HL Deb 05 March 1981 vol 417 cc1519-36

4.19 p.m.

Baroness Young rose to move, That the draft order laid before the House on 11th February be approved.

The noble Baroness said: My Lords, I beg to move that the European Communities (Medical, Dental and Nursing Professions) (Linguistic Knowledge) Order 1981, be approved. If your Lordships approve, the effect of this order and its associated administrative guidance will be to ensure that doctors, dentists and nurses from the European Community cannot practise in the National Health Service unless they can communicate effectively in English with patients and with colleagues.

I must stress to your Lordships that the change here proposed—from a registration to an employment-linked language requirement—has neither the intention nor the effect of departing from the principle that people in health professions must be capable of accurate and vital communication with each other and with patients. We do not regard that as negotiable with any body, whether national or international. We simply propose changing the point of its application in respect of a small minority of practitioners.

The Government accept that the proposed new arrangements are necessary to meet their obligations under Community law. Essentially, the formal view of the Commission of the European Community is that the Treaty of Rome bars us from making knowledge of English an absolute condition of continuing registration of European Community health professionals, because this constitutes a restriction on their freedom of movement. However, the Community regulation of freedom of movement of workers, which has direct effect in member states, does permit employers to impose: conditions, where appropriate, as to linguistic knowledge required by reason of the nature of the post to be filled".

Thus health authorities and private employers in this country do not need new powers in order to carry out the responsibility. Nothing in Community law relieves them of it, nor prevents them from carrying it out. They have not in the past needed to exercise the competence that they have to ensure that prospective employees have the necessary knowledge of English, because they could rely on the link between linguistic ability and registration. Nevertheless we intend simultaneously to issue firm comprehensive guidance to employing and contracting authorities advising them of the administrative arrangements which will ensure that Community obligations are reconciled with the even more vital commitment to maintain the highest possible safeguards for patients. The order before your Lordships will not stand alone.

Statutory provision is, however, necessary to cover NHS general medical and dental practitioners. Despite their contractual status within the service, we have indicated to the Commission that their position resembles that of employees rather than of wholly independent self-employed professionals to whom the Community regulations that I have already mentioned could not apply. As I have said, the Government accept that the measure before your Lordships is necessary to discharge our obligations to the Community, but let us keep a sense of proportion about what is involved. It will affect only a small minority of professionals who come here to work. The scale of migration from countries within the European Community is very modest: since 1977 to date, 449 European Community doctors (other than those qualified in Ireland) have been registered in the United Kingdom. The equivalent figure for nurses in 1979–80 was 35—that was for nine months of that year—and for dentists it is only seven since June 1980. There is no reason to suppose that the present order will lead to any increase in numbers.

We have of course consulted the health professions on the proposed changes, and I know that in general they would prefer that language requirements should continue to be linked with registration for all who come here to work. I respect that view. The virtue of a standardised objective and comprehensive procedure administered by a central body is self evident, and these are just the arrangements that will continue to apply to the vast majority of overseas qualified doctors who wish to work in the NHS. I am pleased to be able to tell your Lordships that, notwithstanding its preference for treating all practitioners alike, the General Medical Council has agreed to make its central language testing facilities available to health authorities in respect of doctors from member states, and that is one of the points that we shall follow up in the administrative guidance to authorities to which I have already referred. The cost of such tests should of course be borne by the people who wish to come here to practise; they would not be a charge on health authorities.

Before turning to the order itself, I should like to make some remarks on two points which have already caused comment in another place. The first concerns the difference in treatment between those who qualified inside the Community and those who did so outside it, and the second relates to private practice. I have already pointed out the limited scope of the order, in that the employment-linked language requirements will apply only to Community nationals—necessarily, because of the power under which it is made. For other people from overseas the registration link will continue to apply. For doctors, this link was finally achieved by common consensus in the Medical Act 1978, and change would require primary legislation. I really would not expect the public, nor the profession, to welcome its wholesale abandonment when there is no need for doing so. I have already mentioned the evident virtues of a centrally imposed requirement. For European Community practitioners, we propose some changes—in method, but not in objective—in pursuance of our obligations under Community law. That does not mean that the safeguards imposed in respect of other overseas qualified doctors are rendered less necessary, nor does it prove that they should be abolished.

In practice, the new arrangements offer no significant advantage to Community nationals, since all overseas qualified doctors wishing to work in the NHS will still be subject to a language requirement. In fact there is even a tightening-up, since a European practitioner will no longer have the six months' period of grace after registration in which to satisfy the General Medical Council of his knowledge of English—a concession not available to other overseas qualified doctors. There was always an outside chance that a European Community doctor could enter NHS general practice in an open area during such a six-months' period. Now he will have to demonstrate his knowledge of English at the outset. Many would see the existing registration-linked requirement as an advantage, since, once it is satisfied, a doctor can move between employment without on each occasion having to prove his linguistic ability.

Finally, we are making efforts to reduce the administrative burden on health authorities. To impose on them the onerous task of applying employment-linked language requirements to the very much greater number of overseas-qualified practitioners would, especially when there is no need to do so, be most irresponsible.

As for private practice, it is quite true that it is our obligation to our Community partners to allow any suitably qualified practitioner from another member state to establish himself in the United Kingdom without creating any obstacle to registration. By the same token, however, we expect other member states to accord that treatment to our own suitably qualified nationals. Certainly, European Community practitioners coming, or proposing to come, here will be advised of their professional responsibility to acquaint themselves with the language and of the consequences of failure to do so. In reality, it is unlikely that a practitioner who could not communicate effectively would be accepted into a private partnership, and, if he planned to practise alone, his employers would be his patients. It is even less likely—and this is, I understand, a view shared by other member states—that he would succeed in attracting fee-paying patients in competition with those practitioners who could communicate effectively.

Turning to the order itself, this is a United Kingdom measure, made under Section 2(2) of the European Communities Act 1972. It arises from our obligations under Community law, and its scope is restricted to Community nationals. Article 1 is formal, and Article 2 repeals enactments which require European Community nationals who qualified in a member state as doctors, dentists or nurses to satisfy the appropriate registration body as to their knowledge of English on or within six months of registration in the United Kingdom.

Article 3 inserts a new subsection 1A in Section 30 of the National Health Service Act 1977. I should perhaps explain that at present family practitioner committees are obliged to forward all applications for inclusion in the medical list to the Medical Practices Committee, the central body which decides on the distribution of general practice. But the Medical Practices Committee is not itself the contracting authority and therefore, in respect of doctors from the Community it is the family practitioner committees and not the Medical Practices Committee, which need to be satisfied that potential practitioners have the knowledge of English which is necessary in their own and their patients' interests. The new subsection precludes a doctor who is a national and who qualified in a member state from having his application for inclusion in a medical list forwarded to the Medical Practices Committee unless he so satisfies the relevant family practitioner committee. A consequential amendment is made to Section 33(5) of the Act precluding a right of appeal against refusal of an application by the Medical Practices Committee.

Article 3 goes on to add a new subsection (2) to Section 36 of the 1977 Act, so as to provide that a dentist who is a national and who qualified in a member state, shall be included in a dental list only if he satisfies the family practitioner committee as to his knowledge of English. Articles 4 and 5 make for Scotland and Northern Ireland respectively similar provision to that made by Article 3 for England and Wales.

The purpose of the order before your Lordships is to meet the requirements of Community law by practical measures involving the minimum of bureaucratic fuss, consistent with the well-being of patients and the professions. I have said that the measures are twofold. There is the order, and there will be firm administrative guidance to the National Health Service which will make clear to the employing and contracting authorities the extent of their responsibilities within the changes that are proposed. Health authorities have well-established appointments procedures, which they will need to adjust so as to require European Community applicants to give evidence of knowledge of English, and to ensure that they demonstrate it at interview. Family practitioner committees will need to make similar arrangements, and this subject will be included in the guidance which is at present under discussion.

This implies some additional work for the authorities, but, against that, by highlighting the language element in the selection of staff the right of authorities to choose people best suited to the local environment and needs is reinforced rather than diminished. With regard to our own United Kingdom doctors and dentists, I am advised that to confine the effect of this legislation to Community nationals other than our own would constitute discrimination in the latter's favour. The practical effect of this in my view is insignificant, since it will be for family practitioner committees, or their Scottish and Northern Ireland equivalents, to determine how to satisfy themselves about the applicant's knowledge of English. They will therefore be free to accept evidence of a United Kingdom or Irish qualification as sufficient.

My Lords, I have devoted much of my time to reference to the medical profession; but the order also applies to dentists and nurses. With regard to the former the numbers affected, as I have already indicated, are small indeed, and the General Dental Council does not at present impose a standard language test on European Community dentists, but relies instead on interviews and relevant qualifications to provide evidence of knowledge of English. In future it will be for health authorities and family practitioner committees to conduct such interviews and to apply any more formal language test in addition, if they so wish, in respect of European Community dentists who apply for a post or entry to a dental list in this country. In respect of the nursing profession, I understand that the General Nursing Council for England and Wales is now finalising a test that can be applied to all overseas qualified nurses, and it is envisaged that the test will be available to NHS authorities in respect of nurses from the European Community.

In conclusion, I can assure your Lordships that NHS authorities will be encouraged to apply standards no less exacting than registration bodies now apply to them. They will even be free to impose a tougher standard if they feel the job requires it. Flexibility to fit people in particular jobs may in some circumstances be helpful to employers who need bilingual staff. I commend the order to the House.

Moved, That the draft order laid before the House on 11th February be approved—(Baroness Young.)

4.33 p.m.

Lord Wells-Pestell

My Lords, we are obviously very grateful to the noble Baroness the Minister for introducing this order in some detail. It is an order of some importance, although I am inclined to say that it perhaps tends to conceal more than it reveals. We on this side of your Lordships' House are not very happy about it. I do not want to go into it at very great length because I happen to know that two or three of my noble friends will want to make a contribution, and I have some idea of the field that they may cover.

We on this side of your Lordships' House are agreed that it is of supreme importance that doctors and nurses and dentists coming from EEC countries must be able to speak English and be understood, and be able to communicate with patients and with colleagues. This is obviously a matter of very great importance. What concerns me at the moment is that, although the order is called the European Communities (Medical, Dental and Nursing Professions) (Linguistic Knowledge) Order 1981, I do not see in the order where in fact it refers to nurses, except in what I would call Article 2, which deals with the repeal of English language requirements for medical and dental practitioners and nurses. Unless I have not been reading it correctly, there seems to be no reference to nurses anywhere else apart from that particular article; and this seems to us to be of supreme importance.

As the noble Baroness said at the very beginning, we had an order, which was known as the Medical Qualifications (EEC Recognition) Order 1977, under which a doctor or a dentist coming from any of the EEC countries could register for a period of six months, and during those six months he or she had to satisfy the General Medical Council that he or she could speak English sufficiently clearly to be understood and able to converse with colleagues. If at the end of six months the doctor coming from the EEC country was not able to do that, I believe I am right in saying that the registration lapsed.

We have a situation now where this matter has been cleared up in this order, I think from the point of view of the doctors and dentists in a satisfactory way, except that we have had to concede to the EEC that we have no right to impose a linguistic test at the point of registration. But apparently we have found a way round that, because the noble Baroness said that it could be linked to employment. Her honourable friend the Minister of Health said in another place on 24th February 1981: However, the Community regulation on freedom of movement of workers, which has a direct effect in member states, permits employers to"— and then he himself quotes— 'impose conditions, where appropriate, as to linguistic knowledge required by reason of the nature of the post to be filled'."— [Official Report, Commons. 24/2/81; col. 836.] So it can be applied, presumably, outside the medical profession. But I should like to know (and I know that my noble friends would like to know) where that quotation is taken from, because he gives no indication as to where it comes from.

As I say, I am not really concerned with the position of doctors and dentists because I feel that this regulation, from our point of view, ties it up very firmly and without any (shall I say?) difficulty at all. But what does concern me is the position of nurses coming to this country. The noble Baroness, as did her honourable friend the Minister of State in another place, said that the scale of migration from countries showed that since 1977 there had been only 449 EEC doctors other than those qualified in Ireland, and then went on to say that so far as nurses are concerned, in the year 1979–80 the number was 35, and for dentists, since June 1980, only seven; and her honourable friend in another place (I am trying to remember the exact words he used) I think said, "We have got to keep this in its right perspective".

This is precisely what I want to do; because, while it may be true that in 1979–80 the number of nurses who came from EEC countries into this country was only 35—and, as the noble Baroness said, it was only 35 in nine months—the fact remains that we are led to believe that there is not going to be a great influx of nurses from EEC countries, whereas in fact in the full year of 1980 there were no fewer than 203 nurses coming from Belgium, Denmark, Eire, France, Italy, Luxembourg, the Netherlands and West Germany. That means that in this country we have at the moment coming from the EEC approximately one nurse in every 70. I should like an assurance from the noble Baroness the Minister that nurses are going to be subject to the same kind of linguistic testing as are doctors. I have already said that I may have misunderstood the order; but, reading the order which is now before the House, I am not clear that it lays that down.

I will not say that it is more important that a nurse should have a good knowledge of English than that a doctor should, but as one who in recent years has spent many months in hospitals I will say that I had more to say, and wanted to say more, to the nurse than to the doctor. The nurses are on duty 24 hours a day looking after the patients and it is tremendously important that there should be no difficulty at all in communicating with the nurses. When it is said, "Let us keep what is involved in proportion", I think the situation of the nurses is very important. I want to ask the noble Baroness the Minister what really is the position with regard to the nurses.

I know that the General Nursing Council have been very careful about the ability of nurses coming from the EEC to speak English clearly and distinctly. I accept that the 203 who came here in 1980 were able to satisfy the General Nursing Council. Are the General Nursing Council going to be able to apply a linguistic test on the nurses? As I have said, it is not clear to me from the order. I should be grateful if it could be pointed out where it explicitly says so. I do not wish to take up any further time other than to say that I think this is a matter which must be cleared up. I know that a number of my noble friends will want to add their contributions.

4.42 p.m.

Baroness Phillips

My Lords, I shall not keep the House for very long but I should like to underline what my noble friend has just said. Recently I was in an hotel restaurant, an experience which many noble Lords will have had, where four of us were attempting to order. It was an expensive restaurant. Since none of the waiters spoke English, the outcome was that the only kind of order which was effective was the kind attaching to the numbers on the menu. If you wanted "No. 42", that was splendid. But if you wanted roast potatoes as opposed to sauté potatoes, that was not understood. It was an irritating and frustrating experience. Anybody who, as I do, spends time on the No. 74 bus knows how entertaining it can be. Even this morning a bus conductor was trying to explain to somebody that that particular bus was the right numbered bus but it was not going as far as the individual wanted to go. This held up all the workers and resulted in some irritation.

Neither of these incidents was serious or dangerous, but if one has been into a casualty station and seen people brought in in a state of stress or shock trying to explain to a young nurse who they were and what had happened, one knows it is absolutely essential that nurses can understand patients and that patients can understand nurses. I cannot underline this too strongly. I think this is an example of what we are seeing constantly with Community orders. I recently went to meet somebody returning from Canada, a good British subject who, having taken out Canadian citizenship, had to come through the "Aliens" entrance while people from the EEC entered quite freely. I am not against people coming in, but there is a total nonsense in this situation if one looks at it objectively. We welcome the nurses, the doctors and the dentists, but it is essential that they speak English clearly and can understand the English of the patients. I am not now emphasising the situation of their professional colleagues. It is not important, perhaps, if a surgeon cannot speak English. He can probably indicate by sign language which instrument he wants. But to the patient it is absolutely essential.

The General Nursing Council are concerned about the matter and have written to a number of noble Lords. I notice that the Minister again repeated that this order will affect only a small minority of the professional people who come here. These were the words used by the Minister in another place. This is the particular phrase which the General Nursing Council, not exactly a revolutionary body, have objected to. My noble friend has pointed out that the numbers were incorrect. Above all, we must have the records straight when we are talking about an important order like this. I should like to say to the Minister that I am sure that the General Nursing Council has communicated with her right honourable friend saying that they continue to believe that proof of linguistic competence linked to registration is logical and necessary. It must be linked with registration. There is no use in having nurses here and then discovering, when they are actually in operation, that they do not have this competence. I feel that this order may go through quietly and unobtrusively if we do not make it clear that it is contrary to the beliefs and wishes of, certainly, the General Nursing Council. As my noble friend pointed out, the medical profession and the dental profession have not made the same overtures. But this representative body of the nurses have approached us, and I hope that due notice will be taken of their fears.

Baroness Elliot of Harwood

My Lords, like the noble Baroness, Lady Phillips, I am associated not with the General Nursing Council but with the Royal College of Nursing, and I have had a very interesting letter which was received also by the noble Lord, Lord Wells-Pestell, putting the points which have been put already by him and by the noble Baroness, Lady Phillips. I should like to say that, while I am a strong supporter of the EEC—and I realise that it is important that there should be freedom of movement between the EEC countries—I agree with what was said by the noble Baroness, Lady Phillips, that this freedom of movement is useless if members of the nursing profession or doctors or dentists come into the country but cannot make themselves understood. Not only can they not make themselves understood but the people they are attending cannot make communication with them. Fortunately, I have been in good health all my life, but when I have been ill it has been absolutely vital to be able to talk with freedom and understanding to the nurse or doctor looking after me.

I feel that this proposal which has been suggested to Her Majesty's Government by the General Nursing Council is one which it is difficult to refuse. On the other hand, I think it is equally important that we should just not accept it without being certain we can make some alteration if we want to or put in some of our own views in order to protect the patients and the profession. As the noble Lord has said, 203 nurses came from the EEC last year and perhaps there will be a good deal more this year or next year. If we are to have coming in a lot of nurses and members of the medical profession who cannot speak the language, that will be very awkward indeed. I hope that the Government—while in the difficult position of not being able to disagree with this—will realise that there is something which might go wrong and be detrimental to the patients and the nursing profession. I hope they will not just accept it with open arms.

Like the noble Lord opposite, I think this a very doubtful order, one which I wish we did not have to accept, although I expect it will be necessary to do so. If we do so, I hope that the noble Baroness and her department will be very strict in administering it, so that we get the very best results that we can in the shape of people who learn the language, understand the language and are prepared to spend time being able to communicate properly in the English tongue with their patients. Although I am not at all enthusiastic about this order, I realise that there are complications in the Community and probably the Government have to accept it. It may have very unfortunate repercussions and I hope that the Government will be prepared to make changes if they are necessary.

Lord Richardson

My Lords, I speak as the immediate past president of the General Medical Council who was concerned from the point of view of the Council, the regulating and registrating body of the medical profession, with the implementation of the National Health Service Act 1977. It worked very well. I know that the noble Baroness the Minister, and indeed all noble Lords and Baronesses who have spoken this evening, regret that those provisions cannot, for EEC legal reasons, be continued. I am however concerned about what I see as a gap. We have been talking about National Health Service employees, Government employees, where employers have to decide about the competence of those they propose to employ and how, in the case of doctors, they will use the existing mechanism. That mechanism works and I feel sure that it will continue to work. But what about those who come to this country who are not employed by the National Health Service and whose employers are not concerned to have them tested for their linguistic competence or those who will have no employers except themselves?

I am concerned about patients, and patients are not confined to the National Health Service. There is here a big gap. It may well be that the noble Baroness the Minister will be able to tell us that in the past six months, since I ceased to be concerned directly and responsible in some sense from the medical profession's end of these matters, some advances have been made. But I am not aware of them.

Regarding nurses, certainly communication is vital for the comfort of the patients and indeed for their safety. It is as great as with doctors. But with both it is absolutely essential not that the patient should be understood but that the doctor should not be misunderstood by the patient. As we all know, all citizens are much concerned with communication between the medical professions, the healing professions, and the public. This is absolutely vital. We must all try to get it better. But there are gaps in ensuring that at least a proper and objective test has been applied so that people can understand, and in order that gross misunderstandings will not occur. Otherwise people will be at risk of further misunderstanding.

4.53 p.m.

Lord Wynne-Jones

My Lords, I am sure that we have all been very grateful to the noble Baroness for the care with which she has outlined this order. But, as my noble friend Lord Wells-Pestell pointed out, there is one gap—and that refers to nurses. Having explained the rest of the order in detail, the noble Baroness pointed out that nurses were also included and indeed that is exactly how it is put down in the order. There is no clear reference to nurses except that they are included in this abolition of the old form of testing.

The noble Baroness said—I am sure she had no intention to mislead the House in the matter—that the General Nursing Council were themselves studying the problem of carrying out the test. This may indeed be true. In fact, it would be strange if they did not study it. However, according to the letter of which I have a copy—and other noble Lords also have copies—the deputy registrar of the General Nursing Council says: Dr. Vaughan knows well that this nurse registration authority continues to believe that proof of linguistic competence linked to registration is both logical and necessary, and that it has refused to respond to the attempts of his officials to take a different view". In other words, the General Nursing Council remains—and this letter to me arrived only today—of the opinion that the proposal in the order is not satisfactory so far as nurses are concerned.

As has been pointed out by several of your Lordships, if one is in hospital—and for one reason or another, I have been in and out of hospital several times over the past two or three months—there is no question at all that the nurse is the most important person. Without the nurse, one receives no attention at all. One may have the best physician and the finest surgeon in the world; but the physician and surgeon cannot come to see the patient whenever the bell is rung. They will only come at certain set times because they have a vast number of other activities to carry out. However, the nurse is there specifically to look after the patient.

It seems to me an incredible suggestion that one can leave the language in which the nurse communicates with the patient to the matter of chance as to what country that nurse happens to originate from. This seems an extraordinary way of doing it. We set out regulations about the qualifications that they have but nothing about the language which they use for communication. Yet, when they are in hospital, their value is precisely in communicating the skill and training that they have, and the instructions that they have been given by doctor, physician and surgeon. They cannot do this without the language of the country.

One would have thought that this was so obvious that it would be meaningless to have any regulations dealing with nursing without making it clear that the nurse must show proficiency in the language of the country in which she is actually practising her job. I implore the noble Baroness to look at this matter with careful consideration. This aspect is not covered by this order. The doctors and the dentists are covered by the order; the nurses are simply thrown in and they are not covered properly by the order, yet they can form a most important part of the whole.

Speaking for myself, I would gladly be dealt with by a doctor who spoke some language other than my own. I might learn the language or, in any case, I might get some fun out of it. But when one is ringing a bell in bed in hospital it is not for the pleasure of seeing the nurses, great as that might be, but the desire to get immediate attention and to be understood.

Baroness Vickers

My Lords, first I must declare an interest in that I am a member of the Statutory Instruments Committee, but of course we are allowed to see only whether the instrument is correctly drawn and are not concerned with the policy of the instrument itself. I should like to raise one point and to quote from what the Minister said during a debate in the other place on 24th February. Dr. Vaughan said this in col. 851: I am aware there is a good deal of anxiety about the position of overseas doctors. I mentioned in opening the debate that it would require primary legislation to change the Medical Act".— I should like to know whether my noble friend can tell me anything about that and say when it is likely to happen— … My information is that, in practice, overseas qualified doctors with British citizenship wishing to migrate to other States of the EEC experience no major difficulty in securing registration on the basis of qualifications acceptable to the General Medical Council. I shall look into this matter again. I hope that the fears expressed today are unfounded, but I understand the desire of overseas doctors to be treated in the same way as other British citizens. I have therefore agreed to meet a delegation from the Overseas Doctors Association and the BMA to look into this yet again". I should be grateful to know whether this has been undertaken or whether it is to be undertaken in the near future.

I should also like to point out that dental nursing is very important in this respect. When I am at the dentist's I find it practically impossible to communicate even in my own language, and I think it may be very difficult to communicate in that state. So I should be very grateful to have an answer as to whether this delegation has been met and what has been the result.

5.2 p.m.

Lord Pitt of Hampstead

My Lords, I should like to follow the noble Baroness because she has raised the question of overseas doctors, and this order seems to me to be another example of the discrimination which overseas doctors experience as opposed to doctors from the EEC. An overseas doctor who wants to practise here has to pass a language test: that is settled. Personally, I think it is right that that should be so; but we now have this new arrangement under which doctors from the EEC can come here. They do not have to pass a language test and they are registered because of their qualification in the EEC. According to the noble Baroness, if they apply for a job in the National Health Service the employing authorities will be given guidelines to ensure that these people speak English properly before they are employed. I would concede that: I think it is quite possible to do that. I would merely hope that the guidelines are tight enough to ensure that all the authorities are strict in observing them.

The noble Lord, Lord Richardson, pointed out, however, that it is not only in the National Health Service that medicine or dentistry is practised and there is nothing at all in these regulations to prevent any doctor from any EEC country setting up in Harley Street, Wimpole Street, or anywhere else: nothing at all. Whether he learns English in one year, 10 years or 40 years, he will still be free to go on practising.

There is also the question of the private hospitals. There will be nothing to prevent any of these private hospitals employing professional people without bothering about whether or not they can speak English. The noble Baroness pointed out that they have the power to control. I agree that is so, but what they will not have is any definite compulsion to do so. Therefore, as the noble Lord, Lord Richardson, pointed out, we may well have a situation in which doctors may be practising even though in fact they cannot communicate. This is something which needs to be looked at because it strikes me that regulations can be made to control certainly the employment of doctors, dentists or nurses in private institutions. I think the Government ought to look carefully at this matter with a view to taking the power to do just that.

I should like also to deal with the point reaised by the noble Baroness, Lady Vickers, because of course overseas doctors are again handicapped when they want to practise in the EEC since the regulations under which EEC members can practise in each other's countries mean that their basic qualification must be within the EEC. Therefore, if a doctor has taken his basic qualification elsewhere he is not allowed to practise and he has not that freedom to practise everywhere in the EEC.

I have never been able to understand why the Department of Health, in its negotiations with the EEC, has not been able at least to get it accepted that doctors who have their MRCP or FRCS or any of the advanced qualifications here, even though their basic qualifications are elsewhere, should not be allowed to practise. As I understand it, the question concerns the basic qualification, and still remains so. I have never been able to understand why it has not been possible for there to be negotiations with the EEC to enable doctors who have senior qualifications to be free to practice within the EEC. I can understand a doctor who has been qualified for quite a few years saying: "I am not going to sit my MB once more in order to be able to go and practise elsewhere"; but if he really wants to go and practise elsewhere—and he could if he had a higher qualification—it would be an encouragement for him to get that qualification. I have never been able to understand why the negotiations have not gone along those lines and why it has not been possible to get that sort of agreement.

I am digressing from the order, of course, but the noble Baroness, Lady Vickers, gave me the chance and I took it. Corning back to the order, I think we ought to look at ways of tightening it. I genuinely believe that the loopholes that have been allowed are too many and that the Government can find ways of tightening them.

Lord Colwyn

My Lords, before the noble Baroness replies, I feel I should say a few words on behalf of the minority profession, the dentists. I must declare two interests: one is that I am a practising dental surgeon and, secondly, I do speak English although perhaps it is usually a one-sided conversation on most occasions. We do appreciate the need for this order to be passed because it brings us into line with the obligations of the EEC. However, most dentists and the General Dental Council are not very happy about it because our system of testing language ability in the past has worked very well and this is now going to move the onus of assessment to the area health authority rather than to the central controlling body—in my case, the General Dental Council. However, this must be done to fit in with the order; and we support it.

It is really common sense and quite obvious that any medical or dental practitioner must be able to communicate with his patients, and we really do not see that under this order there will be all that much change. I thought this afternoon's debate was going to be very good-mannered, and we are talking about discrimination now—this was cunningly brought in by the noble Lord, Lord Pitt. In order to practise in this country —and again I speak as a dentist—you have to register, and to register you have either to pass a recognised examination or take a statutory examination when you come into the country.

We recognise the qualifications from the EEC countries and also from Australia, New Zealand, Malta and Singapore. In the last four countries, their examinations are based on English so there is no problem there, while those practitioners from the EEC did, and will still have to, demonstrate their ability to speak English in order to work in this country. All qualifications in medical and dental authorities are recognised, and thoroughly checked by visits to universities by our own bodies in this country, so there is no chance of poorly-qualified doctors or dentists coming in and working in our system. Dentists from other countries, whose qualifications are not automatically accepted, have to take a statutory examination. This examination is very comprehensive and it is one that is taken in English. If they pass it, one assumes that their ability to speak English is acceptable and further testing is unnecessary.

Recently, when this order was publicised, we read in the ordinary press, and even in the slightly irresponsible dental press, implications that some patients would be faced with long queues in the waiting rooms, queueing up to see dentists who did not even speak the language. That just is not so. I should also like to answer the noble Lord, Lord Pitt, about the prospects of private practice, because I do not see that a requirement to speak English is at all necessary. Again, if you are in practice, you have to register and the registration requires taking the necessary degree or statutory examination. In private practice, the employer is the patient and not the area health authority, so an ability to speak the language is irrelevant. Patients will not queue to see private practitioners if no communication is possible. Such a practitioner would not be able to make a living. Finally, I appreciate the need for the change in this order. I do not think it will necessarily be more efficient, but there is no doubt that it will work, and I support it.

5.12 p.m.

Baroness Young

My Lords, I should like at the start of my reply to this short debate on an important order to say that, of course, I and my colleagues understand very well those who are concerned that people may not be able to communicate with a doctor, a dentist or a nurse. This is a very serious matter, but we must be quite clear about why this order arises. This is not, in any sense, intended to be some kind of debate on the European Community, of which we are now a member. This is, of course, part of our obligations under the treaty that we are trying to fulfil. I would say to all noble Lords who have expressed concern, that what we are attempting to achieve is the best that can be managed within Community law and that, if we were not to move down this path, we could find ourselves in a far worse position than we have under the order.

Just to clarify the position, I should like to set out the background. Noble Lords will be aware that one of the aims of the Treaty of Rome is freedom of movement of workers between member states. For professional people, whose ability to practise depends on the possession of recognised qualifications, this is covered by directives providing for the mutual recognition of those qualifications. There are two directives affecting doctors, which were approved in 1975. One of them is relevant, in that it enjoins member states to see that migrant practitioners acquire a knowledge of the language necessary to exercise their profession in the host country. It was the intention of the Medical Qualifications (EEC Recognition) Order of 1977 to implement this directive in the United Kingdom. That order provides that the General Medical Council must satisfy itself about the knowledge of English of European Community doctors on or within six months of registering them.

However, in a formal reasoned opinion delivered in 1979, the European Community Commission requested the removal of this provision, on the grounds that it constituted a restriction on the freedom of movement of professionals and was therefore in contravention of Article 52 of the Treaty. The Commission's objection extends to doctors and nurses, as these professionals have since been the subject of further directives and the European Community recognition orders containing parallel provisions on language requirements. If its view is not acted upon, the Commission may forthwith refer the matter to the European Court, and it is the Government's view that the present arrangements could not be defended before the court with any conceivable advantage to the United Kingdom. We therefore have this order today and which we hope meets some of the anxieties that have been expressed, without contravening European law.

If I may put it in these rather simple terms, there is a very well-known couplet which goes, Be sure to keep a hold of nurse, For fear of finding something worse", and, in a sense, that very much applies in today's circumstances. I was therefore very glad of the general welcome that the noble Lord, Lord Wells-Pestell, gave to the provisions governing doctors and dentists, and of what was said by my noble friend Lord Colwyn, who spoke about dentists. That was very helpful indeed.

Before turning to the general points that have been raised, perhaps I may attempt to answer the question raised by the noble Lord, Lord Pitt, who suggested that there might be some discrimination against over- seas doctors. This is an issue which is naturally of deep concern to us all, though it is rather wide of the order. But I can well understand the desire of overseas doctors to have exactly the same freedom of movement as other British citizens, and I understand that the Minister of Health has agreed to meet a delegation from the Overseas Doctors' Association and the BMA to see what can be done in that regard.

Most noble Lords—in particular, the noble Lord, Lord Wells-Pestell, the noble Baroness, Lady Phillips, the noble Baroness, Lady Elliot, and the noble Lord, Lord Wynne-Jones—raised points about nurses. Perhaps I may begin on the question of the figures for nurses. The figures which were supplied by the noble Lord, Lord Wells-Pestell, relate to the calendar year 1980 and include at least half of those who qualified in the Republic of Ireland, who will, of course, speak English. The official basis of the published figures is April/April, and I have given the latest figures that are available.

As regards European Community nurses as a proportion of all overseas nurses, the House may be interested to know that there are about 3,000 overseas nurses who register annually in the United Kingdom. Of those, the overwhelming majority come from Commonwealth or other English-speaking countries, with more than 50 per cent. coming from Australia and New Zealand alone. I was asked whether the General Nursing Council was going to apply a test and the answer is, no. It will be for the health authorities to use the facilities provided by the General Nursing Council, if they so wish.

The noble Lord, Lord Wells-Pestell, and the noble Baroness, Lady Phillips, both asked why nurses are not mentioned in the order itself, except at the beginning in the repeals. That is because the order covers only contractors in the service—that is, general medical and dental practitioners—and does not cover doctors and dentists who are employed by health authorities. The reason why it does not cover those doctors is that health authorities already have powers to apply a language requirement and they will be given clear guidance as to how they should exercise those powers. I think that that answers the very practical point which the noble Baroness, Lady Phillips, raised about a casualty department, which would almost certainly be in a National Health Service hospital, and would be staffed by employees of the National Health Service. Of course, guidance will be given to area health authorities to assure themselves, in employing National Health Service doctors, dentists or nurses, that they have this competence in English—

Lord Wells-Pestell

My Lords, before the noble Baroness carries on, I wonder whether she would allow me to intervene at this stage. Is she saying that health authorities can use their discretion as to whether they will apply a language test, so far as nurses are concerned? I think that is precisely what she said; that it would be within their discretion. May I ask her whether the Government would give an undertaking that health authorities will be asked to see that an English test is, in fact, applied to all nurses if they cannot speak English adequately? One must bear in mind that there are large areas of England today where it is difficult to get nurses. I can see the more competent ones coming to areas which are already reasonably well supplied, and those who cannot speak English, unless they are compelled to take the test, will be engaged by health authorities where it is difficult to get nurses.

5.20 p.m.

Baroness Young

My Lords, as I have already indicated, at the moment the number of nurses who cannot speak English coming to this country from the countries of the European Economic Community is quite small. My understanding is that area health authorities will be required to satisfy themselves that doctors in the National Health Service have competence in English and that the same will apply to nurses. If I am in any way inaccurate about that, I shall write to the noble Lord.

A number of noble Lords asked me about the other issue; namely, private practice. The noble Lord, Lord Pitt of Hampstead, asked what would be the position of patients who go privately to consultants. The position is that doctors in private practice will not be required to pass a language test, the view being that nobody will pay to consult a doctor if he is unable to communicate with that doctor—I think there is a great deal of sense in that—and that anybody who employed a doctor privately would be unlikely to employ somebody who could not communicate with patients.

Those running private hospitals or nursing homes will have the right, if they so wish, to test the language ability of the doctors, the nurses or the other people whom they are employing. This is not the direct concern of the registering health authority. The 1975 Act gives to the registering health authority the power to refuse registration where they are satisfied that the person applying for registration, or any person employed in a home or hospital, is not a fit person. Language ability could be relevant in determining whether a particular member of staff was a fit person—that is to say, could speak the same language as the patients. The person in charge of a home registered under the 1975 Act must be either a registered medical practitioner or a registered nurse. The language ability of that person may well be a factor which the health authority takes into account in deciding whether he is a fit person to be in charge of a registered home.

The further safeguard that private employers will be conscious of their legal liability for the consequences of failures on the part of practitioners whom they employ will, I hope, make them very careful before they employ people who might be regarded as unsuitable, not because of any of their medical qualifications but because of their inability to speak the language.

It is extremely important to remind noble Lords that the requirement for registration remains. All doctors coming from the European Community or anybody wishing to practise in this country must be a registered doctor. So one has assurances about their medical qualifications. The only point we have been discussing this afternoon is the requirement that as well as being properly qualified they should also be able to speak English.

I am very well aware of the strong feelings which have been expressed this afternoon in your Lordships' House. I hope I have been able to answer the points which have been raised but if, on reading Hansard, I find that there are any which I have not answered, I shall of course write to the noble Lord concerned. In any event, I shall draw the attention of my honourable friend Dr. Vaughan to this afternoon's debate, which I am sure he, too, will want to study.

Baroness Phillips

My Lords, before the Minister sits down, may I ask her whether there is any definition of this linguistic competence? Luckily I am healthy and have not been in hospital, but we have all suffered at hotel registration counters because of somebody who speaks only about 100 words of English. They can understand you, provided you keep within the tramlines of, "I am so-and-so and I wish to register here". But if you ask them anything beyond that they give you a completely blank look because their English is very limited. In a hotel or restaurant this can be frustrating, but in a casualty department it would be absolutely dangerous.

I recall that a long time ago the miners would not have European workers in the pits. They were very much criticised for this but it was because of the nature of the occupation: the danger of being unable to communicate rapidly. I do not like this period of six months. People could come here and might appear to speak enough English to get by. That would be sufficient in many professions but, whatever the EEC feels, I do not believe it is good enough in a profession where there is an element of danger so far as safety is concerned.

Baroness Young

My Lords, I can reassure the noble Baroness on her last point. The position at present is that EEC nationals who come here to register do not have to take a linguistic test for six months. That will end. This is an improvement. Not only will an EEC national who is a qualified doctor and who wishes to come and practise in the National Health Service have to register; the area health authority which employs him will also have to satisfy itself that he can speak English or can communicate in English.

I understand that the General Medical Council, which at the moment undertakes not only registration but also the language test, will make available for use by area health authorities or, alternatively, family practitioner committees—because a person might wish to be in general practice—their tests. To use these tests requires reasonable competence in English. As the noble Lord, Lord Richardson, quite rightly said, it is just as important that the patient should understand what the doctor is saying to him as that the converse should be true. From the point of view of the patient, the situation is in some respects better now than it was.

I can assure noble Lords that we shall be looking very carefully at the guidance which is to be given to area health authorities or to family practitioner committees about the kinds of test they must apply to satisfy themselves that a person is competent to communicate with patients.

5.28 p.m.

On Question, Whether the said Motion shall be agreed to?

Their Lordships divided: Contents, 92; Not-Contents, 44.

CONTENTS
Airey of Abingdon, B. Long, V.
Alport, L. Lucas of Chilworth, L.
Amulree, L. Lyell, L.
Auckland, L. Malmesbury, E.
Avon, E. Mancroft, L.
Banks, L. Marley, L.
Beaumont of Whitley, L. Marshall of Leeds, L.
Bellwin, L. Massereene and Ferrard, V.
Belstead, L. Mersey, V.
Benson, L. Monk Bretton, L.
Caccia, L. Montgomery of Alamein, V.
Caithness, E. Morris, L.
Cathcart, E. Mottistone, L.
Colwyn, L. Mowbray and Stourton, L.
Cottesloe, L. Newall, L.
Craigavon, V. Northchurch, B.
Cranbrook, E. Nugent of Guildford, L.
Cullen of Ashbourne, L. Orkney, E.
Darnley, E. Pender, L.
De Freyne, L. Penrhyn, L.
De La Warr, E. Reigate, L.
Denham, L. [Teller.] Rochdale, V.
Dormer, L. Rochester, L.
Drumalbyn, L. St. Aldwyn, E.
Evans of Claughton, L. St. Davids, V.
Ferrers, E. Salisbury, M.
Ferrier, L. Sandys, L. [Teller.]
Gainford, L. Seear, B.
Gisborough, L. Selborne, E.
Gladwyn, L. Skelmersdale, L.
Gowrie, E. Soames, L.
Gray, L. Strathclyde, L.
Greenway, L. Strathspey, L.
Grey, E. Sudeley, L.
Hailsham of Saint Marylebone, L. Swansea, L.
Swinfen, L.
Halsbury, E. Teynham, L.
Hankey, L. Trefgarne, L.
Hanworth, V. Trumpington, B.
Henley, L. Ullswater, V.
Holderness, L. Vaizey, L.
Home of the Hirsel, L. Vaux of Harrowden, L.
Hornsby-Smith, B. Vickers, B.
Killearn, L. Westbury, L.
Kimberley, E. Wigoder, L.
Lauderdale, E. Young, B.
Lindsey and Abingdon, E.
NOT-CONTENTS
Aylestone, L. Leatherland, L.
Birk, B. Llewelyn-Davies of Hastoe, B. [Teller.]
Briginshaw, L.
Brockway, L. Lloyd of Hampstead, L.
Bruce of Donington, L. McCarthy, L.
Collison, L. Melchett, L.
David, B. Milner of Leeds, L.
Diamond, L. Oram, L.
Elwyn-Jones, L. Peart, L.
Gaitskell, B. Phillips, B.
Gardiner, L. Pitt of Hampstead, L.
George-Brown, L. Rugby, L.
Goronwy-Roberts, L. Shinwell, L.
Gosford, E. Stone, L.
Greenwood of Rossendale, L. Strabolgi, L.
Gregson, L. Underhill, L.
Hale, L. Wallace of Coslany, L. [Teller.]
Henderson, L.
Jacques, L. Wells-Pestell, L.
Janner, L. Whaddon, L.
Jeger, B. White, B.
Kennet, L. Wootton of Abinger, B.
Kilmarnock, L. Wynne-Jones, L.

Resolved in the affirmative, and Motion agreed to accordingly.