§ 5.29 p.m.
§ Lord WELLS-PESTELL
My Lords, I beg to move that the Medical Bill be read a second time. The main purpose of the Bill is to make provision for the reconstitution of the General Medical Council and for some expansion of its functions. As your Lordships know, the General Medical Council is an independent statutory body which is entirely financed by the medical profession. It has the task of regulating that profession, not only for the protection of the general 1148 public but also to uphold the reputation of the profession itself. It does this in three main ways. First, it maintains the medical register of qualified medical practitioners. Secondly, it has disciplinary powers for the protection of patients, used in respect of doctors accused of serious professional misconduct. Thirdly, it supervises medical education. The General Medical Council, therefore, plays a central role in maintaining high professional medical standards in this country. The present Bill is aimed at consolidating this role and making it easier to carry out.
Before explaining the provisions of the Bill, I should remind your Lordships of some of the background to it. It had become apparent by 1972 that there was a dispute within the profession about the way in which it was regulated. One section of the profession felt that the Council did not fulfil its role in a satisfactory manner. A serious situation developed in that year when the Council, in order to meet rising costs, increased the annual fee, first introduced only two years earlier, for the retention of the doctor's name on the medical register. This was resented by a number of doctors who were dissatisfied about the way the Council regulated the profession. They regarded this fee as unjust because until 1970 doctors had secured an entry for life in the medical register by the payment of a single fee at the outset of their career. The introduction of this annual fee and its subsequent rapid increase gave the profession the means to exert pressure for the reform of the Council. The doctors involved said that they would refuse to pay the fee until the General Medical Council was reconstituted, and the Council threatened to remove their names from the register if they did. This would have had the effect of preventing these doctors from practising medicine within the National Health Service.
It was at this stage that the then Government intervened to avert what was a potentially serious situation, both for the National Health Service and for the profession generally. It set up an independent committee of inquiry under the chairmanship of Dr. Alec Merrison (as he then was) to look into the regulation of the profession. The committee had the following terms of reference:to consider what changes need to be made in the existing provisions for the regulation of the 1149 medical profession; what functions should be assigned to the body charged with the responsibility for its regulation; and how that body should be constituted to enable it to discharge its functions most effectively; and to make recommendations".The committee, which had 15 members, including 7 from the medical profession, produced a unanimous report in 1975 which made 95 recommendations ranging over all the Council's constitution and functions. The present Government, after undertaking wide consultations on the report, found that, although there were some disagreements over the detailed implementation of several of the recommendations, there was a clear consensus of opinion, shared by both the profession and the General Medical Council, that the bulk of the Merrison recommendations should be accepted. My right honourable friend the Secretary of State for Social Services therefore announced, in a Written Answer on the 18th July in another place, that the Government were accepting the principal recommendations of the committee with some reservations. He also announced that the Government would introduce legislation in due course, although this would require further detailed consultations with the bodies concerned to ensure that the proposals would be generally acceptable.
The present Medical Bill forms the first stage in this process, and I want to emphasise, my Lords, that it is the first stage. The Bill before your Lordships covers four main areas: the reconstitution of the General Medical Council; relations with the Republic of Ireland on the question of the regulation of the medical profession (I would remind your Lordships that the General Medical Council is at present constituted on a British Isles basis); the question of doctors' fitness to practise; and the role of the General Medical Council's education committee. These are areas in which the Merrison recommendations were broady accepted in all quarters, and which were seen as suitable for early legislation. Indeed, I should stress that the medical profession is particularly anxious to see the early implementation of these recommendations. It has not been possible to include provisions in the present Bill to enact any of the other Merrison recommendations. It is clear from the comments received by the Government on the report that there is uncertainty as to whether some of the 1150 recommendations should be implemented as they stand. As far as others are concerned, further detailed consultation will be necessary to work out proposals which can be introduced as legislation. When it became apparent that more detailed work would be needed on these other recommendations, it was thought best not to hold back implementation of the uncontroversial and relatively straightforward proposals which are embodied in the Bill now before your Lordships, and it is for this reason that the Government have decided to implement the Merrison Report in two stages.
I know—at least, I think I can guess—that there are a number of noble Lords who will feel that the Bill does not go far enough, and that it ought to include other recommendations; but I have pointed out that these are ones which the Government (and, for that matter, the General Medical Council) feel can be implemented immediately, whereas the others will need consultation over a very large area. However, for those who have some doubts as to what the Government will do in the future, may I say that it is the Government's firm intention to pursue Merrison's other recommendations and to introduce legislation on them. Consultation papers on them will be sent to interested organisations, and we hope that it will be possible to get the first of the consultation papers out early in the New Year.
This Bill is mainly an enabling measure. It leaves the fine detail of the proposals directly affecting the constitution and functions of the General Medical Council to be worked out, as they should be, by the Council in consultation with the profession. We believe that it must be their responsibility. It is also a flexible measure, and, in allowing future amendments to the Council's constitution to be made by Order in Council rather than by primary legislation, the process of adapting this will be infinitely simpler.
The first three clauses of the Bill deal with the reconstitution of the Council. At present, the General Medical Council has 46 members. Eight (including three lay members) are nominated by the Crown, 27 are appointed by certain medical educational bodies throughout the British Isles, and 11 are elected by fully-registered 1151 doctors practising in the British Isles. Your Lordships will note that only 11 of them are elected by fully registered doctors.
The first clause of the Bill will enable the membership of the Council to be altered along the lines proposed in the Merrison Report. The report came out strongly in favour of maintaining a Council which was overwhelmingly professional in membership, on the grounds that it was in the public interest for doctors to continue to regulate those matters, which would be unfamiliar to laymen, concerned with the standard of their professional competence and conduct, subject, of course, to Parliamentary control. I am sure your Lordships' House would accept this verdict. The report argued, however, that there should continue to be laymen on the Council to give it a broader perspective and to focus attention, if necessary, on matters which were seen to concern the general public.
The most important change as regards the membership of the Council advocated in the report was that it should be made representative of the profession as a whole and that there should be a majority of elected members on it. These members, who must be registered medical practitioners, will be elected in four constituencies, England, Scotland, Wales and Northern Ireland. They will be elected by registered medical practitioners who live in these areas. This reform has been strongly advocated by the medical profession and is completely accepted by the present General Medical Council.
I should like to draw your Lordships' attention to the provision in the Bill that voting rights, and the right to sit on the Council as elected or appointed members, are extended to include provisionally registered doctors and doctors who have been temporarily registered for five of the six years preceding the election or their appointment. This provision will make the Council more representative of the profession as a whole.
Universities and bodies in the United Kingdom which have the power to appoint members to the Council under the Medical Act 1956, as amended by the 1959 Act, will continue to have this power; so that one has got to look at the conditions of the 1969 Act in addition 1152 to the 1956 Act. The Council at present has three branch councils: only one for England and Wales, one for Scotland and one for Ireland as a whole. They can undertake a number of functions delegated to them by the General Medical Council. Under the terms of the Bill we are about to consider, the General Medical Council will retain branch councils but their number and the areas which they cover will be altered, as I have said, in line with the electoral constituencies; that is, one for England, one for Scotland, and one for Wales and Northern Ireland.
May I come to the Irish situation, if I may call it that? The establishment of a branch council for Northern Ireland follows on naturally from the provisions in Clause 4 of the Bill for the termination of the 1927 Agreement between Great Britain, Northern Ireland and the then-Irish Free State. This Agreement provides that the arrangements for the registration and control of medical practitioners in the British Isles should continue as they were before the creation of the Free State and Northern Ireland. Thus, doctors and educational bodies in both the Republic and Northern Ireland are represented on the Council and the Council has the right to supervise medical education in the Republic. That is the present position.
Negotiations are at present taking place between the United Kingdom and the Irish Republic Government in order to terminate this Agreement. The two Governments want to do this partly because the implementation of the EEC Medical Directives by the two countries renders many of the provisions of this Agreement unnecessary and partly because they feel that it is no longer appropriate for the General Medical Council to exercise a supervisory role over medical education in the Irish Republic. These negotiations are not yet completed and the Bill makes provision for the preservation of the status quo until the Agreement is terminated. It also makes provision for the repeal of the statutory provisions arising from the Agreement when it is terminated and for safeguarding certain existing rights on termination.
Most of the rest of the Bill concerns the committees of the Council set up to 1153 deal with its disciplinary and educational functions; it follows the relevant Merrison recommendations closely. A major innovation is that the Council is, for the first time, given powers to control the rights of doctors who are physically or mentally ill to practise medicine. At present, the Council can only intervene with a doctor's right to practise if he is convicted of a criminal offence or has done something which is judged to constitute serious professional misconduct.
The Merrison Committee was unable to quantify the number of doctors whose physical or mental health might constitute a risk to their patients, but it came to the conclusion from the evidence it received that the number, though small in relation to the number of doctors practising, was not insignificant because of the potential consequences for patients. Much of this evidence concerned doctors addicted to alcohol or drugs, but it also brought to light cases of doctors suffering from progressively debilitating illnesses. The General Medical Council is very concerned—and, many of us would think, rightly so—about its inability to act in this area at present. Indeed, with the broad encouragement of the profession, it had been planning possible action which it might take in such cases, even before the Merrison Committee reported.
The Bill which follows the relevant Merrison recommendations closely, gives the General Medical Council the powers to set up a Health Committee. This Committee, if it judges a doctor's fitness to practise to be seriously impaired by reason of mental or physical ill-health, will be able to suspend a doctor's registration for up to 12 months at a time, or (and this is another innovation) make it conditional on his compliance with specified requirements.
The Bill also provides for the establishment of a Professional Conduct Committee along the lines recommended by Merrison. The Committee's powers will correspond closely to those of the General Medical Council's existing Disciplinary Committee which it replaces, with one important difference. It, too, will be given powers to make doctor's registration conditional on compliance with certain specified requirements. This will be in addition to its powers to erase or suspend 1154 doctors from the Register. This will enable the General Medical Council to limit a doctor's right to practise if he has committed serious professional misconduct, in a way which will not deprive him of his livelihood but will protect the public interest.
The Preliminary Proceedings Committee will, as its name implies, take preliminary proceedings once a case is notified to the Council. It will decide whether further action should be taken and, if so, whether the case is a "health" or "conduct" matter, in order to send the case to the appropriate Committee. It will also be able to order the suspension of a doctor for up to two months pending his appearance before that Committee if it feels this to be necessary for the protection of the public. The Bill also makes the necessary statutory provisions for the conduct of business by these Committees, the rights of appeal against their decisions and for transitional arrangements.
Last but not least, the Bill makes provision for an Education Committee. This will assume most of the Council's statutory functions relating to medical education. It will be for the Council itself to determine the membership of the Committee with the one proviso that there must be more Council members appointed by educational bodies than the combined numbers of elected or nominated members on the Committee. It will be able to co-opt members from outside the Council.
That is the gist of the Medical Bill. For the changes it will make it seems a fairly long Bill but its length is largely due to the fact that it repeats and consolidates certain existing provisions in the interests of clarity. Its main objective is to increase the effectiveness of the GMC in regulating the medical profession, and to amend the legislation in such a way as to make it easier to vary the Council's constitution in future. The provisions in the Bill, as I have said a number of times, follow closely the relevant recommendations of the Merrison Committee which received the broad approval of the profession and of the present Council.
I said that the other recommendations, which will take some time to discuss with interested bodies, will perhaps form a more comprehensive Bill in the not too distant future. But, with great respect, I 1155 think this Bill is something that can be dealt with speedily; it is something which is welcomed by the profession and the General Medical Council. Because of this, I hope that the Bill will receive a welcome from all sides of your Lordships' House. I beg to move that this Bill be now read a second time.
Moved, That the Bill be now read 2a. —(Lord Wells-Pestell.)
§ 5.53 p.m.
§ Lord SANDYS
My Lords, the noble Lord, Lord Wells-Pestell, can be reassured that, from this side of the House, this Bill will receive a very qualified welcome—qualified very largely because the extent of its remit is, in our view, not sufficient. This Bill follows on a series of measures dating back as far as 1858, each one of them aimed towards broadly the same purpose: to protect the public interest, further the medical profession as a whole and improve professional standards.
It is interesting that much of the machinery in existence today is the direct heir of what was set up in 1858 and 1886 and consolidated with other measures into the 1956 Act. Your Lordships have already been given a very comprehensive description of the background to this particular Bill, and it remains for me to add some further background. I do not think that the noble Lord mentioned one other significant event in the recent past: the report of the Royal Commission on Medical Education (the Todd Report) which was published in 1968. This was necessary both to enable medical schools to adjust their undergraduate curricula to modern requirements and to regulate the important stages of post-graduate training.
The report of the Committee of Inquiry into the Regulation of the Medical Profession (the Merrison Commission), published in 1975, is very well known to your Lordships. We believe that the measure which the Government have introduced to your Lordships' House has been a step in that direction. I quote the words of the noble Lord, Lord Wells-Pestell, when he said that there was a clear consensus of opinion shared by the GMC and the profession that the Merrison Committee's recommendation should be implemented. The step taken in this 1156 Bill is a small one, and we turn to that part of the Merrison Committee's Report which sets out the problems and the weakness which exist at the moment. If I may seek indulgence to quote page 16, paragraph 46, it says:The prime weakness of the present system of control of medical education is that control through the statutory registration system—largely unchanged since 1886—covers what are now little more than the academic preliminaries to the assumption of full responsibility".Then, further on, in paragraph 62, the Committee comes to some conclusions:Briefly, then, we propose that there should be a three-tier system of education for every doctor of the future—undergraduate training, graduate clinical training, and specialist training—and that these should be defined in the system of registration and co-ordinated and controlled by the regulating body".It is very clear indeed that the Merrison Committee put education in a very much higher category than do the Government. The noble Lord referred to it as "last but not least". In Merrison, it occurs as early as Chapter 3 of the report. The Merrison Committee was looking to the future of the profession in the fourth and final quarter of this century, and leading on into the next century—and how right it was. It was very much concerned with the composition of the General Medical Council. There were two most sharply opposed views. One was that it should be small, efficient and relatively cheap to manage; the other was that it should be large and representative and should encompass almost every branch of the profession.
However, what we are looking at today is something which Merrison never envisaged—that is, the enlargement from the present membership of 46 members to 98 members, but without the duties, responsibilities and range of affairs envisaged in the report. The Government may well say: "Yes, we intend to implement Merrison in the future and therefore we are setting up the structure today". But there is a certain emptiness about the proposals which strikes one most forcibly if it is indeed intended to have such a large Council with such a substantial number of representatives from branches of the profession.
I pause here to say how much we welcome the coming to fruition of what the BMA has sought for nearly 100 years: that is, the substantial increase in the 1157 number of elected members. Nevertheless, we feel that their function for the time being at any rate, in what is, after 1978, to be the Medical Council, will not be very considerable. If one looks at what Merrison felt about the legislation, it is very interesting because paragraph 419 displays a distinctly light touch. This is in sharp contrast to the last but one Medical Act of 1956, which sets out most clearly what representatives were to come from which body and ties the hands most carefully. Merrison says this:We suggest that the principal legislation need do little more than say that there should be a General Medical Council consisting of a general council having on it elected, appointed and lay members".So, my Lords, it was left to subordinate legislation to carry into effect a scheme which was thought to be desirable.
I turn now to the chief defect of the Bill, which we believe lies in its very limited scope. After so much preparatory work has been carried out in the educational field and by the Royal Commission, which produced the Todd Report which was published in 1968, it is very surprising that the Government appear to be so hesitant in bringing forward a wholesale and comprehensive measure. I wonder what lies behind this apparent timidity; because we have in the Merrison Report, in supplement to the Todd Report, very clearly-outlined schemes which need both legislation and the goodwill of the professions. Undoubtedly, the professional goodwill has been lined up strongly behind Merrison and we have a Government which at the present time feels that a very cautious and staged implementation is the desirable way forward.
We feel that whole areas have been left untouched—areas which could have been dealt with to some extent at the present time. For instance, Merrison recommended quite extensive changes in the present arrangements for the registration of overseas doctors. I should say here that the Merrison Report mentions a figure of over 13,300 doctors who were born overseas and who practise within the National Health Service at the present time. Chapter 3 of the report is entirely taken up with their registration and the furtherance of the needs of the profession, the public and the doctors.
Finally, as both the General Medical Council and the British Medical Association 1158 have agreed that the whole report should be implemented as soon as possible, we find it hard to see why the Government are so slow; or, to put it the other way round, why legislate at all? We believe that the Government have a case for bringing before your Lordships the Bill as it stands in order to make better arrangements for the reconstruction of the General Medical Council, to set up the Health Committee and to suspend doctors who are unfit because of their physical or mental health. For these reasons, we support the Government's intention on this very limited Bill, and we may wish to bring forward amendments at Committee stage.
§ 6.4 p.m.
My Lords, I have no wish to disappoint the noble Lord, Lord Wells-Pestell, for whom I have immense personal regard—indeed, I must say at once that I am much indebted to him for his clear and lucid explanation of the effects of this somewhat limited measure—but, at the risk of disappointing him, I must say at once that I find it difficult to generate a great deal of enthusiasm over this particular measure. When ordinary folk, and by that I mean patients—and your Lordships do not need me to remind you that noble Lords and doctors are all patients at some time or other—read in their papers this morning that your Lordships' House was to be occupied with a discussion of the Medical Bill, many of those patients must have leapt immediately to the conclusion that this had something to do with them. My Lords, has it? We must wait and see.
At the moment in our Health Service we have resources which are finite and limited, endeavouring to cope with a workload which is growing daily in volume and complexity. Every minute of every hour our Health Service lets somebody down somewhere. It may be the chap who has been waiting for two years for a so-called " non-urgent operation; and, if I may say so, the exact degree of urgency of any operation rather depends on who is going to have it. If you are going to have it, then perhaps it does not seem so "non-urgent" after all. There are patients who, when they ring up the general practitioner, find that all they get is an answering machine, which refers them to another line, which is either 1159 unobtainable or engaged; or who, when they call at the surgery of a general practitioner, are confronted by what they call "the dragon at the gate"—the receptionist—and cannot get much further. Then there is the family which is sometimes disrupted by the psycho-geriatric disturbed elderly person, for whom there is no bed in hospital. All those people are looking for urgent measures to help them. It is possible, of course, that a measure of this kind will help them, though somewhat indirectly, because it is concerned with medical standards and the maintenance of those standards.
As the noble Lord, Lord Well-Pestell, has explained, the whole matter concerns the regulation of the General Medical Council, and the main functions of that Council is the maintenance and supervision of the medical register. Let us say at once that of course we must have a General Medical Council. In the main, it is there for the protection of the public rather than of the profession. The medical profession itself tends to feel that there are already enough controls over it—with general practitioners under the Family Practitioner Committee, hospital doctors under the Area Health Boards, the Regional Health Boards, hospital management committees and so on. But we must have a General Medical Council to ensure that medical practitioners who are on the medical register have been adequately trained and tested and can therefore be accepted as having reached a certain degree of skill, experience and so on.
Perhaps it is not irrelevant to say in passing that I personally am very glad that we operate the medical register in a fairly liberal kind of way in this country and we do not make it illegal for anybody else to practise medicine. Many people practise medicine without any qualifications at all. There are herbalists, the non-medically qualified, osteopaths, chiropractors and all sorts of people. I should not like to see a movement towards total regimentation so that nobody else at all could interfere with medicine. We have done that to some extent with dentistry, where it is an offence to make an impression of anybody's mouth unless you are on the dental register. But at least we are fairly liberal and we allow people to go on practising. I think that is right; but if we are to give the public confidence 1160 that this person is a registered medical practitioner, that of course has got to mean something clear and it must mean something which is not merely reassuring but which will give confidence to the public. That is what this Bill is about.
The noble Lord, Lord Wells-Pestell, explained the origin and the history of the Bill. He explained that there was a dispute about the role and functions of the General Medical Council. He also explained that there was another dispute—perhaps a rather more bitter one—about who should pay for the General Medical Council. That is a dispute which, if I may say so, we have not entirely finished with, and perhaps we could come to that in a moment. But there is no doubt that at the time when the Merrison Committee was set up to investigate these matters, with the terms of reference which the noble Lord has read to the House, the General Medical Council was beginning to appear to both professional and public eyes as somehow a little out of date, a bit antiquated, a bit irrelevant and in need of reform.
This was largely brought about, I suggest, by the kind of publicity which the functions of the General Medical Council get from time to time—publicity which tended to make the general public think that the General Medical Council was much more concerned with any individual doctor's sexual inclinations or aberrations than in his actual standards of professional conduct. They seemed to get much more upset about minor sexual aberrations than about serious departures from professional competence, and so on. I am not saying that was fair. It may be that nothing like enough public attention was given to the real and positive role of the General Medical Council in maintaining educational standards and in supervising qualifications standards throughout our universities and colleges. But that is what happened, and that is another of the things which led to the need for the Merrison Committee and for the Merrison Committee's report, which came out some years ago and which now, at long last, we are thinking about bringing into force.
Some will say, as the noble Lord suggested, that we should have accepted the Merrison Committee's report lock, stock and barrel. I am not entirely sure about whether we should have accepted 1161 the report as a whole and said, "There it is. Let us adopt it". But I underline so many of the things which the noble Lord, Lord Sandys, has said about medical education. On some of the progress which is indicated in the Merrison Report about matters of that kind, I should have liked to see this Bill go a little further; and there are one or two other things which I should like to see it do, but what it does do is no bad thing.
Perhaps I may first go through some of my regrets. I am particularly sorry, bearing in mind that the noble Lord has told us that, in the main, we are concentrating on matters which are not controversial and which can therefore be done fairly easily, that we are not proceeding here and now with the recommendations regarding the registration of overseas doctors. This is a fairly urgent matter, not only for the doctors themselves—and it is urgent for many of them—but also for many of the patients. It is true that, initially, this may have appeared to be controversial when the Merrison Report was first published. But when various bodies, such as doctors and so on, looked at it they saw that there was great merit in these recommendations, and it would have been helpful if they had been brought forward at a very early stage. Therefore, I hope that these will be some of the matters to which the noble Lord referred when he said that we will be having another bite at the cherry in the not too distant future.
I am also rather sorry, particularly in relation to what I said earlier about the need for some reform, that we are not proceeding here and now with some of the changes regarding disciplinary hearings, and, in particular, publicity arising from disciplinary hearings concerning doctors, especially those hearings which result in a finding of not guilty so far as the doctor is concerned. For many of those doctors the damage has already been done, the distress has been caused, and many of us feel that that was unnecessary distress which could have been avoided. I think that Merrison thought this, too, and I should have liked to see us proceed with those matters.
So far as education is concerned, Yes, I should have liked to see this move towards specialist registers and things of 1162 that kind, but—and perhaps here I am batting at the noble Lord when he said that we should leave for the moment such matters as are controversial—I would express just one reservation. I am a little alarmed at the extent to which people become obsessed with the idea that one can improve all the standards of medical care—and that, I am sure, is what we are really talking about—purely by concentrating on the machinery and framework of medical education. All right, we have to do many things. Perhaps we have to do much more in a technological age with regard to specialist training, postgraduate training, specialist registration and matters of that kind. But my experience leads me to believe that what is of much greater importance in having an efficient, humane and able medical profession is much more careful selection, right at the beginning, of people who enter the profession.
Now that competition is so very great, one finds that universities and colleges select students purely on the basis of academic success in a very narrow range of subjects. Therefore, the child has to be pointed towards the medical school when he is round about 13, and then all he does is biology, physics and so on for year after year. He arrives at the medical school knowing all about the cranial nerves of the dogfish, a great deal about the transverse section of the briony leaf and practically nothing else, and I am not entirely sure that this makes for the best kind of doctor.
In medicine, we learn in many ways. In the main, we learn from practising in close association with able, inspiring and dedicated people. We learn much more than we are taught. So do not let us believe that, merely by altering the framework of education, we will suddenly all become much better doctors. What matters is the way in which we are associated with our colleagues. Some of those colleagues are in your Lordships' House and we may hear from some—people who have influenced and educated us every time we have talked to them about patients, and about the medical profession in which we are jointly engaged. But I am sorry that some of the progress has not been made which Merrison pointed to.
Let me come to the fourth of my regrets, and that is the question of who pays. 1163 It is no surprise to your Lordships' House to hear a doctor talking about money. Some people seem to think that doctors never talk about anything else. Indeed, to hear some of my colleagues talk, one would think that it is now much cheaper to have the doctor every day than to buy apples. I do not want to go into arguments of that kind, but it is a fact that the primary function of the General Medical Council is the protection of the public, rather than the doctor. If we are going to multiply its size and have a much bigger General Medical Council with enlarged functions, as probably we should have, I am not at all sure that it is reasonable to expect doctors themselves to bear the financial burden.
I know it is explained that general practitioners get back much of the cost of this by a curious arrangement of reimbursement through the pool system in the expenses factor of their remuneration, but doctors know that the expenses factor is a rather roundabout way of getting remuneration. It takes into consideration the analysis of income tax returns over some years, and it is invariably about three years in arrears. So I warn the noble Lord that if this results in a major increase in the retention fee for hospital doctors and general practioners to pay, there will be dispute and discord and, once again, there will be the kind of crisis with which we were faced earlier. These are perhaps Committee matters which we can think about later, but they are matters which have to be thought about.
Before I sit down, it would be churlish not to say something about the things which I really welcome in this Bill. I am not sure about having a much bigger GMC, except that perhaps having it very much bigger may in certain fields of activity make it more impotent. But, certainly, I welcome the fact that it will become a little more representative. An increase in the elected members, although elected by sections of the profession, must, in the end, make the GMC more representative and more publicly accountable, and that surely is a good thing which we should all welcome.
I certainly welcome a move towards a rationalisation of the anomaly with regard to the Irish Republic. That has to happen fairly soon, and I am sure that a solution 1164 will be found which is mutually acceptable to all the parties concerned. But I particularly underline and welcome, as a matter of some urgency, the new provisions for dealing with sick doctors, doctors who, by reason of physical illness, mental illness, drug addiction, alcoholism or whatever it may be, have become not unfit to practice but a danger from time to time. They are a very real problem. It is one that I have seen at close quarters on a number of occasions. It is a very sad situation about which, in the past, we could do almost nothing, except cover up the problem until there was some kind of explosion—usually, in the end, there was an explosion—or precipitate a sick doctor towards all the indignity and distress of a disciplinary hearing, when what the person needed was care, help and understanding, rather than discipline. So I welcome that most warmly.
I have spoken long enough, and I shall look forward to listening to what noble Lords who are deeply involved in this subject have to say. I assure the noble Lord that, while he may not have the enthusiastic, rousing support of my noble friends on these Benches for this measure, he will certainly not find that there is any opposition generated.
§ Lord STONE
My Lords, before the noble Lord sits down, may I ask him one question apropos of the last sentence of his speech in relation to the ailing doctor, the drunk et cetera? Who is going to report this person? Is it the patient, his colleagues or anyone else?
My Lords, it is not for me to explain the workings of the new Bill, but I imagine that under the new situation anybody will be free to report, and now will be able to report and be encouraged to report, without fear of the possible consequences. I have known, and fellow general practitioners have known, of somebody in our midst who was not safe to practice, but we found it very difficult indeed to take any steps, because of the consequences of those steps. So long as the solution is here—and I think that it is here—then the whole matter of the feeding through of information will take care of itself. But in the past it did not and the problem tended to get hidden, which was itself a danger.
§ 6.20 p.m.
§ Lord HUNT of FAWLEY
My Lords, about 10 years ago my two sons, both then medical students, and their friends frequently grumbled to me about the General Medical Council, its composition and what it did. They said it was out of date, and they were quite right; it was. They are both general practitioners now and I myself happen to be a family doctor.
I and many of my colleagues welcome this Bill, because through it we have a splendid opportunity today to put things right. I agree with the noble Lord, Lord Wells-Pestell, that it is a good Bill; but only so far as it goes, and that is not nearly far enough. It has been worked out very carefully by the Government and by the General Medical Council with its President, Sir John Richardson, who have taken infinite pains over its details. They would like much more to be added to it.
The Bill is based, as noble Lords know, on the recommendations of Sir Alec Merrison's Report of his Committee of Inquiry into the Regulation of the Medical Profession which was published in April 1975. Only general principles are included in this Bill; many details are to be decided in future by Orders in Council. These, and the Privy Council, are mentioned more than 30 times in this Bill, as noble Lords may have noticed. One wonders how effective this dependence upon Orders in Council will be. Some professional matters, such as medical ethics and certain aspects of medical education, do not lend themselves easily to legislation. The Department of Health and Social Security will no doubt draft some of the Orders in Council which will be presented by the Minister for ratification by Her Majesty the Queen in her Privy Council.
This Bill provides that several of the Orders in Council are to be prepared by the General Medical Council itself, in particular some of the most important ones about the work of its main committees; but this does not apply to all of them. So one important question arises: which professional bodies will be approached by the Department for advice on the other matters?
I should like to ask the noble Lord, Lord Wells-Pestell, whether he agrees that a non-political organisation such as 1166 the General Medical Council should be the main body to give advice on most points of detail. No doubt all the Royal Colleges and Faculties, the universities (especially London University with its British Postgraduate Medical Federation) and, of course, the British Medical Association and others will at times contribute, too. Any profession in which by definition one professes to be skilled, and to follow and to apply one's skills to the affairs of others, must set its own standards. If it were thought possible that anything in this Bill could result in the control of professional, academic or ethical matters by law administrators or politicians, I believe it would be bitterly resented and firmly resisted by almost every doctor in Britain.
The main defect of this Bill lies in its limited scope. It implements only two of the five main recommendations of the Merrison Report: those concerned with the composition of the General Medical Council, and its role in relation to sick doctors and their fitness to practise. The three other important recommendations of Merrison which have been left out of this Bill concern postgraduate medical training, with the continuing education of doctors in Britain, the maintenance of standards, and the registration of overseas doctors.
Medical education is mentioned in the Long Title to this Bill. I have taken advice and am told on good authority that we are not too late, and that it will still be possible to include educational and other Amendments, which are within the scope of this Bill, by putting them forward to be considered at the Committee stage. If they are not accepted then the medical profession will be asking for another Bill very shortly. That will mean a second bite at this cherry. With a very full legislative programme, space may not easily be found—for one, two or even three years—for another Government Bill, or even for a Private Member's Bill. I myself would be quite prepared to try to introduce the latter, if necessary. The Government must not be allowed to say: "The doctors have had their Bill; therefore they cannot have another".
The present work of the General Medical Council is largely limited to the undergraduate education of medical students and is based on an Act which was 1167 introduced in 1886–91 years ago—as my noble friend Lord Sandys has pointed out. This Bill must be brought up to date at the earliest possible moment to cover the whole of modern medical education. If a second Bill has, after all, to be introduced, it will really be the second half of this Bill, and I hope that will be clearly indicated in both by labelling them "Medical Bill Part I and Part II".
I should now like to mention a few important points which are included in the Bill that we are discussing this evening. Most doctors warmly welcome its suggestions for reconstructing the General Medical Council with elected, appointed and nominated members. Most people agree, too, about the increase which Merrison suggested in the size of the Council from 46 to 98, or more, members. This number must be flexible to allow for future developments. It is possible, however, that unless the educational clauses of the Merrison Report are incorporated in this Bill soon, as my noble friend Lord Sandys also pointed out, such a huge Council may find itself largely unemployed. Apparent but ineffective participation in anything encourages no one. People cannot be kept happy and loyal unless they know that they are working on something worthwhile.
There are financial implications in this Bill, too. A much larger Council will cost more, especially if it has more work for its committees. Will the registration fee for doctors be much increased, or will the Government be prepared to contribute something in order to help?
General practitioners are the largest group in my profession. About two-fifths of all medical graduates in the National Health Service are family doctors. I, and many others, want to see them well represented on the reconstructed General Medical Council, both individually and by the organisations which serve them. The Royal College of General Practitioners must be represented, I think, on the General Council, and some of its members should be chosen to sit on all the important committees. General practice is a special discipline in its own right. Therefore standards in general practice must be maintained in the same manner as are those in other branches of the profession.
1168 One of the main clauses of this Bill refers to the attitude of the General Medical Council to sick doctors. Few can quibble over what it suggests about them. I really like the sympathetic, thoughtful and understanding approach of the Merrison Committee towards doctors who are ill enough for this to affect their work. That charitable attitude has been carried over into this Bill. But the safety of our patients is paramount and everything possible must be done to protect them.
We know, of course, that there are severe mental and physical disorders which are progressive and incurable, for which drastic steps may sometimes have to be taken. But it is often very difficult to tell when a doctor begins to be a danger to his patients. This is a problem common to all professions. It may even happen with politicians who, when they fall sick, may sometimes become a danger to their Party or to their country. We remember, for example, one of the past Presidents of the United States of America who became very ill when he was in office; and we ourselves had an example nearer home not so very long ago. No doctor or politician is perfect. We all make mistakes, and a professional mistake can be the first indication of illness.
Old age alone may give rise to little serious disability. At least two Members of your Lordships' House, both well over 90, demonstrate this to us brilliantly almost every day we meet. Some doctors can do useful work with terrible handicaps. One who is blind (as I know from my association with St. Dunstan's) can be a good manipulator; one who is deaf can do good pathology with a microscope in his laboratory, or take X-rays; a surgeon who becomes too shaky to operate, or who is partially paralysed, may nevertheless give a very good opinion. I know a general practitioner who has worked courageously for nine years after having his larynx removed because of cancer. Even doctors with some mental illnesses can have long periods of normality between their attacks. A severe incapacitating depression can lift quite suddenly, like a blanket of fog, leaving the patient normal for a long time. Like everyone else doing a difficult job who becomes ill, a sick doctor needs much sympathetic and good advice, help, support and treatment, long before he is frightened by any official warning or 1169 threat of disciplinary action or suspension, with loss of his living. This Bill, I am glad to say, recognises that quite clearly. But care must be taken that a doctor's reputation is not damaged by any action of the Preliminary Proceedings Committee, with perhaps temporary suspension, before his case comes before the Disciplinary Committee.
A few minutes before we started discussing this Bill I received a letter from the medical defence unions, in combination, one paragraph of which reads:I have been asked by the defence societies to draw your attention to a serious departure from all previous rules for the medical profession—that there is to be no right of appeal against interim suspension by the Preliminary Proceedings Committee. Never before has a medical practitioner been at risk of losing his licence to practise without the right to a hearing or to an appeal in the rare event of justice not being done".That is an important point which I thought I must point out.
Now, my Lords, may I say a few words about matters which this Bill leaves out which the Merrison Committee wanted. The General Medical Council has always had a statutory duty to maintain standards. The omission from this Bill of any clause about this, or any recommendation about postgraduate medical training and continuing education, has been a bitter disappointment to many of us. It is two and a half years since these were fully discussed and recommended so firmly in the Merrison Report. The delay has been largely due to differences of opinion within my profession. As a leading article in the British Medical Journal said last week:While accepting the logic of the argument that postgraduate and undergraduate education should be controlled by the same body, and that that body should be the newly constituted General Medical Council, many doctors … are reluctant to interfere in any way with the traditional role of the royal colleges as the inspectors and examiners of postgraduate training for the specialties. There are still conflicting views on the desirability of specialist registration and on the extent to which Britain should try to harmonise its specialist training programmes with those agreed in Europe".Surely, my Lords, a satisfactory compromise will be reached quickly when the new General Medical Council eventually meets, a compromise which may be achieved, perhaps, by introducing subordinate legislation; allowing some colleges and faculties a little freedom, if they wish, covering the "further details" 1170 which the noble Lord, Lord Wells-Pestell, mentioned. These colleges and faculties have this freedom now. I cannot see why problems over the Common Market should be allowed to hold up half of this very important Bill.
There is one other important recommendation of the Merrison Report which has also been omitted, that which concerns the registration of overseas doctors, as has been mentioned. These doctors have made an enormous contribution to the development of our National Health Service and many of them do first-class work. Control of the standards of those at the other end of the scale was strongly recommended by Merrison. This is a non-controversial matter which has been agreed by the General Medical Council, the British Medical Association, and by virtually all of our medical bodies—a plea for limited registration to ensure that overseas doctors practising independently in this country must have reached the minimum standard required of a British medical graduate. Our entry into the Common Market has made this matter even more urgent. It is now four and a half years since the General Medical Council finalised its views on this subject. How can the Government justify keeping it out of this Bill?
My Lords, I have brought with me six possible Amendments to this Bill, two quite short and four longer ones, copies of which I can give to anyone who is interested. These have already been seen by the experts and they are all to be considered in detail again tomorrow morning. I very much hope that they will be discussed and voted upon at the Committee stage of this Bill. I trust that other noble Lords will support me in this. If these Amendments, or suitable variations of them, are by chance agreed, then the need for a second Bill will be eliminated. That will save Parliament and my profession a great deal of time, trouble and expense; and the vitally important educational and registration work of the new General Medical Council will, quite easily start quickly and be brought up to date. If, however, the Government cannot or will not agree, now or at the Committee stage, to these major Amendments, will they please give us a firm assurance that they will introduce Part II of this Bill at the earliest possible opportunity, as the noble 1171 Lord, Lord Wells-Pestell, hinted? But, my Lords, I earnestly hope that that will not the necessary.
§ 6.38 p.m.
§ Lord SEGAL
My Lords, I should like to say at the outset that many of the criticisms made by the noble Lord, Lord Winstanley, arise from a misreading of the Title of the Bill. He has trotted out quite a string of old hobbyhorses that do not really arise from the subject of this Bill, which, as many speakers have already said, is very limited in its scope. Perhaps it might more appropriately have been entitled the GMC Bill, and this might well be the subject of a probing Amendment during the Committee stage.
May I also say how fully I agree with the noble Lord, Lord Hunt of Fawley, in criticising the absence of right of appeal against immediate interim suspension. I am sure that such action will be taken only in exceptional circumstances, where the lives of patients are actually placed at risk. That, I feel, is the sole justification, and a very necessary justification, for the recommendation of the Merrison Report.
As regards all the omissions on the subject of medical education to which reference has been made by almost every speaker, I cannot help feeling that that is a subject that had best be left entirely to the examining colleges. We all know how each specialist is most anxious to have his own speciality included in the curriculum of medical training. It is a burning subject in which I rather imagine the Government would be well advised not to become involved.
This Bill has been awaited for a long time and I hope that a general welcome will be extended to it from all sides of the House. It is now well over two and a half years since the Merrison Committee reported, and four and a half years since it first met. In my view, its report is a model of wisdom and sound judgment and should serve as a guide for future deliberations on these matters, as many problems are bound to arise once the Bill is on the Statute Book. I merely point out that it is a source of profound satisfaction that the recommendations of the Merrison Committee, composed as it was of seven doctors and seven lay 1172 members, were unanimous. It cannot be too strongly emphasised that at no time did a conflicting medical view and lay view emerge from their discussions. For far too long various public interests have claimed to be at variance with the medical profession. The great achievement of the Merrison Report is to state clearly and unequivocally that the best interests of the medical profession and those of the public must always coincide.
There are many important innovations in the Bill and those have already been dealt with by previous speakers. I should especially have liked to speak on the problem of registration of overseas doctors, but I shall leave such matters to others more knowledgeable on the subject. I should, however, like to devote a few brief remarks to the setting up of the new Health Committee—to which reference is made in Clause 7—to regulate the right to practise of registered practitioners whose health is seriously impaired, whether medically or physically. At present, the controls are tenuous in the extreme.
Some remarkable cases are quoted in paragraph 329, on page 111 of the Merrison Report. I can recall the case of an elderly practitioner of 91—certainly not elderly by the standards of your Lordships' House, but still quite elderly among practising doctors. He had his practice within a mile of Marble Arch. He was completely senile and was as deaf as a door-post. He was a typical Gladstonian character, with a high linen collar and starched cuffs that were badly frayed. I remember finding him sitting sadly in his consulting room with a pile of copies of the British Medical Journal at his elbow, still unopened and in their original wrappers. That doctor had a list of 400 patients on his panel, the final residue of a much larger list of 30 years before. Fortunately, those 400 patients almost never consulted him. If any of them did, they were automatically referred to the out-patients department of St. Mary's Hospital. Yet this doctor, fully conscious of his own hopeless inadequacy, still continued to practise long after he should have been allowed to spend his days in honourable retirement.
I recall another case of a gifted young doctor, an anaesthetist at one of our London specialist hospitals, who was a chloroform addict. He was in the habit 1173 of helping himself freely to ampoules of chloroform from the anaesthetist's tray, stretching out his hand slyly under the sheet that covered the anaesthetic preparations and grabbing a handful of ampoules while the patient was undergoing a major operation. No one would openly volunteer to expose him and deprive him of his livelihood. Within two years he had committed suicide. That doctor's life might well have been saved had he been compelled to cease practising, and to undergo a course of treatment.
The problem of the sick doctor is dealt with very fully and sympathetically in the Merrison Report. However, I am not sure whether, in the delicate initial stages of approaching the sick doctor—reference has been made to this by my noble friend Lord Stone—the General Medical Council or anyone appointed by it, is really the best means of dealing with the problem. I should like to ask my noble friend Lord Wells-Pestell whether the services of the Regional Medical Service, which can act only in an advisory capacity, totally removed from any disciplinary overtones, might not be enlisted in the initial approaches to the sick doctor. It already has a long tradition of initial approaches to doctors who might be suspected of having erred, and could prove most useful in this context, even if additional recruitment to its ranks is required.
The General Medical Council has had to face a severe fire of criticism during recent years, especially since the introduction of the retention fee. Yet it is only fair to acknowledge the outstanding services it has rendered in the past to medicine and it deserves to be paid a tribute. The House will recall the massively authoritative speeches of the late Lord Cohen of Birkenhead who was only recently taken from us. He was President of the General Medical Council from 1961 for a period of over nine years. Whenever he intervened in debates in your Lordships' House, he always covered the subject so thoroughly that there seemed nothing else left to be said. He was in the true line of succession of great physicians who, from the time of Maimonides onwards, have adorned the medical profession since the golden age of Spanish civilisation.
When he presided over the deliberations of the Disciplinary Committees of the GMC, he exercised a patience and a 1174 kindliness that were limitless, and he seemed to lean over backwards to avoid having to inflict upon a fellow doctor the ultimate penalty of being struck off the medical register. That consideration and carefulness, in the interests of the patient, be it noted, as well as of the doctor, have been handed down to his successor, but unfortunately the GMC has become hamstrung by its own restricted powers, many of which are now completely out of tune with the times in which we live. Its machinery is clogged up and cumbersome, often operating far too slowly, and against the best interests of both doctor and patient.
I shall not go into many of the other archaic anomalies which the Bill seeks to rectify. Ample opportunities will, I hope, be afforded to the House during its Committee and later stages. However, I should like to say at this stage, how glad I am that this highly important and somewhat technical Bill has been introduced first of all in your Lordships' House, so that, within its accepted limitations, it may eventually proceed to the other place as a universally agreed and, I hope, almost complete, piece of legislation. But there have been so many outdated powers exercised, inequitable decisions arrived at, and even lamentable injustices inflicted, by the General Medical Council in the past on a long-suffering medical profession, that I, for one, welcome the Bill with all my heart.
§ 6.50 p.m.
§ Lord PLATT
My Lords, I am grateful to the powers that be for putting me on late in the debate, because that allows me to cross out most of what I was going to say. I knew that in particular the noble Lord, Lord Hunt of Fawley, had gone into this matter with the greatest care and consideration to detail and that I could trust him to say many of the things that I might possibly have said myself. I should also like to thank the noble Lord, Lord Wells-Pestell, who told me in the course of not too long a speech far more than I could possibly find out from reading this document, which starts with the mysterious words in the Explanatory and Financial Memorandum:The Bill has two main purposes. The first is to provide that the composition of the General Medical Council ("the General Council") …".What does that mean? It is almost impossible to find out from this document. 1175 We can find out from reading the Merrison Report. That committee had in mind a sort of general council, which included everybody, split into sub-committees. However, I hope that we shall not give up the time-honoured and greatly respected term. "General Medical Council" and call it the "General Council" or anything of that kind. I hope that there will be no confusion in anyone's mind by the time we have finished with the Bill.
As noble Lords have said, it is, of course, true that in times gone by the General Medical Council has been greatly criticised for being unfair, behind the times, and so on. But I think all will agree that under the presidency of the late Lord Cohen of Birkenhead that has all been altered. Its outlook has been far more enlightened, and I am sure that that will continue under its present President, Sir John Richardson. When I sat on the Royal Commission on Medical Education some of the best evidence we received was, in fact, from the General Medical Council, written I suspect by Henry Cohen himself.
Without commenting too much on the speeches made by other noble Lords, I should like to say how important it is, as the noble Lord, Lord Hunt of Fawley, pointed out, that general practitioners should have their fair say in the affairs of the profession, as ordered by the General Medical Council. I do not go the whole way with those who want to get it ail done in one Bill now, because I know from sitting on a Royal Commission, if for no other reason, that there are most difficult and controversial matters about which the profession has not yet come to any conclusion—for instance, specialist registration. To put something through next week or the week after on specialist registration might be a great disaster, but that is not to say that I rule out many other possible Amendments which may be made and I look forward to reading what the noble Lord, Lord Hunt of Fawley, and his friends will put before us.
I am almost going to confine the rest of my remarks to the question of elected members and democracy. I cannot contemplate a council of 98 members doing anything really useful. I think it was the noble Lord, Lord Hunt of Fawley, who said that to sit on a committee and 1176 feel that one is doing nothing useful is one of the most deadly things a person can be asked to do. Democracy—to which we all give lip service and, I hope, something more—is finally the best form of government; but democracy can be carried too far. An Election for Parliament is very different from an election to the General Medical Council for the following reasons. Let us suppose that an elector lives in Norwich. In a Parliamentary Election he would have the chance of meeting the candidate or at least going to the meeting and finding out his views. In any case, one's mind is already made up on a Party basis. One votes for so-and-so because one votes Labour, Liberal or perhaps even Conservative.
It is quite a different matter when one comes to elections to the General Medical Council. The man who lives in Norwich does not have to take account of how good the candidate for Southampton is. However, if one is given a list of candidates for some of the 98 places—I forget how many will be elected—it is very unlikely that the doctor in Norwich knows more than 1 or 2 per cent. of the candidates. Therefore, the whole matter is very different. Use can be made of this by bodies who sometimes behave rather more like, say, pressure groups than members of the General Medical Council might be expected to behave.
In the last election to the GMC there were 34 candidates for eight places. It is very unlikely that anybody knew those 34 candidates so the British Medical Association—always helpful—sent round a list of eight people whom they recommended. Most people, not knowing any of the eight, cast their vote for them. Thus they may discard some people of particular merit who perhaps represent minorities, which are very important in this kind of thing. In fact, the British Medical Association recommended eight candidates and gave short election addresses from each of them. It omitted all mention of the other 26 candidates, except their names, although two of them were people of outstanding merit and two had been recognised having been awarded the OBE.
At that time I wrote a letter to Lancet and the British Medical Journal, saying that I thought the least they could do was to publish short election addresses of 1177 100 or 200 words for the other 26 candidates. They did not do that, but at least they published my letter of criticism of their methods. I suggested that one should vote only for someone who one knows or someone about whom one can obtain personal knowledge and personal contacts and that one should not vote blind for another seven or eight people because by doing so one lessens the chance of electing the one candidate one really wants. I was grateful to the editor of the British Medical Journal for publishing that letter but, of course, it was a week late and many people had already voted. It is not clear from this Medical Bill by what method this election is to take place. The Merrison Report suggests the single transferable vote method of proportional representation. This may go some way to prevent pressure groups from keeping out people rather than keeping them in, which is always the danger in the ordinary election.
A great deal is left to Orders in Council and this may be a matter for regret; it may be a matter for comment; it may be a matter for unfavourable comment. On the other hand, it leaves a lot of the decisions to the General Medical Council itself. On the whole, this seems to me to be a good thing, so I do not regret that very much. I think that that is really all I need to say now that other people have spoken so fully about the Bill. In some ways it seems a matter for regret that the Bill only goes so far and no further. There does seem to be a lot of general approval of what the Bill does, and we shall see what happens to it in the Committee stage.
§ 7.2 p.m.
§ Lord FERRIER
My Lords, with others, I can express my gratitude to the noble Lord, Lord Wells-Pestell, for his introduction of the Bill. In saying that, I should like to say that I do not propose to detain your Lordships for long because I do not propose to follow the noble Lord, Lord Platt, on a subject with which I am not competent to deal at all. I have no intention of referring to the disciplinary provisions or the administrative matters within this Bill. As the noble Lord, Lord Wells-Pestell, said, there are two considerations, health and conduct, and it is the health problem which naturally excites me.
1178 I turn at once to Clause 4 of the Bill. Rightly or wrongly, I take the view that the provisions of Clause 4, and particularly of subsection (3), in view of the fact that Ireland is a member of the EEC, amount to a "foot in the door" for arrangements for aligning the conduct of medicine in this country with the conduct of medicine in the EEC. It is a long way away. The noble Lord, Lord Wells-Pestell, referred to this as being only a first stage; and of course that is what it must be.
As your Lordships may remember from previous exchanges in this House, I am particularly concerned with what the noble Lord, Lord Winstanley, described as ancillary services and the problems that nowadays they represent, particularly chiropraxy, which is what they call it in Canada. Denmark, now in the EEC, has accepted chiropraxis as part of its national health system; West Germany and France do the same in some respects. Of course, Switzerland is not in the EEC, but it has its own arrangements in that regard. Within the Commonwealth, New Zealand has for six years had this ancillary service accepted as part of its National Health system.
I would assure your Lordships that I have no intention of talking about amendments in this respect. I look forward to knowing what my noble friend Lord Sandys has in mind when referring to possible amendments at the Committee stage of this Bill. I would only point to Clause 4(2) and the powers which it confers on the Ministry. Admittedly, subsection (7) makes amendment subject to Negative Resolution and, as I have said before, Lord Wells-Pestell's speech referred to the necessity for further stages. Nevertheless, it would appear to be prudent to draw the attention of the Government to the probability of having to provide for regulations in respect of manipulative therapy in the future. I use the word "probability" because I sincerely believe that it is no longer a question of whether or no, but of when chiropractic treatment will be available under the National Health Service.
If this is a correct view, then we must also turn to Clause 14(4), which covers the question of education. This is something which is far beyond what is contemplated in this Bill. Nevertheless, in my view, it has to come. The British 1179 Chiropractic Association controls the Anglo-European College of Chiropractics in Bournemouth, from which 34 students recently graduated after their four year course. Only 11 were British. There is, of course, considerable need for more practitioners of this nature.
I agree with much of what the noble Lord, Lord Winstanley, said about the relative urgency of the various matters which face the Health Service today. I shall read his speech with the greatest interest. Incidentally, I welcome that part of Lord Wells-Pestell's speech that referred to the composition of committees, and even the composition of the Council. These are indications of progress which, from the health point of view, I feel are fully acceptable. I strongly support elected, appointed lay members, as my noble friend Lord Sandys did.
Manifestly, it will take years to overcome the obstacles which lie ahead. Take, for instance, Schedule 4 which some day will have to be virtually re-written. But this is met by what the noble Lord, Lord Wells-Pestell, said would be the subject of further legislation. Of course there are obstacles and objections, and of course there must be proper regulation. There must be a discipline acceptable to all, and this is where the education side comes in and the problems which are raised in regard to the relationship between medical education and the universities.
I was brought up by a doctor of medicine. Indeed, he was a professor of physiology. For a number of years, I was chairman of a pharmaceutical company. Consequently, I have the utmost respect and regard, in more ways than one, for the medical profession with all its faults, to some of which the noble Lord, Lord Segal, referred. I respect the standards of medicine and surgery in this country. Accordingly, I am fully aware that, like the King of the Amalekites, I must walk delicately in what I say. At the same time, the fact is that physical adjustment, including the manipulation of the spine, as a remedy for bodily aches and ills is of worldwide significance. It is generally available in North America and most of Australia.
Although it might be thought that this Bill could well be deferred for a year or two, as somebody has suggested, I am sure that the Government are in the best 1180 position to judge whether this is the time for it or not. I am happy to leave it at that. The noble Lord, Lord Winstanley, seemed to have his doubts, although in the end he welcomed it.
I would conclude by mentioning the Cochrane Committee or, more properly, the working group which will be reporting to the Minister of Health in the early spring, or so I believe, and to which reference is made in paragraph 192 of the Annual Report of the Department of Health for 1976. There is already a multi-disciplinary sub-committee considering how further to develop clinical study, and this will fit into the Bill very well.
I have only one other suggestion to make if the Bill goes ahead. In many cases of back pain, manipulative treatment can effect a saving not only in terms of pain and distress but in the economic sense by limiting the costs of extended and perhaps outdated treatment. Now that New Zealand has been at it for six years, I have heard it suggested that it could assist the Department of Health by giving some assessment of its results in this respect. If the claims, based on the experience of many satisfied customers like myself and as represented by the British Chiropractors Association, of which I have the honour to be a patron, are well-founded, the saving to the nation in expense alone must be substantial, leaving aside the physical relief which can be secured thereby.
§ 7.11 p.m.
§ Lord AUCKLAND
My Lords, joining in a debate of this kind with so much medical talent taking part is perhaps treading on rather dangerous ground. This is an important Bill which emanates from a report of unusual excellence and clarity. Your Lordships will be aware of the surfeit of Blue, Green and White Papers on the National Health Service and the various aspects of it which have been produced in the last decade or so. But of all such documents, the report of Dr. Merrison is one of the most lucid. While I must admit that I have by no means read all of it, I hope to do so before the Committee stage on the Bill because this is clearly a measure which must have a properly discussed Committee stage.
1181 The General Medical Council to the average layman is a rather mysterious and, perhaps to some, terrifying body. Some regard it with considerable cynicism. However, there is no doubt that it does a very good job in difficult circumstances. I am rather perplexed by the part of the Bill which suggests that the age limit for retirement from serving on the General Medical Council should be 70. I do not know whether this is a recommendation from the Merrison Report, but be that as it may, although it might be argued that a surgeon or medical practitioner who has to perform an operation at over 70 years of age might put the patient at some risk, the brains and judgment of a person of that age in giving the judgments which the General Medical Council gives might be very useful. I should have thought there could be some discretionary power over this, although I understand that before the recommendation conies into practice it must go before the Privy Council.
On the question of the declaration of unfitness of a doctor, we know that the medical profession and especially general practitioners are overworked nowadays. Some practices require a doctor to have perhaps 3,000 patients on his list, and if he is not in a group practice there are additional burdens. Small wonder that doctors perhaps do not possess the same standards of health as used to be the case, for with an aging population and more and more people on doctors' lists, the strains on the doctors concerned are bound to be considerable. However, I am glad to see that there are humane provisions in the Merrison Report to the effect that such doctors are not kept from practising for longer than is necessary. Of course, this must depend to a large extent on the conditions concerned.
I have received representations that the Bill does not go far enough on the question of overseas doctors. I do not think this is any disparagement of the work that overseas doctors undertake and indeed the Merrison Report says at page 74:The National Health Service is very heavily dependent on overseas-trained doctors".That is perfectly true, and now that there are far more stringent controls over language problems—their knowledge of English must be more than adequate— 1182 the presence of overseas doctors in our Health Service is essential.
As I said earlier, this is a Bill which requires close scrutiny in Committee. I agree it is an admirable measure to start in your Lordships' House; it is non-political, non-secretarian and an ideal Bill for your Lordships to look at very carefully. Although it has flaws, most of which, as has been said, go to the point that it does not go far enough, at least vis-à-vis the Merrison Report, it contains some very valuable recommendations and I heartily support it receiving a Second Reading.
§ 7.19 p.m.
§ Lord PITT of HAMPSTEAD
My Lords, I asked for my name to be put down last among the list of speakers because I thought I might be delayed in my surgery and not be here early enough to take part. There was, however, a second reason: I thought that if the points I wanted to make had already been made there would be no need for me to speak. Most of those points have indeed been made and therefore your Lordships are in for a short speech from me, and I wish to raise one point which I regard as important.
Reading the Merrison Report, it struck me that it was suggesting that the General Medical Council should be a partnership between the profession and the public; that the profession should elect representatives; that the teaching bodies within the profession should appoint their members; and that the public (that is, the lay persons, the patients) should have a certain number of people appointed to represent them, through nomination by the Privy Council. I was therefore disappointed—and I notice that none of my colleagues were—on seeing that the clause, instead of stating that the nominated members would all be lay members, states that a majority will be, which means that the Government are reserving to themselves the right to appoint doctors to the GMC.
I do not know whether the Amendments which the noble Lord, Lord Hunt of Fawley, intends to put down, cover that. If they do not, then I shall put down an Amendment to remove the words "the majority" and substitute "all" because my view is that in fact there will be enough doctors on the General Medical 1183 Council, and there will be no need for the Government to appoint additional doctors. What is required is that the lay public, the patients, should also be represented by a section of the General Medical Council. Therefore, I should like to have that point looked at, and I will certainly try to see whether the position can be changed.
The other points which I had noted have all been touched upon, and therefore I will not repeat them. But I want to say this: Since so much of the Bill allows the Government to deal with these issues by Order in Council, I cannot see why there could not have been an enabling clause to empower the GMC to do something about the registration of overseas doctors. In other words, we need not have had a definitive clause at this moment, but there could have been an enabling clause. I hope that that will come about, though I suspect that the noble Lord, Lord Hunt of Fawley, has an Amendment to cover that.
I also want to support the noble Lord, Lord Winstanley, on the question of finance. Unless the Government think again on this matter, there is likely to be trouble. It is perfectly all right to say that through the expense allowance the general practitioners will get at least most of their outlay back, but there is no such thing for the hospital doctors. That means that they will have to pay their whack and get nothing back, and there is bound to be some dissatisfaction over that. What Merrison suggested was that the bulk of the cost of the GMC should be borne by the profession, but that the Government should make a grant. I cannot see any reason why the Government should hesitate about doing that.
I hope that this matter will also be looked at, because it is silly to spoil a good Bill by an approach of this kind. I have no doubt that if it is left as it is then, sooner or later, if the cost of running the GMC gets quite high—and that means if registration fees become high—there will be problems. So I hope that the Government will think again about the question of making the grant to defray some of the costs of running the GMC. All the other points that I intended to make have already been covered, and therefore I shall not waste the time of your Lordships' House by referring to them. I support the Bill, 1184 but I hope that the Government will look at the points which have been raised, particularly those raised by the noble Lord, Lord Hunt of Fawley, because the Bill can be improved, and we ought to take the opportunity of improving it.
§ 7.25 p.m.
§ Lord HILL of LUTON
My Lords, I should like to plead the indulgence of the House in order to make the briefest of observations, stimulated by what I have heard in the debate. It is natural, proper, and useful that in a Second Reading debate there should be concentration on omissions from the Bill and criticisms of defects in it, and that we have had this evening. But I hope that that normal, natural, and useful exercise will not obscure the immense progress that is made in the Bill in one fundamental change. For the first time in the history of the General Medical Council, there will be a majority of practising doctors, doctors in daily contact with patients and in touch with their treatment.
Some of the other criticisms may well be justified, and no doubt we shall look with interest on any Amendments that are put down, but do not let us for one moment forget the immense importance of that change. Difficulties there may be in devising electoral systems. The doctors may complain of the increased cost, and seek reimbursement. They are details that should not obscure from public gaze the fact that this is a change of immense importance in the interests of the public as well as of the medical profession, and I welcome the Bill for that commanding reason.
§ 7.27 p.m.
§ Lord WELLS-PESTELL
My Lords, I must confess that some of your Lordships frighten me. I am really concerned at the suggestion that the Bill should be enlarged to include a number of other matters. My noble friend Lord Hunt of Fawley—he is my noble friend, although we share a different political view—was rather vehement about it. What I tried to say very clearly at the beginning was that there are a number of matters, a number of recommendations made by Merrison, which the Government accept, but which cannot be included in the Bill for the simple reason that there must be 1185 much discussion between the Government and the various bodies concerned. It is important that we have these discussions. If we do not, we shall find ourselves in precisely the same position we have found ourselves in time and time again; namely, putting legislation on the Statute Book that we have regretted within a comparatively short period of time.
We have often made virtues of necessity without giving enough thought to the matter in hand. I do not want to take up your Lordships' time in reciting Bill after Bill which is now giving us anxiety. The best way to have legislation on the Statute Book, which will be of supreme importance in the future, is to give it now the detailed consideration that it needs. By and large these matters are not controversial. They are acceptable to the profession, to the GMC, and so on. Let us get them through. I would appeal to my noble friends on the other side of the House who have said, quite rightly, that there are other matters that must be dealt with, that there is a time to deal with them. Let us get this Bill on to the Statute Book.
The noble Lord, Lord Hunt of Fawley, asked me to give an assurance that we would do something about these other matters in a reasonable time. I give him that assurance. I cannot say what I mean by a "reasonable time". I know that when various Departments of Government get together to discuss matters, my word! it is a job to shift them. I do not think that bodies outside Parliament, for that matter, are any different. There is a whole wealth of experience, a whole fund of knowledge, that we have to draw on. It is far better to wait, and then come forward with Bill No. 2, or whatever it may be called, knowing full well that it is the result of considered opinion, and get it on the Statute Book, knowing that it will work, and that we shall not for ever and a day afterwards regret that it is there. I give the assurance that the Government's intention is to pursue Merrison's other recommendations and introduce legislation at the first available opportunity.
Having said that, may I say to the noble Lord, Lord Sandys, who raised the question of overseas doctors, as did the noble Lord, Lord Hunt, and a number of other noble Lords, that we all know that this is full of difficulty. Time and time 1186 again we have touched on it in your Lordships' House when we have been introducing various Bills. It is not a simple matter. Do not, for goodness sake!, let us rush into this and then find that we have not given it the consideration we ought to have given it. Let us get the matter right once and for all.
The noble Lord, Lord Winstanley, said he had no enthusiasm for the Bill, but by the time he sat down I thought he had done us proud in the sense that he saw that what we were trying to do at this stage was highly desirable. He, too, mentioned the whole question of education and the finances of the GMC, as did my noble friend Lord Pitt. But, again, look at the time that we have spent in your Lordships' House on the whole question of education—weeks and weeks. I know that this is education within certain limits; but, nevertheless, they are important limits. We have said time and time again that the future depends on the quality and the content of our educational system, and not only on the people who teach it. The quality, if I may say so, of the members of the medical profession, their competence and, in the last analysis, their ability, will depend on the right concept of what education for medicine is all about, and upon its content. I do not think we can hope to deal with these things quickly. Again, we must have discussion, and it is because the Government attach great importance to the future of medical education that they wish to spend time on this matter.
Now, if I may, I come to the question of the Government's contribution to the finances of the General Medical Council. I have not said, and I do not think anybody has said, that the Government are unwilling to contribute, but I cannot say that the Government are willing to do so. Far be it that I should presume to speak for the Treasury. Nobody in their right mind would do that.
§ Lord PITT of HAMPSTEAD
My Lords, if my noble friend would allow me to interrupt, it is said here that it will cost the Government nothing. That is the point. It is here in the finances of the Bill.
§ Lord WELLS-PESTELL
My Lords, at this stage it is not costing us anything and it will not cost us anything; but this Government have always been receptive 1187 to other people's ideas, wherever they come from. While I am not going to promise that the Government will do anything at all in this matter, I think the most important question which has to be weighed up in this context is the independence of the General Medical Council: whether they want the Government to do anything in this matter; whether they might not feel compromised if the Government were to make some contribution. The medical profession is regulated by an independent body, and it may well be that they will feel it desirable to remain completely independent of the Government. But this is a matter for consideration.
I think I have dealt with all the matters raised by the noble Lord, Lord Hunt, with the exception of one thing, and that is that all orders made under this Bill are subject, as I said in my opening speech, to the Negative Resolution procedure of both Houses of Parliament. That is a political safeguard; and as so many of the matters have to be considered and discussed with the General Medical Council and other bodies with a view to framing a second Bill, it is not inappropriate—in fact, I think it would be quite right—that they should play a large part in forming the various orders. But in the last analysis every order is subject to the Negative Resolution procedure in Parliament, so Members of your Lordships' House and another place will have an opportunity to see them, to read them and, if necessary, to exercise their rights.
I think the only other matter raised by the noble Lord, Lord Hunt, with which I want to deal—and I take his point on this, which I think was also raised by my noble friend Lord Segal—is this power which is given to the preliminary proceedings committee to suspend a doctor for two months without (and I think the noble Lord, Lord Hunt, made a strong point of this) the right of appeal. Said like that, it seems unreasonable; but is a body of competent medical people, members of a preliminary proceedings committee, going to suspend one of their colleagues for two months without very good reason? It is not a group of lay people which is going to do this: it is going to be a group of medical people. Are they going to do this lightly? Of course they are not. And how often is it going to occur? I would 1188 have thought that this would not occur very often; and, in any case, the health committee or the professional conduct committee, whichever is dealing with the case, has, under the Bill, the power to revoke that suspension. So another body of medical opinion has that power. I do not think, if I may say so with very great respect, that this is something that one really need bother about. I cannot see members of the profession acting unreasonably, and I hope the noble Lord, Lord Hunt, and my noble friend Lord Segal will feel that this is so.
My noble friend Lord Segal raised the question of local machinery to approach sick doctors, and I think he said that it might be better if the regional medical service did this. I think we need to think about this. I would not know, and it is no good pretending that I do. I would have thought that it would probably be the wrong machinery, because I think it ought to be left chiefly to the General Medical Council in consultation, perhaps, with the health authorities; but I should not like to go further than that except to say that we will make a note of the point of view of my noble friend Lord Segal, to see whether there is anything that can be done in this matter. I am grateful to the noble Lord, Lord Platt. I think his point was right—naturally I think it is right because I agree with it—that we ought not to overload this Bill. I think I have said all I want to say on this. I think it would be a mistake. He raised the question of the 98 members who are going to be so shockingly unwieldy. That was the first thought that crossed my mind when I saw Merrison's suggestion of 98. But this is not a sacred figure. Nobody will say for one moment that it will be 98. This is a recommendation, and it may well be that certain people, in their wisdom, will feel that the whole affair can be managed with fewer.
The noble Lord, Lord Platt, referred to the possible change of the title of "General Medical Council" to "General Council". May I assure him that I understand that this is not in any way intended. I regret to say that it appears in the 1956 Act, where it refers to the "General Council", but I think I can honestly say without giving offence that that was a piece of lawyer's shorthand. It should have been "General Medical Council". There was no intention, as far as I know, that anything should be changed.
1189 The noble Lord, Lord Ferrier, referred to chiropractics and back pains. I was glad that he seized the opportunity of saying something about this because I know how informed he is on these matters and how anxious he is to see this in some way included in the National Health Service. He speaks with a good deal of knowledge about this—probably with more knowledge than anybody in this House. I take his point that this is something that we ought not to forget.
The noble Lord, Lord Auckland, talked about retirement. I think that this figure of 70 as the age limit for retirement stems from the recommendation in paragraph 391 of the Merrison Report which says:We recommend that nobody should be eligible for appointment or election after his sixty-sixth birthday—thus ensuring that no member of the General Council will be over 70".I think that this stems from that.
I think that, even if I have not covered them adequately, I have dealt with every point that has been raised by noble Lords. I finish where I began; that is, I hope that noble Lords will think not twice but three times when they put down amendments to this Bill, for it would be a great pity if it took so long that it ran into time difficulties. I shall say no more than that. I am not going to say that it would do so; but there is a lot of legislation before both Houses and it would be a great pity if this Bill were to suffer. I am grateful to noble Lords who have taken part in this Second Reading, for the contributions they have made and for the points they have raised; because, although I feel that these are matters for the future, they are, nevertheless, important matters.
On Question, Bill read 2a and committed to a Committee of the Whole House.