HL Deb 09 December 1974 vol 355 cc500-29

7.23 p.m.

Lord HILL of LUTON rose to move, That this House takes note of the Eighth Report of the Select Committee (Session 1974) on the Doctors and Dentists directive (COM(69)127). The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper. In inviting the House to take note of this Report, I would first remind your Lordships of the relevant provisions of the Treaty of Rome in this respect. Article 3 of the Treaty states that the activities of the Community shall include the abolition as between member States of obstacles to freedom for persons and services. That is the basic provision. The details are developed in Title III of the Treaty. Articles 48 to 51 in Chapter 1 lay down that freedom of movement for workers shall be secured within the Community; Articles 52 to 58 in Chapter 2 provide for the movement of self-employed persons; while a third set of Articles in Chapter 3 deals with persons living in one member country providing services in another.

Oddly enough, the draft directives, as we have seen them hitherto and as we have studied them, relate directly to self-employed persons like general practitioners, but not to employed persons like hospital staffs; but I am told that revised drafts yet to be revealed are to be prepared covering both self-employed and employed persons, using the powers in Chapter 1 referring to workers. No one will deny that hospital staffs, medical and lay, are workers. There have been other changes since the Eighth Report was printed. Indeed there is an unending stream of changes in all the documents emerging from Brussels and it is not easy to keep abreast of them, despite the painstaking help that we have had from the Department of Health and Social Security.

But, my Lords, tonight I will describe briefly and as best I can the present position. First, a general point: these draft directives apparently affecting only doctors and dentists have an application to all professions; for all are covered by the Treaty. The doctors have been taken first, with the dentists and the veterinary surgeons soon to follow; but the provisions for the doctors are to be the model with appropriate modifications for all professions. The Treaty is comprehensive in its coverage. Even the lawyers are not excluded; although I suspect that they will be the last in the queue.

A word now on the present position in this country. As your Lordships know, the General Medical Council admits to the medical register those who complete courses of instruction in teaching establishments that it approves and who satisfy the examination requirements that it lays down. Nationals and non-nationals are treated alike in this matter of full registration. In addition, non-nationals registered in their own countries can be entered here on a temporary register while they hold particular posts, without requalification here. Neither of these procedures is affected by these draft directives. What the directives require is that any national of a member country who is medically registered in that country shall have the automatic right to be entered in the register of every other member country without further test of any kind. This is complete mobility—and with it goes the right to practise in that country as a general practitioner or, with few exceptions, in a hospital or other post, so that there will be inter-changeability of qualifications and freedom of establishment. The Commission will be responsible for the operation of the scheme and they will be advised by an Advisory Committee which will keep under review the quality of training and the developments in training in all member States, reporting any shortcomings to the Commission. It will lay down minimum periods of medical training as well as qualitative standards.

So, my Lords, what will happen to the role of our own General Medical Council? For the home product, its position and powers will be unchanged; although, of course, the home-produced doctor will be free to practise in other member countries. For the temporary registered foreigner, too, the position will be unchanged. For the overseas doctor registered in this country—say, the doctor from India or Australia—the position will be unchanged here in the United Kingdom; although, if he is not a United Kingdom national he will not be free to practise in the other eight countries.

As for the power of General Medical Council, at present, if an approved teaching establishment here or overseas lapses below the approved standard, the General Medical Council can decline to register its graduates until they reach its standards and the establishment meets its criticism. Will it enjoy this power over continental teaching establishments within the Community which lapse below the standards it expects from similar establishments in this country? We have not found it very easy to obtain a clear reply, and this is not in any way the fault of the Department. We were told in evidence that the procedure would be for the GMC to report to Brussels, when the Advisory Committee would investigate and advise the Commission of any necessary action, and that the ultimate right to reject a graduate of a teaching establishment which was thought to have lapsed would remain, though the case could go to the European Court.

The next version we had was that there would remain to the GMC a right to defer the consideration of applications in such circumstances. There is a latest version: it is that the member States which suspect that a qualification is below par would inform the Commission which, to quote the exact words, shall examine the matter as soon as possible and shall confirm, if such is the case, that there is compliance with the minimum standards.

That is the end of the quotation and there is no mention of deferment. It is all very puzzling. However, my own view, for what it is worth, is that for the GMC to retain the absolute right to reject would be inconsistent with the Treaty.

Now a word on the Advisory Committee to the Commission. This is, incidentally, a development due mainly to British argument and British pressure. This body is absolutely crucial to the maintenance of the standards of medical education. The Committee will advise and the Commission will decide. On present form, the Committee will consist of 27 members, three from each member State, one a practising doctor, one a teacher and one a representative of the country's registering body. There is still some discussion about this. Our doctors, who have been fully consulted throughout, want a larger representation of teachers—they want a post-graduate teacher as well as an undergraduate teacher to belong to the Committee, and they want national medical associations to provide the practising doctors; but these are matters which are still in the melting pot. Unfortunately, however, we have no information about the powers and duties of the Advisory Committee, though it is on the effectiveness of this body that the quality of medical care in the Community will depend. It seems most unlikely that the Advisory Committee will have the power to inspect the teaching establishments of the Community. It may be thought—and I venture to say this, though unwilling to depart from the path of neutrality—that, bearing in mind the heavy public interest, we should know in detail the powers and procedures of the Advisory Committee before we yield up our own procedures.

My Lords, there is another problem which is not unimportant to medical care. Should there be a language requirement for practitioners claiming admission to our register from another member country? To take an extreme case, should a doctor not knowing a word of English be permitted to set up in general practice in this country and to treat patients? Similarly, should a British national not knowing a word of German be permitted the automatic right to treat patients in Germany? The answer to this question is simple and direct: the Treaty of Rome does not permit a language requirement. To insist, say, on an incoming Italian doctor, who is entitled to be entered automatically on our register, learning some English first would be discrimination and it is forbidden by the Treaty. There is of course nothing to prevent a hospital, in appointing a foreign doctor, taking into account in making that appointment the candidate's knowledge of English; but if such an incoming practitioner decided to set up in a practice in an under-doctored area, nothing could prevent it, even though he knew no English.

What has been done in the latest version of the directives is to allow member States to establish information centres from which migrating doctors may obtain information on health and social laws and on codes of professional ethics. "May obtain information" on these subjects: there is no mention of language. I suppose, in a way, that this is not surprising. The primary purpose of this plan of freedom of establishment is not of itself to raise the standard of medical practice; it is to apply the principle of the Treaty of Rome that within the Community there should be freedom of movement and interchangeability of qualifications as part of the Community ideal. Of course the Advisory Committee will seek to maintain the highest possible standards, though one might be forgiven for fearing that a Commission in Brussels with no powers of inspection will not easily be wholly effective in this matter of universities and other teaching establishments from Sicily to Copenhagen and from London to Frankfurt. However, it must be frankly admitted that we ourselves do not at the present time apply a language requirement to foreigners seeking full registration after qualification in this country.

My Lords, certain other questions arise in one's mind. Will all this lead to an exodus from this country of doctors whom we sorely need? After all, standards of remuneration are much higher in France, Germany, Holland, Belgium and Luxembourg than they are in this country. Will British doctors leave the country in search of sun or cash, or both? I do not know; nobody knows. While it is anybody's guess, the movement to other member States could be considerable.

Finally, my Lords, may I remove two doubts which may have arisen in people's minds. The first relates to the power to discipline doctors: all the doctors on the register, migrants and others, will remain unaffected. Secondly, as we all know, there are in this country very large numbers of doctors from overseas who are fully or temporarily registered. Of course, they are absolutely essential to our hospital service and will in no way be affected. If they are not nationals of this country, they will not be able to claim registration in other countries of the Community; but, setting that aside, fortunately for us, their position will remain unchanged. Incidentally, they often come from countries which need them greatly but, because of the greater attractions of this country, they come here. However, that is another subject.

To sum up, I would emphasise to the House that we are looking now at the general plan for the freedom of establishment of all professions. We are not considering a problem which purely concerns doctors. We are in effect considering the problem of all professions and of the gains and losses which flow from the application of a fundamental principle, the freedom of establishment contained in the Treaty of Rome. My Lords, I beg to move.

Moved, That this House takes note of the Eighth Report of the Select Committee (Session 1974) on the Doctors and Dentists directive (COM(69)127).—(Lord Hill of Litton.)

7.41 p.m.

Lord ABERDARE

My Lords, this is indeed a very important Report from the sub-committee of the Select Committee and we owe a great debt of gratitude to the noble Lord, Lord Hill of Luton, for allowing us to discuss it this evening and for having set us on our way with such a carefully considered and competent speech, if I may humbly say so. I do not feel that there is very much more I can add to what he has already said. We are indeed fortunate in this House in having people who are prepared to give up their time to serve on these sub-committees. From reading the evidence, one is made aware that this sub-committee contains a most active and intelligent group of people who are watching our interests in this respect.

I certainly found the Report we are considering tonight a great deal more illuminating than the draft directive it was commenting upon, which I found completely out of date and hardly worth reading. Clearly it was drawn up long before this country became a member of the European Economic Community. It refers only to the original six members. It is drafted in their own terminology and, in the words of my noble friend Lord Lauderdale during the last debate, it is like looking up a train in last year's Bradshaw ". This Report certainly brings us up-to- date, and what the noble Lord, Lord Hill of Luton, has said brings us even more up-to-date on what has happened since the Committee itself reported.

I would agree with him straight away on the importance of the proper solution of the problems of the medical profession, because it will lead the way into the kind of arrangements to be made for other professions within the European Economic Community. This was made quite clear in the debate we last had in this House on 10th April 1973, when we considered the European Economic Community and the professions. We had a number of distinguished speeches on that occasion—one of them from the noble Lord, Lord Cohen of Birkenhead—on the problems of the medical profession. The noble Lord made it quite clear that this present directive is totally un-suited to our own medical profession, especially in view of the fact that there are only quantitative requirements for qualification and for specialist status, and that the requirements pay no heed to the quality of the training.

Since that directive was issued a great deal of work has been done by a great many people who are mentioned in the Report and to whom we should express our gratitude: the Standing Committee of Doctors in the EEC, the EEC Committee of the BMA and officials of the Department of Health and Social Security, who have all co-operated to ensure that the Economic Working Group comes to conclusions which take into account the problems of the British medical profession. Personally I am very happy to hear that the idea of an Advisory Committee on medical education has won general acceptance. This seems to me to be the right way forward for the medical profession and, in due course, for other professions.

I listened with great interest to what the noble Lord, Lord Hill of Luton, told us about the problems which will attend this Committee and the kind of decisions which it will have to take. I can only express the hope that sufficiently eminent people will be appointed to the Committee to give it the status it will undoubtedly require if it is to do the kind of job envisaged for it. I notice that there are still a number of details to be worked out about its operation, and I should like to ask where these details are being worked out. Is it something with which the Economic Working Group are concerned, presumably with advice from the Standing Committee of Doctors? Can the noble Lord give us any idea as to when these new arrangements are likely to be finalised in a directive that is acceptable to all the members of the EEC?

The noble Lord, Lord Hill, also drew attention—very rightly and with great clarity—to the question of the language barrier, which certainly seems to be a very serious drawback. I am still not quite clear how it can happen, because it is my recollection that doctors—that is, doctors who work for the National Health Service rather than those in private practice—work to contract. If they are in the hospital service they have a contract, and if they are GPs they are individual contractors to the Health Service. As things stand at present I should have thought that all doctors were in contract to an Area Health Authority. If that is so, I can quite see that it is right that an Area Health Authority should not in any way discriminate against a doctor, regardless of whether he comes from this country or from a member State of the EEC, provided he has equal qualifications. But I would have thought that language was one of those qualifications and I would not have thought that it was really conceivable for an Area Health Authority to give a contract to a doctor, whether in the hospital service or as a general practitioner, if he spoke no English. I may have this slightly wrong, I suppose, in the case of a general practitioner in an area which is "under-doctored"; but does he still not need a contract and would it not be within the powers of an Area Health Authority not to give a contract to a person who might be registered, but, in their view, would not be suitable because he was unable to speak sufficiently good English?

I do not think I can add anything further to what the noble Lord, Lord Hill of Luton, has said. I should like to know something about the time-scale, if possible; that is to say, when it is hoped to finalise these arrangements. I noticed that in the course of the evidence given to the sub-committee mention was made on page 3, paragraph 5 to "draft directives as now amended". I suppose, therefore, that documents exist which are not as out-of-date as this COM (69)127, because these other documents are amended and up-to-date. I think that it is rather a pity that we cannot see these draft directives "as now amended", and perhaps it is even more of a pity that it is unlikely the subcommittee saw them either; at least it does not say that they saw them in the Report. I wonder whether these draft directives are available in their amended form. If so, it would enable us to see exactly what progress was being made.

7.50 p.m.

Baroness SUMMERSKILL

My Lords, I am sorry that the noble Lord, Lord Amulree, has had to leave, because he always makes a very informed contribution to debates of this kind. I have studied these directives, and on the face of them I think any doctor would agree that they appear to be innocuous. But I was very impressed by the contribution of the noble Lord, Lord Hill. When we give further thought to it, we can really only surmise how they will operate.

In the field of language, I am quite shocked to think that a doctor can come over here without any knowledge of our language, customs or ways, and establish himself in a consulting room and invite patients—simple, ignorant men and women who normally have great faith in their doctors—to come in to see him. I hope that this will be altered by the time this really becomes a fait accompli. I am raising a point which I am sure none of the male Members of this House has thought about. It is only because I am a woman who has been concerned very much with the approach to women in medicine over the years that this has occurred to me. I am going to talk about what might be a by-product if these directives are followed and this scheme comes into operation.

I was surprised to hear the noble Lord, Lord Hill, say—and I am interested to think that this is the way in which his thoughts have been running—that he thinks there will be an efflux of doctors from this country to the Continent. He may be wrong; I may be wrong, but I think the opposite. The fact is that Britain has fewer doctors per thousand of the population than any other European country. I think his answer to that would be that the European doctor is paid more and therefore the doctors from Britain will be tempted to go to Europe. We must recognise that the doctor is often a dedicated man and however much he may be paid in France—if he is unemployed it would be because so many doctors were working there—he would find it difficult to conduct his profession as he would like to conduct it. Of course he would be very attracted to the thought of going to a country where he found ample room. What I am going to say anticipates that more doctors will come to this country than will leave it. If we are to judge from the present emigration pattern, they will all be men.

The noble Lord, Lord Hill, is an absolute authority on these things, and I believe we lose about 400 qualified men every year from this country. Women doctors seldom emigrate, because a woman is a home maker essentially; she is not a roamer. More than that, we have to remember that most women doctors get married these days and they marry business men or professional men. Because their husbands are working in this country for the most part, they tend to remain in this country. Therefore, I think we can anticipate a further influx of male doctors from abroad.

I have said this before. It is ironic that since that fatal mistake was made of reducing the number of medical students by 10 per cent., in the past years we have had a potential source of supply of doctors in our talented girls, all of whom can speak perfect English, yet this has been deliberately by-passed in favour of doctors who cannot speak English and know nothing of our customs and ways. One has only to go into a casualty department to see the casualty officer, without adequate English. He probably thinks that he has basic English, but he is trying to struggle through the work with unfortunate people who have had to go there because of some medical emergency.

The governors of our medical schools have deliberately discriminated against women although the country has been desperately short of doctors. When it became difficult to ignore the high academic standard of these young women, the medical schools resorted to the trick of demanding a higher standard in the "A" levels for girls than for boys. I hope nobody here will question this. I was on the Select Committee on Sex Discrimination and we discovered this when a professor from a medical school informed some members of the Select Committee what was happening: making the standard higher for girls to get into medical schools than for boys was a way of keeping women out of medical schools. However, I am glad to say that after years of trying to defend this discrimination against women, the medical schools have been forced to adopt a more liberal attitude and the percentage of women in them, particularly in the Provinces, is much higher than it was; but there is no question of any equality.

As I see it—and we can only surmise—we shall have a large number of men doctors who have the right to establish themselves here permanently. We shall see the reactionaries in our medical schools being given the excuse they are longing for to limit the number of medical students, and undoubtedly the axe will fall on women, if the past is any guide to behaviour. My argument stems from what has happened in the last twenty to thirty years. If we are to introduce some measure of justice at this stage, I believe that before these directives are put into operation the medical schools should be told that they should aim at least to provide educational facilities for equal numbers of both sexes.

The curious part about these directives—the noble Lord, Lord Hill, will correct me if I am wrong—is that I cannot see any limit to the numbers of doctors who may come in here; there is no limit. This is the most extraordinary thing. According to this, we may be swamped, and nobody has suggested in these directives that there may be some way of limiting the numbers, which makes my case even stronger. Inevitably, if there are large numbers of doctors coming in here and establishing themselves, it will be necessary for medical schools to say, "Once more we must limit the number of our medical students, we do not want them. Europe is providing fully qualified doctors." No doubt there will be some people who will say, "This is very nice. We shall be able to save quite a lot of money because Europe is paying for the education of these doctors and we in Britain are enjoying the luxury of having them fully qualified and coming to us without having to provide money to educate them."

These are matters which should be considered very carefully before this scheme becomes operative. I understand that the Government have been advised by the British Medical Association (EEC Committee), the General Medical Council, the Committee of Vice-Chancellors and Principals and the Council for Post-Graduate Medical Education. As I have considered the position of women in this scheme, I should like to know—and I do not ask the noble Lord, Lord Wells-Pestell, to give me the information today; he might give it to me in a letter—what proportion of these advisers are women.

I understand that prejudice and discrimination against women medical students exists not only in this country but is common on this side of the Iron Curtain. I have to confess that when I crossed the Iron Curtain into Russia and China I found such a change in approach that it was scarcely believable! Women medical students in Russia and China are welcomed, educated and given jobs of great responsibility. I was glad to see that the Secretary of State for the Social Services, in expressing her gratitude to overseas doctors for the service which they have given, said that traditionally they came to the United Kingdom for further experience and training. She expected that to continue, and added: But it remained our policy to reduce excessive reliance on help from that source ". What I am saying to the House tonight is that we in this country have a great source of supply of excellent doctors if we like to use it. They can be found in every town in Great Britain where bright girls are denied an opportunity of a career in medicine because of the prejudice and discrimination exercised by those in charge of medical education.

Now we are going to take part in a change in the professional world not only of medicine but, as the noble Lord, Lord Hill of Luton, said, in other professions. I think it is right at this stage to anticipate what the repercussions may be in every field of medicine for both men and women. The new influx of male doctors will offer an excellent excuse for the old policy I have described to be resuscitated unless special provisions are made and the greatest vigilance exercised at this stage.

8.2 p.m.

Lord ANNAN

My Lords, I rise to speak in this debate only because the Vice-Chancellors' Committee have asked me to express on their behalf the general agreement with the directives as they now stand, and to congratulate the Government and the previous Government for having carried out some remarkable negotiations in Brussels and saving us from a very rigid, bureaucratic approach by which the number of hours of instruction was to be the sole criterion for determining whether a doctor was qualified or not. In this debate I know that a great many people took part and we have achieved a very considerable success by compelling the Community to accept this notion of an Advisory Committee.

First of all, the representations that we made ensure that adequate standards of practical training should be achieved. The second achievement was that the Advisory Committee should be set up. I understand that its composition was rather different from the view of the noble Lord, Lord Hill of Luton; that is to say, there should be a representative of Government, a representative of the profession concerned—in this case medicine—and a representative of the teaching profession, in this sense the universities.

Lord HILL of LUTON

My Lords, the truth is midway between our positions. It was of the Government; it is now registering bodies; but many of those registering bodies in some countries are Governments.

Lord ANNAN

I am grateful to the noble Lord. My Lords, the Standing Committee of Doctors of the EEC. and that includes (does it not?) a representative of the BMA, has expressed some opposition to two features of this Advisory Committee. They have expressed some doubt as to whether the way of nominating these representatives is right. I think the medical profession, perfectly understandably from their point of view, wanted three separate representatives, as it were, to be nominated without question and that no Government could possibly intervene or refuse to accept a nomination, for instance, of the medical profession.

I am not sure that that has been achieved. As I understand it, the position is that if a Government do not want, for example, the particular representative of the teaching profession who has been nominated, they can say that they refuse to accept him. On the other hand, as I understand it, the Government concerned certainly could not nominate someone of their own wish. They would have to ask the institution concerned, either the medical profession or the universities, to nominate somebody afresh. Here again, although there is this slight, small "niggle", we have achieved a reasonable compromise. I do not think the Government could simply throw out nominees and put their own nominees in. There was, I understand, a second objection by the medical profession. That was regarding the undergraduate and postgraduate parts of the profession being represented by the same person. Unless one increases the numbers so largely in the Advisory Committee it would be difficult to achieve separate representation for each of these parts of the medical profession.

We in the universities well recognise that the BMA is in a difficulty. They supported nobly the British notion of the Advisory Committee and it was something which came from this country. They worked with the Committee of Vice-Chancellors to achieve this particular compromise, which is crucial to the whole professional qualification problem in the EEC. But, of course, as always happens, the BMA is also a member of the Committee of Doctors of the EEC. Indeed, I understand that they provide both the President and Secretary, and here they naturally get opposition and want to try to get agreement among the medical profession of the EEC. In this case they might find themselves up against some of their European colleagues.

I am deeply suspicious in this debate of those countries which have a much more authoritarian administration than in this country—namely, France, Belgium and, indeed, in one sense, Germany. I believe they are intent, if they possibly can, to wreck the idea of the Advisory Committee. The French in particular are deeply opposed to this idea. It goes against the whole tradition of French Government which is a very highly centralised form of government, and the bureaucracy is the body which really lays down the law. Advisory Committees of this kind are absolutely unknown in France—it is no business of the public to provide an Advisory Committee at all! I see the medical profession is in this difficulty; I hope they will stand firm and stand by the notion of the Advisory Committee. I hope they will not go contrary to what I understand is the policy of the Government at the moment.

If I may now move from that point to the speech of the noble Baroness, I am surprised at the notion that this country is to be flooded with male doctors from the continent of Europe and that this will therefore give an opportunity to the reactionary medical schools in our country to cut down on the number of women who are admitted to them and who will then become doctors. I have always thought that the noble Baroness has a very good point in this regard. Indeed, in previous debates on this matter I have agreed with her that in the past there was discrimination against women in our medical schools. As I once said to the noble Baroness, I thought that some time-in the long distant past the medical schools' intake was governed very strongly, in London at any rate, by the need to provide the best rugger side possible! But, having said that, these days are past, and when the noble Baroness asks what guarantee there is against such discrimination coming back, there is a very good guarantee; that is, that the Committee of Vice-Chancellors and Principals laid down as a principle, which they published—I think it was in the days when Mrs. Thatcher was the Secretary of State for Education and Science—that there could be no quotas and no kind of discrimination against women in medical schools. I might add that the quotas which we had in the 1950s and 1960s had been imposed in medical schools in order to compel them to produce a number of women doctors. So the notion of a quota was not in the first sense discriminatory; it was a way of stopping discrimination.

Baroness SUMMERSKILL

My Lords, I know that the noble Lord has always been a champion of women, but if there is prejudice and discrimination, people who are governed by these horrible considerations think out ways to outwit the quota. I have just told your Lordships about it. After the quota was established, the professor told me, they thought out an excellent way of saying: "We are not having enough women good enough to accept". So they were demanding higher "A" ratings from girls than boys. I am telling this to the noble Lord, who has been wonderful in the past, to show to what depths people stoop in order to exclude women.

Lord ANNAN

My Lords, the noble Baroness has quoted a case; I could quote a great many cases against that being the common practice in medical schools today. I believe that this is a matter of the past. It is past history, but nobody would wish to minimise the degree to which the campaign which the noble Baroness has for years conducted on this matter has been brought, I believe, to a successful conclusion in which we do not any longer, and we will no longer, tolerate that kind of discrimination against women doctors.

I do not want to make a speech about the composition of our medical schools. I wondered whether this picture—of the influx of male doctors producing a complete change in not merely the structure of the profession in the country but also the intake in the medical schools—was not just a trifle far fetched. But I understand the noble Baroness's passion on this subject. The only request I am making is that the Government should confirm that the position that we have reached in the EEC debates on this matter is as satisfactory as could be expected, in view of the understandable compromises and negotiations which must be conducted between member States.

8.14 p.m.

The Earl of HALSBURY

My Lords, my name is not on the list of speakers but may I make a brief intervention on this language question. The danger is not from the general practitioner who speaks not a word of English. If he spoke not a word of English he would not have a patient. The danger is that man who speaks English not quite so well as he thinks he does. One can have an Honours degree in a foreign language but still not speak it very well in the colloquial sense. Even a doctor trained in the Home Counties would have to learn many new dialect words, such as "nesh" and "mardy", if he wanted to practise in the industrial North; otherwise he could not communicate with patients. This is a danger against which no system of licensing, or insisting on educational qualifications, will ever safeguard us. This is the real danger and we ought to keep our eyes on it—the failure to communicate because knowledge of the language is not quite good enough—rather than on this imaginary figure, the man who speaks not a word of English and yet has the temerity to come here and to try to practise.

8.15 p.m.

Lord PLATT

My Lords, my noble friend Lord Halsbury has spoken for one minute. I hope that I shall not take much more time than he did. But just before we wind up, as the noble Lord, Lord Amulree, has had to withdraw, I thought I might just thank the noble Lord, Lord Hill of Luton, first of all, for so clearly expounding the present position, which I am sure many of us were almost as ignorant about as I myself was, and secondly for his chairmanship of the sub-committee. I agree with my noble friend Lord Halsbury about this language difficulty. After all, one need not go to see a doctor if he cannot speak one's language at all. If he speaks nothing but Italian one need not go to see him.

Baroness SUMMERSKILL

My Lords, may I ask the noble Lord what one does if he is the only doctor in the neighbourhood?

Lord PLATT

My Lords, that is a matter for the Health Service. I do not think that there will be a large exodus of doctors from this country, owing to the notorious inability of English people to speak any language except their own. I rise only to emphasise this question which the noble Lord, Lord Aberdare, raised. We are well protected from the posible dangers of this situation, which I do not think are tremendously great, by having the Health Service. As the noble Lord, Lord Hill of Luton, has clearly said, one need not appoint a Danish or an Italian person, who cannot speak any English, to be a house surgeon or a registrar in a hospital; one has complete control and just does not appoint them.

I am not quite sure of the situation in general practice. It seems to me that the noble Lord, Lord Aberdare, was not quite sure, either. I suppose a person has a right to put up a plate if he is qualified, but does he then get any of the privileges of the Health Service? Can he, for instance, prescribe drugs which his patients will obtain free on the Health Service? If he wishes for those privileges, does he not have to have some kind of a contract with what used to be an executive committee and is now I think a family doctor committee? Is there not some kind of choice on the part of the committee as to whether or not they will accept this doctor? I ask these questions simply because I want the answers, which I do not already know.

8.18 p.m.

Lord WELLS-PESTELL

My Lords, there was a debate in your Lordships' House on 10th April 1973 when the noble Lord, Lord Aberdare, explained fully the processes by which the Community worked to produce the directives which give effect to Article 57 of the Treaty of Rome, which requires provision to be made to facilitate the freedom of movement of professionally qualified persons. The noble Lord, Lord Hill of Luton, has dealt fully with this matter, and if he does not think I am being impertinent I would say how much I, and I am sure everyone in this House, appreciated what was a most balanced and informative speech. I have not been asked to say that; nor have I been asked to say what I am proposing to say now, which is that I think we owe a great debt of gratitude to the officials at the Department of Health and Social Security who over the months have burned the candle at both ends in order to get across to the Advisory Committee and the people with whom they have been negotiating our own particular views—and with very great success. Our discussions over the past months have been particularly designed to ensure the maintenance of a very high professional standard of medicine.

Also in the debate which took place last April a good deal of attention was focused on the arrangements whereby Her Majesty's Government consult with the various professional interests at home. I propose now simply to draw attention to some of the most important issues and to set the scene by describing the present state of progress which has been reached in those proposals. The medical and dental directives have been under discussion in the Council of Ministers for a number of years, long before the accession of the United Kingdom to the Community. During that time it was decided that all doctors, whether employed or self-employed, should come within the scope of the directives, as is permitted by Articles 45, 49 and 57 of the Treaty to which the noble Lord, Lord Hill, made detailed reference.

Since then the United Kingdom has participated fully in the discussions on the medical directives and has brought forward—and I want to emphasise this, my Lords—some constructive proposals, all of which have been formulated only after prolonged consultation with the bodies representing the professions at home. So there has been very close liaison between the Department and the various medical associations in this country. As yet there have been no discussions on the proposals relating to the dental profession, but obviously—and the noble Lord, Lord Hill, drew attention to this point—the pattern developing for the medical profession had implications for the dentists and, indeed, for practically every other profession for which similar proposals exist or will be prepared. The Government have recognised throughout the interests of other professions in the doctors' directives which were chosen by the European Commission to pioneer the way.

This opportunity should be taken to draw the attention of your Lordships to the work undertaken by the European Standing Committee of Doctors in connection with medical directives, and I am sure your Lordships will be interested to know that this year Mr. Lewin, who is Chairman of the Council of the British Medical Association, was appointed Chairman of the Committee, and that Doctor Derek Stevenson became the Secretary General. The Committee has played a large part in convincing our European partners of the importance of defining the minimum standards of training by reference to the quality of that training, rather than simply to its duration. This is really the important point—the quality, not so much the duration.

My Lords, the House should also be aware that consultations have taken place on the issues arising on the medical directives with the British Medical Association's EEC Committee, the General Medical Council, the Committee of Vice Chancellors and Principals and the Council for Post-graduate Medical Education. My noble friend Baroness Summerskill raised the question of the number of women members. I was not sure whether the noble Baroness was referring to the number of women members on these various bodies, or to the women members of the Committee which will consist of three experts and three alternates from each member State. In that first case, they would come from the professions, the university world and the General Medical Council. The provision for alternates will allow for the inclusion of members with expert knowledge of postgraduate education. If my noble friend was referring to the three members and the three alternates, I have to inform her that at the moment no nominations have yet been made and I can only draw the Government's attention to what she has said tonight. However, the noble Baroness can rest assured that, so far as that Committee is concerned, no nominations have yet been made. If my noble friend is referring to the other bodies with which she is more familiar than I am, she will know that, out of a membership of 47, the General Medical Council has, I think, two women. The Council for Post graduate Education is made up of 30, and I understand that there are two women. The Vice-Chancellors' Medical Commit tee—the noble Baroness may like to talk to her noble friend Lord Annan about this—is made up of 8, and I believe that there is one woman on that Commit teex2014;—

Baroness SUMMERSKILL

The statutory woman!

Lord WELLS-PESTELL

—and a very delightful person, sometimes, my Lords. The British Medical Association's EEC Committee is made up of 10 members, two of whom—20 per cent.—are women. In other words, 8 per cent. of the total of these bodies are women.

Baroness SUMMERSKILL

My Lords, I regret to see that the noble Lord, Lord Annan, has just gone.

Lord WELLS-PESTELL

No, he is here.

Baroness SUMMERSKILL

My Lords, may I remind the House that the noble Lord, Lord Annan, said that nothing has changed.

Lord WELLS-PESTELL

My Lords, if nothing has changed there has been an improvement over the years.

Lord ANNAN

My Lords, I was talking about medical schools. The noble Baroness should not joke about that.

Baroness SUMMERSKILL

My Lords, I never joke about women.

Lord WELLS-PESTELL

My Lords, the new ideas which have been put into the discussion by various United Kingdom bodies seem to have stimulated an examination of the proposals that has resulted in improved solutions. Most of the important issues have now been settled at Council Working Group level, and I have been asked—I think by the noble Lord, Lord Hill, and also by the noble Lord, Lord Aberdare—why the latest texts of the medical directives have not been laid before your Lordships' House. My understanding of the situation—I want to be perfectly frank about this—is that some of the matters have yet to be agreed and are at present under discussion. Until they have been agreed it will be a little unwise to make known the substance of them. But I understand it is hoped that there will be agreement in the near future, and they should be available within the next six months. In fact, the medical directives will probably come into effect during 1976, and in order to give effect to the directives in this country amendments to our own legislation will be necessary.

Therefore, through a long process of discussion and negotiation the United Kingdom delegation eventually persuaded their partners in the Working Group to have criteria for medical training set down in the directives. These criteria will be sufficiently flexible to take account of future developments in medical training, while safeguarding the final standard which is achieved. They include adequate scientific and clinical knowledge and supervisory experience in hospital. It has always been urged by the United Kingdom that it was not sufficient to set down the criteria; it was necessary also to have the means of ensuring that they were fulfilled in practice. The machinery which was proposed for this was an expert Advisory Committee. Such a committee could ensure that the training courses in the member States maintained a high and comparable standard that would lead to qualifications which were recognised by all member States. This has now been accepted by the Community.

My Lords, in the case of the medical directives a draft Council decision makes provision for an Advisory Committee on Medical Education. The committee will consist of three experts and three alternates. Perhaps I need not pursue this matter, because I have dealt with it already. Provision is made in the directives for doctors who are established in one country to offer their services in another without changing their place of residence. This situation occurs, for example, in frontier regions where doctors regularly cross the border in the course of their normal work. It also can arise when specialists are called in from another country to assist in the treatment of patients, when their knowledge and skills happen to be required at a certain time. It has seemed desirable to Her Majesty's Government to make provision for this kind of activity, provided that there were adequate safeguards. It has now been agreed that the activities of doctors providing services will be subject to control, in that such doctors will be subject to the normal disciplinary rules governing the practice of the profession in the country that they visit.

It had been hoped that it would be possible to require doctors seeking to establish themselves in another country to spend a period acquiring knowledge of the practices of that country, and demonstrating a command of the language. In this matter I have to be perfectly frank, and admit that it is difficult to provide such a period of adaptation without erecting a further barrier, to the removal of which the directives are dedicated.

So far as language proficiency is concerned, the regulations on the freedom of movement of workers within the Community mean that any doctor from a member State seeking employment in a post in our National Health Service hospitals or community health services could, if the employing authority wished, be subject to an assessment of language proficiency. It is now proposed that the directives should include provisions for doctors other than these to be given advice on the acquiring of an adequate knowledge of the language of the country in which they seek to establish themselves. The directives will also provide for centres of information in each State, which doctors may attend to learn about medical practice in that State.

In total, these arrangements seem to be satisfactory and, after all, it is improbable that doctors without an adequate knowledge of English would wish to try to establish themselves here, or would attract patients if they did. But I think we must bear in mind that in this country, as in every other country, there are pockets of other nationals. For instance, I can think of one place in this country where there is a very high concentration of Italian workers, and perhaps it would be reasonable for one, two or more Italian doctors to come over and minister to their own nationals. We do not envisage any serious problem, because we feel that those coming over will come in the main for that kind of purpose. Doctors who do establish themselves in another country will face many difficulties initially, and it is to be expected that they will readily avail themselves of any facilities which will enable them to settle down. It should be borne in mind that some doctors may move in order to make specific contributions, as I have just said.

The House will be well aware that in the United Kingdom we have at present no statutory system for registering medical specialists. Recognition is accorded to those obtaining National Health Service consultant status. This presents a difficulty, for our European partners need to have a means of recognising specialist qualifications similar to their own. The whole question of specialist registration, as many of your Lordships know, is currently being reviewed by the Merrison Committee. Meanwhile, it would be possible for a competent authority in the United Kingdom to issue a certificate on completion of specialist training which would be accepted by the competent authorities in our partner countries.

The original proposals set a firm face against the possibility of part-time postgraduate training. This is understandable, because of concern about the possible abuse of such a system. In the United Kingdom, however, part-time training under proper safeguards has been an established part of our system of medical education. It is particularly important in the case of married women doctors with children, who would otherwise be unable to undertake such training. This is significant in the United Kingdom, because of our large and growing population of women medical students and doctors. Not only would it be a loss to them personally; it would deprive society of a good deal of medical skill. Happily, an acceptable solution to this problem has been found which will permit member States to continue to allow approved part-time training so long as the standard is in no way impaired. Within four years of the adoption of these directives, the question will be reviewed to see whether any changes are needed in the arrangements.

The medical directives will give freedom of movement to doctors who are nationals of a member State and who have qualifications acquired in a member State. As the noble Lord, Lord Hill of Luton, pointed out, doctors who are nationals of a third country or who hold qualifications acquired in third countries, do not come within the scope of the directives. This means that the directives will not affect in any way our existing arrangements for registering and employing in this country doctors from such other countries as Australia and Canada and India.

The Eighth Report of the Select Committee draws attention to the exercise of official authority and employment in the public service. While the great majority of National Health Service posts are already open without restriction of nationality, in certain member countries the doctors in the public hospitals have the status of being civil servants. This effectively restricts these posts to nationals of the member States. Right of access to those posts within three years of the adoption of the directives by doctors of other member States has now been assured by draft Council Statement.

We now come to a point to which the Select Committee attaches great importance. The mutual recognition of qualifications is based on mutual trust and the assumption that the European doctor carries out broadly comparable functions and is trained to an approximately equivalent standard in each member State. In general, therefore, a doctor who is suitably qualified and allowed to practice in any one State will be accepted and permitted to exercise his profession in any other State. The competent authority of a receiving State—in the United Kingdom it is the General Medical Counci—will satisfy itself that the doctor genuinely holds the qualifications he claims, and will then admit him to the register. It is not envisaged that there will normally be any reason to interrupt the usual process. It is, however, conceivable that at some time a situation might arise when the General Medical Council, or the competent authority in another country, has justifiable reason to doubt whether graduates of a particular teaching establishment have been trained to the standard required by the directives. This is a matter which can be dealt with.

When this matter was raised by the Lords' Select Committee, departmental witnesses said that, in the last resort, if the General Medical Council has reason to believe that the qualifications given in a particular teaching establishment fail to reach the standards set by this country, it will have the same right to register or not to register as is enjoyed at the present time. The Committee was told that this was unlikely to happen in practice, and it should be stressed that we do not anticipate this event arising. If the situation did arise it would be a a quite exceptional event, but the Select Committee were right to consider the possibility. Their overriding concern, like that of the Government, is to safeguard public health.

Subsequently this specific point was further discussed in the Council's Working Group. However, the opinion expressed in Brussels on the legal position arising under the draft directives was not completely in accord with what the Departmental witnesses had believed the position should be and would be. As a result of the Select Commitee's examination and our further pursuit of this matter in Brussels, the Community has now recognised that there was a gap in the provisions. They have agreed to a Council Statement, the terms of which have almost been finalised, which aims to provide the sort of safeguard the Government consider to be sufficient, and I hope this will be available in the not too distant future.

Should the unlikely event occur the sequence of events might be as follows. First, the General Medical Council would probably contact the competent authority in the member State to see whether the difficulty could be resolved; secondly, if this did not result in a satisfactory solution, the General Medical Council would warn Her Majesty's Government and the Commission would be informed; thirdly, the Commission would no doubt avail themselves of the services of the Advisory Committee in considering the problem, and meanwhile the General Medical Council would defer registration, pending confirmation by the Commission that the criteria for training had been complied with.

It will be seen from the foregoing that a great deal of thought and effort has gone into ensuring that the medical directives which facilitate the freedom of movement for doctors safeguard the public health and maintain our standards of medicine. The close co-operation and efforts of the profession have been of great value in helping us to meet these objectives. What will be the result of adopting these directives, your Lordships may well ask. In the immediate future nothing very dramatic is likely to result. A few doctors may move from one country to another, but there are of course still restrictions which will tend to limit movement. I think language is a very real one. Perhaps the younger doctors will begin to take advantage of the right to move and, as time goes by, there will no doubt be an increase in the number of exchanges which take place at present. As your Lordships know, for one purpose or another some 900 doctors leave our shores every year. Some 550 of them annually do in fact return. In the long run we believe this movement of professional persons will be to the benefit not only of the profession itself but also to the ultimate advantage of the public as a whole.

My Lords, I do not know whether I have covered all the questions which have arisen. I hope I have. The criteria for medical training have been laid down in the directives, and Article I of the Directive on Co-ordination provides that during his complete training the student must acquire adequate knowledge of the sciences on which medicine is based, a good understanding of the scientific methods, including the principle of measuring biological functions, the evaluation of scientifically established facts and the analysis of data; sufficient understanding of the structure, functions and behaviour of both healthy and sick persons as well as relations between the state of health of the physical and social surroundings of the human being". It then says, There must be adequate knowledge of clinical discipline and practices providing him with a coherent picture of mental and physical diseases, of medicine from the point of prophylaxis, diagnosis and therapy, and of human reproduction; suitable clinical experience in hospital must be undertaken under appropriate supervision. So far as I have been able, I have tried to deal with the question of language posed by the noble Lords, Lord Hill of Luton and Lord Aberdare, as well as the possible problem of doctors going abroad.

My Lords, perhaps the only other useful thing I can say relates to the Advisory Committee on Medical Education. I think I was asked the terms of reference of the Advisory Committee on Medical Education. The draft Council decision provides that the task of the Committee shall be to help to ensure a high standard of medical training in the Community with regard to both the training of the general practitioner and of the specialist". The draft Council decision provides that it will carry out this task by exchanging information as to training methods and content, by discussion and consultation, with the object of developing common approaches to the standard to be attained, and by keeping under review developments in medical science and education.

My Lords, with regard to language, perhaps I can add this. We should not be able to apply language tests to doctors entering to become general practitioners. They are not National Health Service employees. For National Health Service general practice there are selection procedures for all established practices. In the future, as now, language proficiency will no doubt be taken into account.

At this stage I do not think I can add anything that is useful. I would conclude where I began, by thanking the noble Lord, Lord Hill of Luton, for raising this matter, and by thanking the officials of the Department of Health and Social Security who are very much seized with these problems, and who, over a period of many months, have improved the conditions for entry into this country.

The Earl of SELKIRK

My Lords, if the noble Lord will forgive me for interrupting him, have there been any moves with regard to training in law? There are aspects of the medical profession into which the law enters, and which differ from country to country. Has any consideration been given to that?

Lord WELLS-PESTELL

My Lords, so far as I know, there have been no such directives at this time. As I understand the position, it really all hangs upon what is the final outcome of the doctors and dentists directives, because what is decided for the doctors will have a very marked bearing on the other professions. But in answer to the question of the noble Earl, Lord Selkirk, I do not think there has been any progress.

8.49 p.m.

Lord HILL of LUTON

My Lords, I will be very brief. First of all, may I thank those noble Lords who have spoken in this debate and, perhaps even more, those who have had the fortitude to stay to listen to others speaking. Secondly, may I warmly endorse what the Minister said about the industry, the effectiveness and the co-operation shown by the members of the Department responsible for this burdensome, unending and difficult task. Of course I accept the point of the noble Earl, Lord Halsbury, that the man who believes he is speaking good English is more dangerous than the man who speaks none at all. I will answer the question if I may—although I ought not to do this—about the contract of the general practitioner. Everyone on the British Medical Register is free to set himself up in practice where he likes outside the National Health Service, and in an undoctored area in the National Health Service, without anyone else's permission. That is the fact of the situation.

Lord ABERDARE

My Lords, may I ask the noble Lord whether automatically he gets a contract from the Family Practitioner Committee?

Lord HILL of LUTON

My Lords, he puts his name on the register in an under-doctored area, where any registered medical practitioners are free to go. This of course, is full of unknowns. We do not know how the Advisory Committee will work. While I am full of admiration for the Minister's glowing, glossy anticipation of how it will work, he knows and I know that neither of us has the faintest idea how it will work until we see the terms of reference, the powers, and indeed perhaps after a period of working. We do not know whether doctors will leave this country for more sun and greater remuneration in certain European countries. We just do not know whether there will be an outflow. I have my suspicions, doctors being human, and, as Lord Halsbury knows, rather more than human. No one knows, but it might happen, and if this results in an outflow of doctors to the wealthier countries of Europe from the poorer countries of Europe, then I think it will be dangerous, if not disastrous.

Lord HOY

My Lords, if the noble Lord will forgive me, when he is making this argument I think he will also take into account that a considerable number of doctors who sought their Eldorados abroad have now returned to this country to practise under the National Health Service.

Lord HILL of LUTON

My Lords, it could well be. Nobody knows the answer. I think what is worrying me in all this business is that there is such a mass of paper; there are so many changes in directives; there is so much inevitable confusion and so much is unknown that we in this country are in danger of being submerged by all this, even covering it with cosy and hopeful interpretations. We may find profound changes in our life in this country, and in this respect in all probability profound changes in professional life and organisation.

If I may make one last observation, this at least shows the advantage of periodic debates in this House in which the Select Committee, under the chairmanship of the noble Baroness, can bring forward matters on which it and the public should be informed and which should be debated. If ever there were justification for such debates, it seems to me to be in the two debates we have had this evening.

Lord WELLS-PESTELL

My Lords, I take it the noble Lord would not deny that our intervention over a period of a good many months now has created a far better situation than any of us could have envisaged, and that there is no reason to suppose that our officials will not be able to do as well in the future in bringing about the state of affairs that we want as they have succeeded in doing in the past?

Lord HILL of LUTON

My Lords, with the first part of the noble Lord's observation I agree; great progress has been made. With regard to the second part, I get more cynical and suspicious as I get older, and I do not propose to share that glow of optimism that further changes will be made, even for the delight of agreeing with the noble Lord.

On Question, Motion agreed to.