular teaching hospital. If not acted on very soon, valuable time may have been lost and the leeway may be almost impossible to recover. It is all very well to muddle along, but not, I hope, at the cost of still further overworking our already heavily-overworked doctors, be they specialists or general practitioners. So I would ask the Government to take the initiative in working out now, with all the representatives of the teaching hospitals and the colleges concerned, plans to extend their pre-clinical medical facilities and to ensure that future medical students are given the widest possible contacts in the multi-faculty colleges to equip them as fully as possible for any responsibilities they may have to face in the future.

6.50 p.m.

LORD PLATT

My Lords, in the first place I should like to add my thanks to my noble friend Lord Brock for giving us this opportunity of debating the Report of the Royal Commission on Medical Education which he opened in his best forthright and critical manner. Secondly, I must give to the House the very great regrets of my noble friend Lord Todd whom I saw only the other day (though "regrets" is too weak a word to use for what he feels) in having to miss this debate after chairing this Commission —which he did so splendidly. As your Lordships know, he is one of those people who finds it difficult to believe that he himself could ever be ill. He reminds me of a doctor friend of mine who, in similar circumstances, said that he always thought that this kind of thing only happened to patients. Anyway, he is doing very well now and is filling up his time learning Chinese; which will be a nice addition to the portfolio of languages, including Russian, which he already speaks with considerable fluency.

My Lords, as I am the only other member of the Commission who is also a Member of your Lordships' House, it falls to me to say a good deal in reply to some of the criticisms that have been made of the Report. But I hope that you will remember that Lord Todd, I am sure, could have done this very much better and is more familiar with his own Report than I am, although I had a great deal to do with it, and that what I say is not to be taken as "the word of Todd".

My Lords, this is not going to be a very easy task because so many criticisms have been made—particularly of the section which deals with the University of London. In the first instance, I should like to say—and I shall go into it in some detail later—that we had to divide ourselves up into subcommittees. I was not myself on the subcommittee which dealt with medical education in London. By saying that, I am not trying to make any excuse or to say that I disagree with this part of the Report—because I was quite convinced, and more and more convinced as our meetings went on and we got the reports of the subcommittees, that they were on the right kind of track and that many of their recommendations were very wise ones.

My Lords, you could think of this Report in general terms, dividing it in various ways. You may think that some of it is really a matter for universities and the University Grants Committee, whereas other parts of it obviously require political action and decisions at Government level. Or you may see it in two ways: on a time scale as containing certain things which really do require immediate action, such as the increase in the number of medical students to be trained, and certain others which are no more than a blueprint for the future and which contain our ideas of the directions that medical education should take. These are by no means meant to be implemented in the next year or two or, above all, to be taken as oracular pronouncements from our Royal Commission. These thoughts are relevant to our recommendations for the pairing or twinning of the London medical schools and the changes which might take place in the administration and grouping of the postgraduate institutes. If one reads the Report carefully, it will be seen that we are merely making suggestions knowing that a great deal of this has to be threshed out in the years to come. What we do mean, and mean strongly, is that before major decisions are taken about rebuilding or increasing the size and so on of the London medical schools, there should be very considerable thought as to whether these changes will fit into the pattern of the future of medical education as we see it.

I should like also to make it clear— and this answers one of Lord Segal's points—that many of our recommendations are not original at all. The noble Lord, Lord Brock, also referred to several of our recommendations as being things that the Royal Colleges had already been doing for a good many years. We were codifying them; we were telling those who wished to read the Report that we agreed that these were good things and that they should be done. And in this connection we found ourselves helped by the Report of Lord Cohen of Birkenhead from the General Medical Council and by Reports from bodies such as the Royal College of General Practitioners.

I accept, of course, that it is an important function of your Lordships' House to be critical, and that therefore many of the things of which you really approve in this Report perhaps have not been stressed as much as they might have been. This may perhaps be paralleled by the Commission's not giving full enough praise to Institutions like the Postgraduate Medical School at Hammersmith or the Postgraduate Institutes of London. These are absolutely splendid, with worldwide reputations attracting people from all over the world; and we should be loud in their praise, all of us. If we have not written that out fully enough, then I think that I can apologise on behalf of the Commission. I would remind your Lordships that we did our work in two and a half years—not three years, as the noble Lord, Lord Segal said. I do not mean therefore that it is a rapidly drawn-up and ill-considered Report; I mean that we did not want to pack it with a lot of detail which perhaps was not entirely relevant.

Therefore it is probably very easy to find instances of omissions—as did the noble Lord, Lord Stamp. I am sure that forensic pathologists will say that we did not do them justice; I am sure that child psychiatrists will say that we did not do them justice; and there are many other areas. Some of these are for the people themselves to look after. Surely Professor Camps and Lord Stamp himself might be "getting at" the universities over the question of education in forensic pathology; it is not necessary for a Royal Commission to go into every detail of that kind.

Some of the matters with which we dealt have had very little attention in this debate; and I shall not delay the House over them at this late hour. We considered the future trends in medicine. I think there is quite an interesting chapter on that which I hope that most of your Lordships may have read. It is a matter for speculation, of course, but it seems that the conquest of the great bacteriological diseases by prevention and treatment has left a hard core of illnesses, very often in old people—illnesses due to degenerative processes in the body which are very much more difficult to tackle. One cannot at the present moment, for instance, say that any great progress is being made in these directions. Of course there will be changes in the nature of medical practice; a great deal more will be automated and will depend on computers, though I do not think that the personal interview between doctor and patient can ever be dealt with in that kind of way.

My Lords, perhaps I might at this moment say something about the staffing structure. There is a Report of a working party—usually called the Platt Report— on medical staffing which was issued a good many years ago. One of the things it pointed out was that this question of shortage of staff at the junior hospital level is not a matter simply of the National Health Service. It exists in America, for instance, where in the City of New York we were informed that about 50 per cent, of the junior doctors in the hospitals had had their training abroad. They came from Puerto Rico, the Philippines and various other parts of the world. The same problem exists in Germany. It is a problem of the nature of the medical processes carried out in hospitals which is different from what it was in my day, when for some years I was the only medical registrar in a large hospital. Now, I suppose, eight people do my work—I am not surprised at that, of course. Enormous technical progress has meant that people at that stage of their medical life are particularly appropriately equipped to carry out these technical procedures, and the need for them has increased enormously.

Under the present staffing structure, these are looked on as temporary training posts. If you increase the number of medical graduates to fill all these places with our own men, and still they hold them only for a few years, they will be out of work for the rest of their lives. So you cannot do it that way; and the Platt Working Party suggested that there should be somebody called a medical assistant. It was an illchosen name, and I do not think that we gave him enough scope for independent judgment. But it was suggested that there should be such a person who would be prepared to take a post of this kind on a more permanent basis. This idea was not looked on with any great favour in the profession. But, on the other hand, if you tell the consultants that they should do more of this work, that also is not looked on very favourably.

We in the Todd Commission tried to get over this by a period of training which would give a man the rank of hospital specialist. A man who had done this amount of training would be able to take hospital cases on his own responsibility, without referring them to a consultant in every instance. We think that this is, in fact, going on today to quite a large extent, although the men are called registrars and senior registrars. We think the profession might possibly be more willing to accept this kind of thing; and from the best of these specialists could be chosen the consultants of the future, who would hold the final responsibility as heads of units, and to whom difficult cases would be referred by other members of the team. This is one of the reasons why we recommended that there should be specialist registers about which the noble Lord, Lord Cohen of Birkenhead, has spoken.

My Lords, we thought that there must be a controlled system of postgraduate training and that the present system is chaotic. Young men go from post to post, and as soon as they start work in one post they are applying for the next job. They may have to move their families around the country, and there is no coordinated plan; so we planned for that. We felt strongly—and in this we were backed up by the B.M.A. and the Royal College of General Practitioners —that there must be a much better programme of training before a man becomes a principal in general practice. In itself, general practice is a speciality that needs further training.

The noble Lord, Lord Brock, said that there were to be eight years postgraduate training before general practice, but it is unknown to me how he reached this figure. There is the postgraduate year, the pre-registration year, which remains more or less as before in our Report. That is followed by general professional training for three years, which we believe should be partly in hospital and partly in general practice—if a man's aim is general practice. That seems to me to make four years, after which the man becomes an assistant in general practice, which is what he would be doing now. That makes five or six years, if you look upon an assistant as still under training— as, up to a point, he is. We are increasing the time by three years but not making it eight years. That is absolutely wrong, and it may be just a misreading of what we said.

I will not bother to go into other details of postgraduate education. I have already mentioned staffing structure and training for general practice. We have pointed out the importance of proper teaching of psychiatry, preceded by pre-clinical teaching of psychology, which I think has been very much neglected in the past. This leads us to one of the reasons why we feel that medical schools in London have to amalgamate. It is because we cannot go on for the next 20, 30 or 40 years thinking that the only things a student needs to know before he comes on the wards are physiology and anatomy. We now take the view that he should have a grounding in sociology and phychology, at the very least, and probably also in statistics, and be introduced to various other subjects at that time. You are not going to get St. George's, the Westminster, Charing Cross, Bart's, Guy's and so on, all to set up special departments of sociology and psychology, and the rest of it, in order that their students will not have to go away.

I will not go into the question of community medicine, and the noble Lord, Lord Cohen of Birkenhead, has dealt adequately with vocational registration. We had a lot to say about the reform of the undergraduate medical course which we thought we would try to make more flexible. I think that the right reverend Prelate the Bishop of Leicester was the only one to refer to sex education. I myself wrote the chapter in the Report on that subject. It is quite extraordinary, I would say to the right reverend Prelate, that until recently sex education in medical schools has been entirely an extracurricular activity. We did refer— I thought quite a bit—to women in medicine, and I think that we said the right things. But we should not deceive ourselves by thinking that if we brought a large number of women back into medicine we could get rid of all the foreigners who are in our hospitals at the present time, because the two problems are different ones.

We considered how new places could be found, having determined, first of all, that we were quite sure that there really was a shortage of doctors. Obviously the more economic way is to expand the existing schools, rather than to build new ones, but new schools are now starting at Southampton and Nottingham, and we have recommendations of places where some others will be needed.

That brings me to the suggestions that have been made that the Report is prejudiced against London. We may have been lacking in some grace in not saying enough about the excellence of London, but we have put it in several places. For instance, after saying how London has led the country and the world in medicine we say, in paragraph 419: Failure to accept the need of an overall plan for development during the next thirty years or so might well lead to a serious decline in the importance of London as a centre of medical education. That surely does not suggest that we want to see the decline of London in any form or that we do not think it important at the present time. Our Report further says: … only the radical action that could be taken as the result of the recommendations of a Royal Commission is likely to be effective if London's special position in medical edution is to be related to the needs of the country as a whole and if the high standards of the past and present are to be maintained in the future." (paragraph 420.) What we were putting forward is a blueprint for the future, but we knew that our suggestions were very tentative and would have to be worked out by a number of bodies concerned. As most of your Lordships know, there is a Steering Committee of the University of London, under its Vice-Chancellor, Sir Brian Windeyer, who was a member of the Royal Commission, working in close connection with the Medical Committee of the University Grants Committee. So things are already happening, and I think that they are by no means wholly anti-Todd.

I have already said that a number of new pre-clinical subjects are developing and need looking after. Also, there has been a big change in medical research. In the nineteenth century, when most of the postgraduate institutes and special hospitals were founded and built, there was need for people with a special interest in subjects like neurology and ophthalmology to get together and work together on new methods of treatment, and so on. But recent advances in medicine have not always come from persons studying a single special subject with a special technique. The next advances in ophthalmology, for example, may come from a physicist, a chemist or an immunologist and not from the eye men themselves. This is one of the principles we have in mind when we say that some of these special and very famous postgraduate hospitals and institutes would now be better off if gradually, as opportunities arose, they could group themselves nearer to general hospitals where all these other disciplines are to be found developing and developed and, if possible, nearer to schools of science and scientific research. Dermatology surely benefits from being in closest touch with general medicine rather than in a hospital devoted only to the diseases of the skin. So our recommendations in these respects are based simply on the directions in which we think the scene would gradually go, knowing full well that in four or five years' time, when new opportunity arises, the scene may have changed and the exact recommendations of our Report may no longer be appropriate.

But with regard to the question, London versus the Provinces, I think perhaps there is too much concentration of expertise South of the Wash and that a little more might be devoted to the Northern universities. We had a very interesting report showing where medical students settled, after graduation, and whether it was really the case that a man who graduated from Sheffield was most likely to be found in the Sheffield region. This is so, but not to the extent that some of us imagine. What we felt was that the reason for siting a new hospital further away from London was not so much this question of where people settled, which might solve some of the shortages of doctors in the North, but because a good many sixth-formers or fifth-formers in places like Leicester and Hull, big cities which have no medical schools at all, might be more inclined to go in for medicine if there was a medical school in their immediate neighbourhood.

There was a little confusion in the mind of one speaker, I think, between general postgraduate medical training, which is dealt with in Chapter 3, and specialist postgraduate training in depth, which was really the theme of the noble Lord, Lord Cottesloe, and is, in a way, a different subject altogether. But he was very right in reminding us of the great work which the Postgraduate Medical Federation has done in its courses for general practitioners as well as in looking after its special Institutes.

The noble Baroness, Lady Summerskill, referred to the fact that there was only one medical woman on the Royal Commission. I am sure that that was regrettable. I think that we might have had more than one general practitioner. But I would remind her that we had no anatomist. We did have another woman, the Head of Bedford College; we had a headmaster and a hospital administrator. We tried to get a wide body of knowledge and wisdom on the Royal Commission, rather than the representation of every possible specialty. I have already referred to the speech of my noble friend Lord Cohen of Birkenhead. I agree that the philosophy of medical education pronounced by the General Medical Council, a good deal of which I think was written by the noble Lord, was absolutely in tune with the views of the Royal Commission, which benefited very much from his Report.

I was interested in the remarks of the noble Lord, Lord Annan, which I thought showed a great deal of wisdom. The noble Lady, Lady Ruthven, mentioned the special position of postgraduate education; the need to look after it, the need if necessary for earmarked grants, and especially the need for the present teaching hospitals, postgraduate and undergraduate, to hang on to their endowment funds, which have been so important in doing things when public money could not have been found for the purpose.

My Lords, I think that is all that I need say at this time of night, except to conclude by reminding Her Majesty's Government that we know that it will cost a lot of money to put some of these recommendations into effect. But a large amount of money will have to be spent on medical education, in any case, whether the Government follow the lines of the Todd Report or reject it. I hope that the necessary funds will be found.

7.26 p.m.

BARONESS PHILLIPS

My Lords, as several noble Lords have said, it is now nearly two years since the Royal Commission on Medical Education issued their Report, and we are grateful to the noble Lord, Lord Brock, for giving us the opportunity to discuss developments since then. I believe that on a previous occasion the noble Lord, Lord Cottesloe, referred to the composition of the Commission as including " a weight of intellect and experience ". I can endorse that. Also, the quality of the debate that we have had today reflects the knowledge of noble Lords in this field. I should like to add my good wishes for the speedy recovery of the noble Lord, Lord Todd. We are sorry that he could not be with us today, and I am sure we all hope that we shall soon see him back in your Lordships' House.

The Royal Commission, under the Chairmanship of the noble Lord, Lord Todd, carried out their remit with great thoroughness, and I would endorse what the noble Baroness, Lady Brooke, said and pay tribute to the Royal Commission on behalf of the Government. I am told by those who have analysed the Report that there are at least 144 recommendations. Perhaps it was rather clever not to tabulate them, because it forced us to read the Report much more carefully in order to discover what the recommendations were. This formidable tally directly affects or concerns nearly as many institutions or organisations. I think that is the important point. Most of those are autonomous bodies, and it is for them to decide how far they are prepared to implement the suggestions in the Report. Thus, Her Majesty's Government are not in a position to deal with the Report as a whole.

One of the main reasons for setting up the Royal Commission was, as some noble Lords have indicated, the serious impending shortage of doctors that became apparent in the early 1960s. Medicine is a university faculty (that explains why I am standing here replying on behalf of the Government) and it is for the University Grants Committee to determine priorities between universities and between faculties in their building programme allocations. In the case of medicine, however, where the course is long and costly and the development of the schools closely linked with that of the hospitals, the Committee have always kept closely in touch with the Health Departments so as to match provision of places as closely as possible to ascertained manpower needs.

As soon as it became apparent, soon after 1960, that the supply of doctors emerging from the schools would fall short of need, the University Grants Committee and the universities took remedial action. It was, however, clear that the position was serious enough to warrant special consideration, and this was a major factor in the decision to set up the Royal Commission. Before the Commission had reported, the Committee and the universities—with some extra funds from the Government—had pushed the annual intake to the schools up from 2,000 in 1960 to 2,550 in the autumn of 1967, and had made plans that enabled 2,700 I to be admitted to the pre-clinical schools in the autumn of 1969. Those plans included provision for a start on a new medical school at the University of Nottingham, following the University Grants Committee's advice, accepted by the Government in 1964. A start on the building of the pre-clinical school has been unavoidably delayed, but the first students will be admitted to temporary accommodation this autumn.

While the University Grants Committee can do much to expand existing medical school facilities in the context of university development as a whole, a completely new school is a very costly undertaking, involving close integration with hospital development. The complete job, pre-clinical and clinical, is likely to cost upwards of £7 million, apart from the cost to the Health Services of the hospital itself. This means that the Government are involved in such a decision, even though the decision as to location is primarily an educational one dependent on the University Grants Committee's advice. Some 15 universities have made known to the University Grants Committee their interest in establishing medical schools, and in general it was felt that the decisions should be left until the Royal Commission had reported. In one case, however, Southampton (and I wish that I were replying to the right reverend Prelate the Bishop of Southampton, which might have made things a little easier), planning of a new hospital had reached a stage in 1967 when a decision had to be taken if it was to provide clinical teaching facilities. The Government made extra capital provision available so that the project could proceed with a view to admitting the first students in 1971. The work is now well advanced.

The Royal Commission examined evidence about the future need for doctors, and concluded that, despite the then existing programme of expansion of medical schools, there would be a continuing and increasingly serious shortage of doctors. As soon as the Report was published, examinations by the central Departments of the manpower recommendations and by the University Grants Committee of the suggestions for expansion of the schools, were put in hand concurrently, and, of course, in consultation. This meant that when the first-phase manpower target—requiring 3,700 entry places in the schools by 1975—had been agreed and announced by my right honourable friend the Secretary of State for the Social Services on April 14, 1969, my right honourable friend the Secretary of State for Education and Science was able at the same time to make known the plans for providing the places. Broadly, this was—apart from the new schools at Nottingham and Southampton—to expand existing schools.

I think that perhaps this would be an appropriate point at which to mention the selection of students for the medical schools, to which several noble Lords have referred. If I may remind your Lordships, the medical schools as university institutions are responsible for their own admissions policy and selection of students. There are, I know, always many more candidates than there are places available, and it is for the medical schools to decide what action to take regarding the suggestions in the remarks about selection in the Report of the Royal Commission. I would endorse completely the remarks of the noble Baroness, Lady Brooke, the noble Lord, Lord Amulree, and, indeed, those of the Royal Commission on this subject. I share the view that the main criterion for admission to a medical school should be the candidate's suitability for it, the ability to profit from it (and we might say that this should be the criterion for any post) and to become a good doctor. I was delighted that my noble friend Lady Summerskill did not miss the opportunity to press home her point. I am only sorry that after twenty years it is still necessary for her to do this.

The figures that I was given of the admissions seem a little more heartening than my noble friend's, though I would at once suggest that they are not good enough. Some of the hospitals have admitted 25 per cent. of women; one has actually admitted 30 per cent. In each case they appeared to be over the recommended number or the number that they mention in their prospectus; and as my noble friend will know, happily some hospitals make no reference at all to a figure. This is not a dramatic move, but at least I hope that my noble friend will agree that it is a move in the right direction. Certainly the comments of the Royal Commission, and the remarks made in the debate to-day, will again reinforce the need for the appointment of students on the ground that they will become good doctors, irrespective of their sex. As my noble friend herself has indicated, there are many excellent examples of splendid women doctors.

The Royal Commission's terms of reference were not only to consider how many doctors were needed and how the medical schools should be expanded; they were to examine the way in which doctors were educated and trained. I would say to the noble Lord, Lord Brock that the Report made a number of recommendations and suggestions about the organisation and content of the undergraduate medical course. I feel it is not necessary to remind the noble Lord that, as in the case of all university courses, this is essentially a matter for the universities themselves, although in medicine they need to ensure that their courses and examinations are acceptable to the General Medical Council for the purposes of registration. I do not propose to touch on this question further in relation to registration, because I felt that the noble Lord, Lord Cohen, did this so splendidly, and it will be quite unnecessary for me to attempt to follow up the very valuable points that he made.

I understand that the General Medical Council last year asked universities for comments on both the Council's own recommendations made to the schools in 1967, and to the Royal Commission's suggestion. The replies show that many of the medical schools are making or considering making the changes suggested by the Council and those mentioned in the Royal Commission's Report. There is some movement towards science degrees within the undergraduate course, towards changing the pre-clinical/clinical balance towards all sorts of progressive assessment. Some schools, not surprisingly, expressed reservations about making changes until the pattern of post-graduate training emerged more clearly. Having regard to the statutory function of the General Medical Council, and the importance of preserving the freedom of the universities to determine the pattern and content of their own courses, it would be inappropriate for the Government to seek to press the universities to action on these recommendations. Perhaps it would not be out of place to say that we are glad to see that the Council's and the Royal Commission's labours in this respect are attracting interest and inspiring promising developments.

Now I turn to postgraduate medical education and training, to which the noble Lords, Lord Cottesloe and Lord Brock, referred, as did several other of your Lordships. Postgraduate medical education and training is a complicated subject, and the three main contributors to it—universities, Royal Colleges and National Health Service—cannot be put into neat and separate compartments. The Royal Commission's proposals for postgraduate medical training have been the subject of considerable discussion within the profession. In fact, if I can believe what I hear, it has been quite animated discussion. This discussion is continuing and for this reason it will not be possible to-day to make a firm fore-cast as to the extent or pace at which the Commission's proposals will be implemented.

The Government have a great deal of sympathy with the views of the Royal Commission, but equally accept that the control of standards of training within the medical profession is a subject on which it is vital to have the full and considered views of the profession itself, and we shall not know finally what those views are until after a special representative meeting of the British Medical Association in May. In this connection the noble Lord, Lord Brock, suggested that the Todd Report proposals would lead to Government control off postgraduate educational Standards. If I may remind your Lordships, the Todd Report recommended that the General Medical Council, in conjunction with the College and universities, should set standards in postgraduate education fulfilling a somewhat similar role to that which it already fulfils in the under-graduate field. I do not think anyone would suggest that the Government control standards in undergraduate education, and I do not see why it is thought that this is what would happen in postgraduate education. We certainly do not wish to see education subordinated to the needs of the National Health Service; nor indeed did the Todd Report.

The noble Baroness, Lady Brooke, asked about the Government's decision on the division of finance for postgraduate education between education authorities and the National Health Service. The Secretary of State for Social Services announced last July that the Government accepted the Royal Commission's view that the National Health Service should pay for professional postgraduate training for National Health doctors, and the universities for academic training. This is broadly what happened in the past. I hope that that will reassure the noble Baroness.

Now I turn to possibly the most controversial area, that of the reorganisation of medical education in London. I again admired the way in which the noble Lord, Lord Evans, was a propagandist for the University Grants Committee, and I should have done exactly the same thing were I in his position. I am always intrigued by the way your Lordships so very ably use every opportunity to press the claims of anything with which you are particularly concerned. This is splendid, and is probably one of the best functions of a debate of this kind.

The London medical schools are schools of the University, and the Royal Commission's proposals for reorganising them in pairs and associating them with multi-faculty colleges was primarily a matter for the University, in consultation with the schools concerned and with the University Grants Committee. The teaching hospitals that provide clinical teaching facilities for the schools are, however, playing an increasingly important part in providing hospital services for their local communities in London, and this was an essential factor when their reorganisation was considered. After full and careful examination of the Royal Commission's suggestions, the University Grants Committee and the University of London issued in August, 1969, a joint statement agreeing to implement four of the proposals for pairing medical schools. These were: The London and St. Bartholomew's, the Royal Free and University College Hospital, the Middlesex and St. Mary's, Guy's and King's Charing Cross and St. George's, which were already being rebuilt at Fulham— I am happy to see that it is still called Fulham, as we suffer from it being called Hammersmith—and Tooting were left unpaired. This left Westminster and St. Thomas's and, although pairing them had much to commend it educationally, their health service district responsibilities made pairing the hospitals undesirable. Possible links short of full pairing were left for further examination. At the same time, as some of your Lordship's have mentioned, the Secretary of State for the Social Services announced that he considered it appropriate to link the first eight hospitals in the same way as the medical schools, but indicated that for service purposes Westminster should co-ordinate with other hospitals North of the river and St. Thomas's with those to the South.

In passing, I would say to the noble Baroness, Lady Brooke—she made some reference to the large hospitals to which people might be brought from a great distance—that I am at the moment visiting a very famous teaching hospital not too far from here, in which all the patients in the ward come from very long distances. I do not see that this diminishes in any way the quality of the attention, and certainly not the kindness, of the nurses. Sometimes we are a little hard on the large units because they in turn reflect very much the quality of the people who work there.

The plans to rebuild the Charing Cross medical school at Fulham and that for St. George's at Tooting, with the new hospitals, were too far advanced to be put aside to take account of the Royal Commission's suggestions. The Report had made it clear that the Commission's suggestions as a whole represented a long-term development plan, but were not impossible to change in detail. The London medical schools are the oldest established medical schools in the country, and they have a proper pride in their own identities and traditions. There is no reason why these traditions should not be maintained and their reputations enhanced under the new arrangements, as and when these come to be implemented. This is a time when the best possible use of resources is of considerable importance. The combined schools, with greater numbers, will offer opportunity for staff with a greater variety of specialities and more and better equipment than they could command as separate smaller institutions.

The Royal Commission recommended also that the postgraduate institutes in London should be linked to and later become part of the merged undergraduate schools and that their associated postgraduate hospitals should be rebuilt near or within the undergraduate teaching hospitals, and a scheme of linking was suggested. The noble Lord, Lord Cottesloe, and I believe the noble Lord, Lord Stamp, both challenged this recommendation; and Lord Cottesloe went on to make a number of suggestions for the future disposition of the individual institutes which the Federation comprises, as well as their associated hospitals. The University of London and the University Grants Committee felt it right when considering the Royal Commission's Report to give priority to settling the pattern of undergraduate schools before turning to that of the postgraduate institutes. But discussions on the needs and future role of the postgraduate institutes are in hand, and I understand that the stage will soon be reached when the outcome can be announced. I feel certain that the views expressed today will be borne in mind, particularly coming from one as knowledgeable as the noble Lord. The future of the associated special postgraduate hospital is of course bound up with the decisions on the future of the postgraduate institutes.

The noble Lord, Lord Cottesloe, referred to the great part which the British Postgraduate Medical Federation and its institutes had played in postgraduate medical education; and I think he felt a little sad that there was not more reference to it in the Report. I would certainly not wish to dissent from that. The postgraduate institutes, most of which are associated with postgraduate teaching hospitals, have been widely recognised as centres of excellence with an international reputation, and I see no reason to doubt that they will continue to play a leading part in the training of teachers of medicine.

The noble Lord, Lord Evans of Hungershall, mentioned the reorganisation of the London medical schools and suggested some sites. I would say to him that the problem of finding appropriate sites has now been taken in hand by London University, with the University Grants Committee, in consultation with the medical schools concerned. Their suggestions were outlined in a general statement by the University Grants Committee and the London University in August, 1969. I understand that negotiations in respect of the sites concerned are now proceeding. The noble Lord, Lord Cottesloe, suggested the pairing of St. Thomas's and Westminster. The pairing has much to recommend it educationally, but the health services have district responsibilities which make the pairing undesirable. Possible links short of full pairing are still being explored, and I hope the noble Lord will get some comfort from that.

The noble Lord, Lord Evans, spoke about the implementation of the Committee, for the London reorganisation—I think it was almost the last item in this section of the Report. That was not accepted because it would have interfered too much with university autonomy. Indeed, the matter is now being handled by the London University's own coordinating committee and consultations are taking place with the University Grants Committee and the Department of Health and Social Security.

The noble Lady, Lady Ruthven of Freeland, referred to the Green Paper and expressed some concern about the implications for the teaching hospitals and the medical schools under the future organisation of the health services in England. I would merely say to the noble Lady that the proposals in the Green Paper are for an alternative form of organisation relating to the health services comprehensively, and not of course just to the hospital specialist services. The Government made it quite clear that the proposals in the Green Paper are still for consultation, but they do, of course, spell out in the Foreword the points on which they must take firm decisions: the Health Service to be reorganised outside local government; the health areas to correspond in general in number and size with the new local government areas (with special arrangements in London), and the division between health and social services to be as shown in the Green Paper.

As regards the teaching hospitals, noble Lords may rest assured that my right honourable friend appreciates and is very well aware of the unique contribution they make in medical education and research. I would remind your Lordships that when the Green Paper proposals were debated last month my noble friend Lady Serota emphasised that special care would be taken to ensure that this contribution would not be lost and that the central Department in approving programmes of capital and revenue expenditure of area health authorities would ensure that proper account would be taken of the needs of the medical and dental teaching services and research. My noble friend also mentioned that this important Working Party had been set up, which includes representatives from the University of London and the University Grants Committee.

Several of your Lordships referred to the question of doctors emigrating overseas. I think the noble Lord, Lord Annan, made a most valuable contribution when he emphasised that this figure has remained fairly constant under not only this Government but the previous Government; and that the reasons for migration are several. But the improvements in postmedical education recommended by Todd would, if implemented, surely discourage this. This is something to which we must put our hand. It is, of course, the policy of the British Government to help the developing countries of the world to build up their own public health and medical services, and in the medical aid programme the Government give the highest priority to the development of training institutions within the developing countries themselves. I noticed that the noble Lord, Lord Amulree, and I think the noble Lord, Lord Stamp, entered a caveat there and thought perhaps that this was not all as desirable as it might be. But that is a deliberate policy of the Government and has been built up over a period of years.

My Lords, I have endeavoured to cover the questions that were put to me directly in relation to Her Majesty's Government, and I think your Lordships will be heartened to know that, bearing in mind the number and the range of the recommendations of the Royal Commission and the many interests involved, which will always be a factor in slowing things up, the progress that has been made since the Report was published represents considerable achievement. The first stage of the expansion of medical schools is under way; broad agreement has been reached on the London undergraduate school reorganisation, and the discussion of the postgraduate proposals is far advanced. The proposals for postgraduate training and career structure may not have moved as fast as was hoped, but consultations are now in progress and they will ensure that, when changes come, they will be firmly based on agreement among all those vitally concerned. My Lords, I think the noble Lord, Lord Todd, can look back with pride on his Commission and their work, and I hope with satisfaction at the way in which it has shaped, and will continue to shape, the development of medical education in this country.

7.47 p.m.

LORD BROCK

My Lords, at this late hour I will be as brief as I can. I think we have had a useful, full and comprehensive debate, and I am personally very grateful to all those who have taken part. There have been so many intelligent, skilled and practical comments that it is difficult to acknowledge them all. The noble Lord, Lord Platt, said that a certain number of items in the Report had been criticised—and this of course is one of the inevitable results of a Report—but he also drew attention to the fact that a very large number had not been criticised; and he quite rightly assumed that therefore we all agree with them in general. I am grateful to him for his admirable survey and summary of the debate.

Quite obviously there are certain general features of agreement. The noble Lord, Lord Stamp, observed that the Report had made medical men everywhere think deeply about the question of medical education and research. This is a very important observation. I was also impressed by the observation of the right reverend Prelate, that he would like to see a shorter version of the Report, so that many more people would be able to understand it and profit from it.

It is necessary to take ladies first. I noted Lord Amulree's comment, that only some 26 per cent. of medical students were women; and the noble Baroness, Lady Summerskill, quoted only 15 to 19 per cent., although I believe that that figure was largely corrected by the noble Baroness, Lady Phillips. I was of course attacked by Lady Summerskill, who said that she thought I ought to blush. I am afraid that I do not blush. I have been through the whole expanse of this question of education, or acceptance, of women medical students, and the medical school to which I belong is only one of the diehards in London that refuse resolutely even to think of taking women.

I remember one day in 1944 when the Dean of the Medical School at Guy's had a telephone call from the Dean of the Medical School for Women in London, who said, "We were hit by a bomb last night. We are in trouble. Our laboratory has been destroyed. Can you help us?" The Dean of the Medical School at Guy's said at once, "How many students would you like us to take?", and she said, "We should like you to take 50"; and he said immediately, "We will take them".

It was a year or two later that the Goodenough Committee said that we should take 10 per cent. of women, and I am interested to see that the percentage has now crept up until it has now reached 25 per cent. In my view, it would have been unreasonable to expect us to accept straightaway 50 per cent. of women medical students. I do not blush at this. I think we are proceeding in a reasoned and intelligent way to the figures that have been suggested by some of the speakers. The noble Lord, Lord Amulree, asked why could we not have double the number. Personally I shall be content to see the higher numbers, because I have noticed that the women medical students have a very high standard indeed; and as house officers and residents the women doctors who have been my residents I count as absolutely first-class. I cannot remember ever having an indifferent one.

The problems of postgraduate education and the postgraduate hospitals have been well presented by the noble Lords, Lord Cottesloe, and Lord Stamp, and also by the noble Lady, Lady Ruthven of Freeland. Their appeals were almost impassioned, and I notice that it has been pointed out by the noble Baroness, Lady Phillips, that the view of the Government will be influenced by the comments that have been made. I was particularly impressed by the comment made by the noble Lord, Lord Stamp, that the provision of postgraduate training for overseas teachers is very important and is one of the best ways of providing help to backward countries overseas.

With regard to the length of training, the noble Lord, Lord Amulree, was not worried about it, but the noble Baroness, Lady Summerskill, finds it unrealistic. I believe that there is a great deal to be said for that view, and I think she commented that it may well deter a great many potential students. Many people are in fact deterred by the ordinary length of five years for medical training, and if the period were to be pushed up another x years it would be even more disturbing. In this connection, I have taken note of the comment made by the noble Lord, Lord Annan, about the importance of assuring postgraduate trainees that they will not have to struggle for many years on very inadequate pay.

The noble Lord, Lord Platt, questioned the accuracy of my statement that eight years of postgraduate training were required for general practice. I had anticipated great disbelief among my listeners in regard to this because I thought myself that it sounded somewhat unlikely, so I went into the matter very carefully, and if your Lordships will forgive me I will just read the lines that I quoted: 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. I was interested in the reference to the time needed for the implementation of these recommendations, because this is one of the things which has struck me as being a barrier to their implementation. The noble Lord, Lord Evans of Hungershall, mentioned a time such as twenty or thirty years. I was interested to hear the noble Lord, Lord Platt, say that he realised that in four or five years' time their recommendations may not be appropriate. This is my difficulty. I cannot see how we can today plan for twenty or thirty years ahead. I know we can provide plans which we hope may go on progressively, but to say that we are going to do something in London in twenty, thirty or forty years' time seems to be unrealistic. The question applied to a great extent to the sites available for the fusion of medical schools. There are great differences in cost and it presents a need for urgent action. I was relieved when the noble Baroness stated that we are in fact intending to take urgent action on the acquisition of sites.

The difficulties of the pairing of medical schools have already been stressed, and I think it is clear from the discussion that careful thought is necessary before we go into the details of them. It is interesting to me, when I read the recommendations of the Commission, to find that they are already largely out of date—at least, not out of date but that they have been very considerably changed. I was most interested that the noble Lord, Lord Segal, suggested that there are alternatives to the question of pairing. That was something I emphasised.

The eloquence of the noble Lord, Lord Cohen of Birkenhead, presented specialist registration to us in a way that needs no further emphasis, but I am particularly interested in this matter because he may remember that some five or six years ago I came to the General Medical Council headquarters with my two brother Presidents in London and presented to them the very thing that he has been putting to your Lordships, because we recognised, as a result of our own plans for postgraduate organised training, that it would become necessary to have a specialist register.

I am relieved to find that Her Majesty's Government do not wish to support a medical education for the service needs of the National Health Service. That gives me great comfort, because in common with many of my friends I have been disturbed at the thought that that might creep up on us unawares. Hence I am glad to hear this definite statement. Finally, I would mention the teaching hospitals and the boards of governors. I was interested in the emphasis placed by the noble Lord, Lord Annan, on the need for more protection for teaching and research in the organisation of Area Health Boards. He emphasised that it is necessary to find a way to earmark money for teaching and research. That is something which I feel we should remember and endeavour to implement. My Lords, I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.