§ 6.22 p.m.
§ Lord Wells-Pestell
My Lords, I beg to move that this Bill be now read a second time. Recent events appear to have overtaken it. On Friday last I was listening to the eight o'clock news on BBC Radio 4 when I was informed, along with countless others, that discussions had taken place, presumably between the junior hospital doctors and the Department of Health and Social Security, regarding shorter working hours. On Saturday morning I saw in the Guardian:Britain's 25,000 junior hospital doctors yesterday negotiated a cut in working hours. The Department of Health agreed that they should not have to work more than 90 hours a week. At the moment, 28 per cent. of them work for more than 104 hours a week, not all of it on their feet (for some of this time they are only on call) and 72 per cent. work more than 80 hours".I introduced this Bill and it received its First Reading on 17th December. At no time since then have I been given to understand by anybody, least of all the department represented by the noble Lord the Minister, that there had actually been discussions with regard to a shorter working week. Had this been so, and had been told that this was likely to come about, I should not tonight have troubled your Lordships with the Second Reading of this Bill. It would have been helpful if I could have been told that these discussions had taken place.
However, now that the Bill is before the House, I hope that we shall be able to concentrate our minds on the question of shorter working hours for junior hospital doctors. I am glad to see that half of the noble Lords taking part in this Second Reading debate are distinguished members of the medical profession— 507 six out of 12, if my arithmetic is right. I think I can say that they have held very high office in the medical profession. One is a present Vice-Chancellor of a university, while another is an immediate past Vice-Chancellor. Between them they have been past Presidents of something like six Royal Colleges. 1 mention this because, so far as 1 can tell, no junior hospital doctor will speak tonight in this debate. I should like to feel that these noble Lords will be able to put the point of view of the junior hospital doctor.
The Bill seeks to restrict the hours worked by junior hospital doctors in order to improve patient care, to safeguard patients and, for that matter, to safeguard doctors themselves against the effects of over-tiredness and stress due to long spells of duty and insufficient sleep. It may be that not all noble Lords will agree with the details of the Bill. However, I am sure we all recognise that the long hours which junior hospital doctors are expected to work must be—there is evidence of this fact—detrimental to patient care.
So far as time permits, I want to demonstrate the problem and to indicate that the situation has worsened and has received very little attention. This is in contrast to other occupations, such as the transport industries, where the danger to passengers of drivers working long hours has been recognised and employees' hours restricted.
I am aware of the cost involved if the objects of the Bill now before your Lordships are to be implemented. recognise that it would be difficult for the progressive reduction of hours to be accomplished in the time set out in the Bill. Nevertheless, the suggestions embodied in the Bill could be thoroughly discussed in Committee, as could other ways of reducing the long hours undertaken by junior hospital doctors.
The problems of junior hospital doctors and the associated effects on patient care were brought to the attention of the Social Services Committee in another place when they reported on perinatal and neonatal mortality. This is the second report of the House of Commons Social Services Committee, HMSO 6/63. The committee subsequently investigated medical education. In this report, the committee's fourth, they noted:Junior doctors in this country are now on duty or on call for an average of 90 hours a week, and in many cases more than this".Details of junior doctors' contracted hours, given in a Written Answer in another place by the Secretary of State for Social Services in February 1981, showed that in most specialties over one-quarter of junior doctors are contracted to work 104 or more hours a week, and that in two specialties, both surgical, more than one half of junior doctors are contracted to work for over 104 hours. The Social Services Committee of another place, to which I have already made reference, commented:Not only does this represent exploitation of junior medical staff but a doctor who has been on duty all day and all night cannot possibly be providing the best service to the patient".The fact that doctors work only a proportion of their contracted hours has been used to argue that restrictions are unnecessary, but anybody who knows the workings will realise that it is of paramount importance that something is done fairly soon. Hours 508 actually worked vary tremendously between specialties. A junior doctor in casualty may work harder at night than during the day, whereas a colleague in psychiatry may be called out only once a night, if that. In addition, a population's health is not scheduled to deteriorate at an even rate, and whatever the specialty, the demands on doctors' services vary considerably. In my submission, the fact that, on average, doctors work only a proportion of their contracted time is not a valid argument against restriction. It is important to recognise that situations can and do arise, so I am told, where a doctor may work almost continuously for two days and a night, during which time numerous decisions affecting patients' health are made.
I acknowledge that it is difficult to quantify the effects of this on patient care. Many doctors relate incidents where, because of tiredness, incorrect decisions have been made but corrective action has proved possible later. However, this is not always the case. The Health Service Commissioner's report on investigations completed in April to September describe the case of a senior registrar's delay in responding to an emergency call to attend a birth in the early hours of the morning. The baby was stillborn. The explanation for the delay was that the senior register fell asleep again after he had put down the telephone. The Health Commissioner concluded:The failure of the senior registrar to go promptly to the patient had a tragic result. It has not been denied that the stillbirth was avoidable. Overpowering fatigue is a familiar torment of those who work in the caring services, but duty is not to be denied and the senior registrar should have come when called".This was the statement made by the Health Commissioner.
Many doctors, because of the high degree of professionalism and responsibility expected and accepted, may believe along with the Health Commissioner that long hours go with the job. I am sure that that will be argued this evening, although I hope it will not. The second study, to which I have already referred, demonstrated the doctors' stress came as much from subjects trying to conform to what was expected of them as the fact that they had been awake for a long time. This can have fatal consequences for doctors as well as for their patients.
Last year—1 have the name but I will not mention it—a senior house officer in a Manchester hospital killed himself. His parents said that he was terrified of making a mistake while overtired and blamed his suicide on that. Most doctors' experience is different; they find reserves of concentration and energy which enable them to react quickly and relatively efficiently in emergencies. Once the emergency or period of duty is over, however, they react in expected ways to the long working hours. There are several reports of doctors who have been involved in car accidents because they have been found to be tired. In 1976, another doctor whose name I will not mention fell asleep while driving and killed himself. He had been working continuously for more that 24 hours. The increase of sophistication of medicine over the years has added to the causes of stress in junior doctors. Many of the specialties existing today did not exist 10 or 20 years ago. Modern perinatal and neonatal care, and cardiology, demand fast accurate decisions alongside a great deal of technical competence. 509 Stress has also increased because the means of contacting doctors have been improved. The system of bleepers was introduced in the early 1960s. Prior to that time a request for a doctor was given by a light; but if the doctor was busy with another case, the light was not immediately noticed. Bleepers have changed all that. Improvements in medical technology and communications have improved patient care enormously. Meanwhile, the same improvements have increased the pressure on doctors because their hours of work have not changed to take account of the extra demands which are being made upon them.
While most people have benefited from improvements in the standards of living over the past 20 years, the position of junior doctors has stayed the same. I might say that it has even got worse. This relates not only to conditions of work but also to non-employment activity. Twenty or 30 years ago, it may have been acceptable that a junior doctor, because of long working hours, could not contemplate starting a family until he had become a consultant or a general practitioner. But that situation will not be, and should not be, acceptable today. Real incomes were such that many people had to postpone having a family. Improvements in living standards, particularly over the past 20 years have permitted fuller participation in family life and leisure activities, but I suggest that these general improvements are denied to a large number of junior doctors and their families. It is not good enough for us to say, "This is the sort of thing they knew was going to happen. They knew that this was the sort of thing they would have to put up with. It happened in our day and we are all right as a result of it."
The striking aspect of the junior doctors' situation is that there has been little official assessment of the effect of these long hours on patient care and doctors' health. I believe that the little sympathy which has been shown towards junior hospital doctors, or understanding of the contribution they make, has caused them a great deal of unhappiness. There are numerous other situations in which regulations on working conditions have been imposed to minimise risks to life, backed by extensive medical research This is particularly true of the transport industries, where passengers' lives arc at risk. Part IV of the Transport Act 1978 and the subsequent amendments limit the hours of work for a driver of motor vehicles or locomotives to eight hours a day, with a maximum of 48 hours a week—because beyond that, perhaps, they would be considered a liability to the lives and limbs of other people. There are also provisions for rest periods and for limits on periods of continuous driving. If we find it necessary to do that in respect of the transport industries, I want to say with the greatest respect that it is all the more important that we should do it in our hospitals.
The risk to air passengers from aircrew overtiredness and stress has been recognised almost since planes began to fly. The Civil Aviation Act 1949 set up the Air Navigation Order which requires that an airline operator produces a scheme for the regulation of the flight time of the crew members. This scheme must be approved by the Civil Aviation Authority which itself puts restrictions on hours to he complied with by the 510 operators. The Civil Aviation Authority's regulations stipulate maximum duty hours, which vary according to the type of work. Pilots are under more stress, as your Lordships know, when taking off or landing. So hours are more restricted for shorthaul flying, and by the type of duty, on standby, on call or actually flying. Restrictions on doctors' hours could similarly take into account the type of work and duty performed. As yet doctors' work has not even been systematically studied. This is one of the things I hope the members of the medical profession who are speaking tonight will say is essential and should not be delayed any longer.
Most of the research on aircrew stress has been done in connection with military aviation. It is recognised that in time of national emergency aircrews must perform at peak efficiency, the cost of failure being great. In recent years several aspects of the nation's health have come under scrutiny, and the costs of correction weighted against the costs of neglect. Cigarette smoking is one example. More broadly, the basis of the National Health Service has always been some notion of national accounting of the costs and benefits of improving everyone's health. It seems all the more surprising, therefore, that the way medical services are provided in terms of working conditions of junior doctors, has never properly been scrutinised.
The Bill calls for reduction of hours in the first instance to 60 hours a week. It is an indictment of how we treat doctors at present that if we expected the same numbers of hours to be worked we would require, with a 60 hour week, a third more doctors. While it is realistic and while many of us will feel that this has to be done, I accept that it cannot be done immediately. But what I want from the Government, and therefore from the noble Lord the Minister, is some understanding of this problem, some acceptance that there is a problem, and what is more, some assurance that something will be done, and done speedily.
I want to draw your Lordships' attention to the fourth report of the House of Commons Social Services Committee dealing with medical education, and I quote from paragraph 121, which states:It strikes the Committee, as outsiders to the profession, that the hours that many junior doctors are expected to work and be on call—in many cases well over 90 hours a week—are indefensible. They represent exploitation of these doctors and, more seriously, a considerable risk to the patients they treat. We believe that the reduction of the doctor's contracted week, initially to a maximum of 80 hours, should be one of the Government's top priorities, and that the existing agreement to achieve this for junior doctors should be enforced. To this end we recommend that the Government should study different patterns of shift work and work sharing between different firms in a district".The number of junior doctors on call could be reduced if cross-cover was arranged between specialities. There is an overlap in the training for certain specialities. I was going to quote geriatrics and general medicine. It is not necessary in terms of patient care to have two teams on call at the same time. Similarly, the number of wards covered by one person could be increased when doctors arc on call. I hope those members of the medical profession who are going to speak tonight will not think I am being presumptuous in saying that, being a non-medical person.
Better organisation of surgical care could reduce the number of doctors on call and the amount of work done by ancillary services. At the moment a patient goes into hospital the day before an operation. and will often 511 only be seen in the evening, by which time the surgeon or consultant has already done a day's work. The patient is checked, both to ensure that he or she is generally fit and to sort out the details of the operation. Sometimes the operation, for medical reasons, has to be deferred, and that means that the next day's schedule is disrupted, and the day's work on in-patient care has been expended unnecessarily. The suggested remedy for this is that the patient goes in as an out-patient during the day before the proposed operation. Checks can be made during the working hours, and the time the patient attends the hospital prior to the operation is reduced, thus minimising expenditure on ancillary services. If the patient is found to be unfit for the intended operation, additional savings are made on the ancillary services. The patient does not have to suffer the stress and disruption to normal life associated with an unnecessary stay in hospital, and operation schedules could be more efficiently organised.
I suggest that further savings could be made without harm to patients if non-specialist doctors could do the general checks on the patient, leaving the specialists—shortage of whom exists in some subjects—to attend to problems specific to the proposed operation. In some hospitals improvements in efficiency have already been made in this or similar ways. There are indications that the changes are occurring because of the cuts in the Health Service. Some surgical teams, for example, have been forced to reorganise their work because of reduction in the number of available beds. But efficiency varies between hospitals and between firms within hospitals, and this is a matter which I think should be looked at.
At present about one-quarter to one-third of the junior doctor's time is spent waiting between clinics, or for consultants to do their rounds or on call. If further improvements in efficiency continue to be forced by reductions in Health Service finance, the number of hours actually worked will increase. The hazards to patients, and to doctors themselves associated with stress and fatigue, if doctor's contracted hours are kept the same as at present will also greatly increase.
This is not to say that improvements in efficiency are undesirable. Indeed, a reduction in junior doctors hours would increase the pressure to re-assess and change methods of work. The restriction on hours, however, would safeguard junior doctors' working conditions, and consequently safeguard their patients. This is not a matter which can be argued fully on an opening speech, and it would not be right for me to do so, or during the time of a short debate. It does need a careful investigation of what is really happening to junior hospital doctors. Again, I hope those who are taking part, who have many years of experience and a profound knowledge of what goes on—as distinct from what some of us think goes on, and I acknowledge there is that difference—will be able to support the view that we ought to be looking at this matter very carefully.
§ Lord Elton
My Lords, if the noble Lord will be so kind and if the House would permit, there is not a moment after the noble Lord has said, "I beg to move", when I can say, "Before the noble Lord sits down". I want to put one thing right. There was 512 no question, at the conference to which the noble Lord referred, of any sort of negotiation. It was not that kind of meeting. I shall be referring to it in my speech and to the reasons leading up to it. But I would not like your Lordships or the noble Lord to feel that it in any way changes the parameters within which this debate is being held. It was not that kind of conference, and that was a misleading report, if I may say so. I must not make this a long interruption: I will expand on this later.
§ Lord Wells-Pestell
; My Lords, I am most grateful to the noble Lord the Minister. I hope that he will expand on it, because it seemed to be very dogmatic. I shall confess that I was a little grieved that something like this should be going on—at least I thought that it was going on—when I might have been told about it. But if the noble Lord—I am coming to a conclusion—can say something which will give some of us hope and some of us encouragement that something will be done in the very near future about junior hospital doctors' hours, together with some kind of inquiry, some kind of investigation, into what the present position is and how it can be changed for the better, then I think that many of us might feel that this has not been in vain. My Lords, I beg to move.
§ Moved, That the Bill be now read a second time.—(Lord Wells-Pestell.)
§ 6.51 p.m.
My Lords, I think that the noble Lord, Lord Wells-Pestell, has rendered an important service by bringing forward this somewhat cautious little measure, if he will forgive me for so describing it. I describe it as "cautious" because, as the noble Lord, Lord Wells-Pestell, himself explained, its provisions are to be phased in over a period of years so that the full impact of the noble Lord's Bill is not actually felt until 1st January 1991—in other words, the noble Lord is proceeding by what I think Sir Winston Churchill once described, "the inevitability of gradualness".
But by 1st January 1991 much water will have flowed under many bridges. Many who are now junior hospital doctors will have become perhaps comparatively senior doctors in other capacities, and the junior hospital doctors of those days in 1991 may very well be working in hospitals of a very different kind from the hospitals which we now know. They may be working in forms of medical practice which are very different from the forms of medical practice with which we are now familiar, and they will also be working in a society in which there will have been, by then, a great change in our attitude towards the work ethic as a whole, and in which there will have been very many changes in the working pattern throughout life as a whole.
Nevertheless, I repeat that, whatever the fate of his Bill, the noble Lord has rendered a service by allowing us to debate a matter which really is of considerable public importance. I genuinely believe that, by ventilating this particular matter, it is possible that certain action might be taken administratively. It is also possible, perhaps, that the noble Lord the Minister who is to reply might be able to give us information regarding a number of current developments which 513 are, in point of fact, relevant to this issue and which are already having an impact on our hospitals and which, perhaps, might help or might even hinder developments along the lines to which the noble Lord has referred.
The noble Lord has said, and rightly, that it is a fact that every day somewhere in Britain, perhaps in many places in Britain, there are junior hospital doctors who are performing important, intricate, even dangerous work when they are, frankly, in a state of exhaustion. If that is the case then it is something which, frankly, should not be allowed to continue—the noble Lord's Bill or otherwise. It is something which could be dealt with in other ways and, indeed something which perhaps ought to be dealt with in other ways.
But having said that, I must also look at the reality of the picture as I see it. While I do know as a matter of my own personal observation that there are junior hospital doctors working very, very long hours indeed, and doing real work, I also know as matter of personal observation that there are many junior hospital doctors who, frankly, are doing very little real work at all. I must go further and say that I am also aware of many junior hospital doctors who are working quite long hours and doing a lot of work, but work which, with respect, is often totally wasted, because it is duplicated and repeated by others.
What I am trying to suggest is that one of the main problems with which we are faced is the uneven pattern of hospital staffing and, if I may say so, sometimes, and in some parts of Britain, quite luxurious overstaffing of certain teaching hospitals while certain other outlying hospitals in the regions are desperately under-staffed. Moreover, in those areas junior hospital doctors are often carrying very, very heavy burdens indeed. What we are to do in the end to make sure that we attract sufficient doctors to posts in certain of those outlying hospitals in the regions, I really do not know, but I think possibly we may have to consider some kinds of inducement to doctors to work in what might be called "less favoured areas" or in the kind of areas in which they are not automatically recruited.
The teaching hospitals undoubtedly have a basic inbuilt advantage in that a post within one's teaching hospital is often regarded as a necessary prerequisite or preliminary to a later successful career as a consultant. Therefore, those posts are sought after irrespective of the inducement so far as the work is concerned or the remuneration or other matters. Indeed, I think it is right to say that at the moment, just as in the days past when the elderly doctors to whom the noble Lord referred were themselves junior hospital doctors, the principal inducements to young doctors to take certain posts are a consideration of the kind of experience they will gain, the kind of teaching they will receive and the degree of responsibility that they will be allowed to exercise. It is only by exercising responsibility that one really learns. It is those kinds of inducement which, I think, recruit doctors to certain posts. In a sense that is saying that this is not an area in which one can leave recruitment wholly to what is usually called "market forces". The market forces are somewhat different in this particular field, and the result is that certain areas are left perhaps impoverished in so far as filling vacancies and being adequately staffed is concerned.
514 So one of the main problems here is not the total number of junior hospital doctors, but the way in which they are distributed throughout our hospitals. That is something which I think ought to be looked at, and looked at fairly urgently. But I see some danger signals on the horizon, and on these matters perhaps the noble Lord the Minister will be able to comment as we proceed.
As I understand it, the Government have already announced that there is to be an increase—a welcome increase—in the number of consultant posts. But I also think that it is true that the Government have announced that while that increase in the total number of consultant posts is being brought about, there is also to be a moratorium on the establishment of new junior hospital posts. I am bound to say that it seems to me very, very difficult indeed to talk about cutting working hours while one is, at the same time, operating a moratorium on the creation of new posts. I do not think that the one can go on without the other.
Another difficulty which I see at present is that, as I understand—and I am informed that this is a matter about which the noble Lord, Lord Richardson, perhaps may have more knowledge and may comment later when he comes to speak—there is at the moment, or has been, a reduction in the number of pre-registration posts. Noble Lords will remember that pre-registration posts are resident hospital posts as house surgeons or house physicians which young, newly-qualified doctors are required to do before they are finally liberated as free to practise without restraints.
There was a certain amount of cynicism in days gone by about the establishment of the pre-registration posts. I qualified in the very early days of the war, at a time when the teaching hospitals were paying house surgeons almost nothing and working them very, very long hours indeed, but recruiting those doctors because they felt they needed to be there in order to be close to the professor and close to future advancement. But once the war came and people were not quite sure what kind of advancement it was going to be—it might in many cases be advancement into the grave, as so it proved with some of my colleagues—doctors started thinking about their own personal prosperity and comfort, and they sought jobs not in the teaching hospitals but out in the municipal hospitals, in which perhaps they got more experience and more responsibility, but in which they were being paid a great deal more money.
I still have in my possession three letters written by the Dean of Clinical Studies at one of our teaching hospitals to the medical superintendents in three municipal hospitals who were then paying quite reasonable salaries, as things were, to junior house surgeons and house physicians, whereas the teaching hospitals were paying almost nothing—I think it was 10s. 4d. per week. This letter from the Dean of Clinical Studies pointed out to the medical superintendents of these three municipal hospitals that the teaching hospital was having great difficulty during those early wartime years in recruiting surgeons, and then went on to suggest that it would be helpful if the municipal hospitals reduced the rates of pay to their house surgeons. In other words, that was perhaps the way to feed people back towards the teaching 515 hospital. That matter was exposed and did not get very much further.
But when the pre-registration posts were introduced at a later period—and I should say at the outset that no doctor in his right mind would stand up and seriously say that a newly qualified doctor, having passed all his exams, ought to be totally free to practise outside, alone, unfettered without, first, having had a reasonable range of hospital experience in resident posts; and I fully accept that principle—so that it was compulsory for doctors to do these posts before they could be regarded as fully and finally qualified and registered by the General Medical Council (about which the noble Lord, Lord Richardson, knows so much), there was the feeling that this was the creation of a kind of slave labour because it was, in fact, the creation of posts which it was compulsory for people to take.
With regard to pre-registration posts, once you have those posts—which really are work—which doctors are required to do before they are finally registered (so they are in a sense compulsory), as an employer you then, clearly have a very important duty with regard to the safeguarding of working conditions and rates of remuneration. You are in a totally different area, in which market forces of no kind exist or apply at all.
However, I am told that at the moment, despite the fact that we now have an increased intake, or at least an increased output from our medical schools of more newly qualified doctors, there is, in fact, a reduction in the pre-registration posts, so it is becoming difficult for some of these doctors to get the pre-registration posts which they need for final registration.
There is another point of difficulty with regard to the precise terms of the noble Lord's Bill, or at least with regard to doing something about this here and now. I refer a little more to the patients' point of view. I have talked to patients on this particular issue, and on this issue of patients being treated by doctors who are, frankly, exhausted. It is a fact that a patient in a hospital not for a prolonged stay but for a stay of a fortnight or three weeks, or whatever, for an operation or for whatever else it might be, develops a relatively close relationship on an almost daily basis with the house surgeon, the house physician, or perhaps the junior registrar, or perhaps even the senior registrar. They get to know him or her quite well. They arrive at a situation in which they feel free to talk and to understand. The patients arrive at an even more important situation in which they genuinely believe that the doctor generally and fully understands all their anxieties, and there is a total understanding between them and the doctor.
Once one has regulation of working hours by statute in the kind of way envisaged by the noble Lord, the difficulty is that one then has the immediate problems which arise from the hand-over situation, as between one doctor going off duty and another taking over. When one talks to patients, as I have, they tend to say that they would rather have a very tired doctor whom they know very well, to whom they can talk and who they know understands their position, than another doctor who is totally fresh and rested, but who they 516 have never seen before at all during their hospital period.
When we are considering changes of the kind that the noble Lord envisages—and many of these changes are necessary—I think that we must go on to consider the importance of continuity of care on a daily and continuing basis for the patients in hospital—care, not only by the nurses, but by the junior hospital doctors whose relationship with the patient is so much closer than is the relationship of, perhaps, the consultant who has overall clinical responsibility for the case.
Finally, the noble Lord has pointed to the fact that speaking in this debate are many elderly doctors. As we look back to our days as house surgeons or house physicians, I think that we can all say: "Yes, we worked very long hours. We were glad to work very long hours. There were all sorts of reasons why we worked very long hours. "Confidentially, we might be prepared to admit that some of the work that we did during those very long hours was not quite so exhausting or arduous as one might think. Sometimes we were playing bridge and doing other things while we were on call. It is also true that we were paid very little. But all of us in my age group, and that of other noble Lords here who are medically qualified, must guard against the tendency to feel that because we went through it in that kind of way, others must do the same now.
Frankly, it is that kind of attitude which kept the nursing profession in thraldom, and for so very long. Embittered ward sisters of the past, who had been ground into the dust by their seniors when they were nurses in training, tended, when they became sisters themselves, to say why should not their probationers go through it as well. Fortunately, nursing has grown out of that restrictive phase, perhaps because of the presence at long last in the nursing profession of a sufficient number of male nurses who take a different kind of attitude. But the result is that nursing has changed with the times. So must medicine change with the times. I think that elderly and conservative-minded doctors must be prepared to forget about their years of dedication in house posts years and years ago, and realise that we cannot now allow to continue a situation in which individual junior doctors are required to do dangerous and important work while they are in a state of exhaustion. That is something which should not go on.
How we deal with it, I am not quite so sure. I am not entirely sure of the noble Lord's intention with regard to his Bill. If he wishes to press it, I should not oppose it; but I think that I would want to look at it very carefully in Committee. I do not believe that it is wholly right to try to bring the philosophy or the machinery of the shop floor into medical practice and deal with matters of this kind by statute. I think it is right that they should be mentioned, but I think that they can probably be dealt with in other ways.
I hope that in his reply to this debate—this very important debate that we will have had by then—the Minister will be able to tell us what the Government are actually doing now—not on 1st January 1991—in order to safeguard the interests of patients, which is the overriding consideration, and also to safeguard the interests of some of the doctors who are working too hard; at the same time recognising that while 517 there are some junior hospital doctors who are doing very little work, there are others who are having their work wasted; and that the real need is to look to the overall staffing of our hospitals and to ensure that it is ironed out and evened out, rather than that we persist with the kind of disparities which we have at the moment as between certain teaching hospitals and certain other outlying hospitals in the regions.
§ 7.9 p.m.
§ Lord Hunter of Newington
My Lords, I too should like to pay tribute to the noble Lord, Lord WellsPestell, for his concern for the medical profession, and also to pay tribute to what he has done for that profession in a number of ways in the past.
Junior doctors contract for a basic 40-hour week. Thereafter they contract for a stand-by, or on-call, duty in blocks of four hours, called units of medical time. They are paid at 30 per cent. (that is, A units of medical time) or 10 per cent. (B units of medical time) of the basic rates depending broadly on whether the doctor is required to be in hospital, immediately available, or at home, but still on call. The rates of pay for UMTs are set out according to the recommendations made by the Independent Review Body on Doctors' and Dentists' Remuneration. I understand that they are looking closely at the overall remuneration in their current review, which is due in April, and have undertaken a survey of juniors' hours of help.
Between 1949 and 1969 the population of this country increased from 43.8 million to 48.8 million. The number of general practitioners fell during that period; the number of consultants doubled; the number of junior hospital staff was increased four-fold. I am sure that there have been considerable further increases since. It is disturbing to find that after this substantial increase junior doctors are still contracted to work 80 to 100 hours, and the majority—and may I quote the requirement—are,required to be physically present or on standby in the hospital available for work as urgently as the situation requires".That is the requirement for the A standby; they must be ready to go in the hospital.
In the beginning of this new method of payment about six years ago it was estimated that perhaps 40 per cent. of overtime would be required for these A units of medical time, and 60 per cent. would be required to pay for doctors from outside the hospital but on call and,for telephone advice, consultation, and occasional non-urgent calls".That is the background to the situation. But of course the formula for calculation (which is boring but it is necessary to understand it) which young doctors are advised about—not by the Government—is that there are 168 hours in the week, and that that divides into 42 four-hour units. The doctor then is advised to subtract 10 standard units from this, leaving 32. Then he divides that number on the rota with the number of other doctors in his category. Therefore, there is very little flexibility in the staffing, and flexibility is not mentioned.
He gets additional payments for study leave, what is called continuity of patient care, teaching and research, and administrative duties. This was a sincere attempt, I believe, at the time to get a work-sensitive contract 518 for junior doctors. But of course, as has been said, to give one example, there are in the medical specialties at the present time 10,156 basic units in England, and the A plus B—the additional payments—of 12,713. Of these, 99.4 per cent. are A units. In other words, the doctors are apparently on near-emergency call. This is a situation to which I should like to refer again.
Taking from the noble Lord's Bill the proposal that by 1983 doctors should work for 60 hours, I have done a little arithmetic on the possible consequences, assuming that the duties required are the same as at the present time. The result would be that we should require 120 additional staff in the medical specialties. One can see that if we extend that to all medical staff we should be thinking in terms of new medical schools and new teaching hospitals, and things of that kind. Therefore, some other solution has to be found.
How does this system work? One rather extraordinary effect of it is that senior registrars often get paid more than the basic consultant salary. I do not know what work studies have been done to determine the staffing of different types of unit, but I would support what has been said that the different types of unit require to be examined. For units such as dermatology and neurology, for example, in the period in 1980 to which I referred for the UTMs, in dermatology there were just over 2,000 basic units and 2,500 A and B units; 61 per cent. of them where the doctor was on urgent call.
There must be many ways of covering a dermatology department. It could be done by an experienced senior registrar in general medicine. He could surely stand in for the almost unheard-of emergency. But then of course the problem arises, because, if you do not give them reasonable remuneration, you will have difficulty in recruiting dermatologists. The matter is serious and the profession must co-operate fully in finding a means of using and spending these resources better. What is required is an urgent investigation into flexible rostering. I believe that it is possible—and I agree with the noble Lord, Lord Wells-Pestell—to get an average of 80 hours a week by doing this. I understand that it is the profession's view that it could be brought about by changes in patterns of working and full co-operation between different categories of staff concerned.
It is a tragedy that junior doctors are paid in the way that they are, but the experience of the last six years suggests to me at least that all junior doctors should be employed for something in the region of 60 hours, and that the additional payments over and above that should be very exceptional or only for those who are on the most urgent duties.
§ 7.17 p.m.
§ Lord Perry of Walton
My Lords, I am perfectly sure—we must all be perfectly sure—that this Bill has been actuated by the purest of motives. The need to avoid patients being treated by over-tired doctors and the need to safeguard the health of doctors are admirable motives for any Bill. The dilemma is that the two problems are not new, and that they are not amenable to legislation. To attempt to legislate is asking for trouble.
Almost all the points I would wish to make have been made already. I shall be extremely brief. The 519 only way to solve the problem is to have enough staff to carry out the job properly, or to have a better distribution of staff, as has been mentioned already. I was a junior hospital doctor many years ago during the war. At that time the problem was even more acute than it is now, because of the temporary war difficulties.
One of the things that existed then and that has been lost in the National Health Service was that there was in fact some one person in charge who could handle the situation, and whose word was law. There seems to be no one in charge of our hospitals at all now except committees. I do not think that they do the job very well. The second point I want to make which has already been made is that "on call" can mean lots of different things. It is only some doctors, some of the time, who are tired by being on call.
The third point I want to make has also been made. It is that if you had only 35 hours of work per week you would require five doctors for any one ward, and that would provide very little continuity of care. While sympathising with all the reasons for bringing forward this Bill, we ought to not accept it. This is not something that we can legislate for. We must hope that the profession, as has been mentioned, will take reasonable steps itself in response to the noise that we make about the problem, rather than the laws we make about it.
§ 7.20 p.m.
§ Lord Molloy
My Lords, I am conscious of the distinguished noble Lords who have spoken and will speak in this debate, men who have made a massive contribution both to the National Health Service and the whole field of medicine. I pay tribute to my noble friend Lord Wells-Pestell and, unlike the noble Lord, Lord Perry of Walton, I believe he has brought to the attention of the House tonight a matter of vital importance to many people who are not doctors, consultants or registrars. Ordinary people know what terrible anguish and grief can be exacerbated if it is thought that the loss of a loved-one has occurred because someone has been over-tired, over-worked or has not been in tip-top form.
Therefore, I say with great respect to all the distinguished people concerned with medicine that this issue is not the prerogative of consultants, registrars and the whole range of medicine; it involves every soul in this land of ours. That was behind the great dream of Aneurin Bevan when he created the National Health Service, a service which needs our every consideration, especially these days when billions of pounds are spent on weapons of death in all sorts of Christian and non-Christian countries. When we in this country created the National Health Service, we put on the statute book the finest picee of legislation ever witnessed not only in the history of our nation but in that of any other, and great successors of Aneurin Bevan have given of their utmost to improve it.
Having said that, it is clear that the NHS still has its weaknesses, one of which has been revealed tonight by my noble friend Lord Wells-Pestell. Let me make it clear that I have no connection with any of the great professions in the NHS, except that I have been involved with, and still am concerned in, the Confederation of 520 Health Service Employees, the activities of which range right the way through the service, including doctors and consultants down to nurses, SRNs, state certified midwives, ambulancemen, student nurses, ancillary staffs—in short, the whole structure of hospital administration in Britain—and it is against that background that perhaps I too have a small contribution to make.
My noble friend Lord Wells-Pestell said that no doubt there would have to be a cost involved in putting into practice his proposals in the Bill. That may be so, but I suggest to him in the friendliest possible way, and to the House, that a cost is already being paid: every time a junior doctor is over-worked and someone's pain is prolonged or a return to health is delayed, that is a cost being paid, and we cannot wait to arrive at the frontiers of understanding only when our own soul is smitten with grief; in other words, when it is us or someone close to us who is suffering. Then we want the mountains moved and any inadequacies of government removed. In this case we cannot wait till then. There are savings to be made now, and that is one of them. There are also savings to be made in relieving the strain on anyone connected with medicine, from the raw recruit nurse right up to the consultant. These people are, and must be, devoted men and women and it must be a crime if we permit that sort of devotion to a noble profession to suffer unnecessarily.
It has been my experience from talking to a range of junior doctors that they feel unhappy about the present situation. Sometimes they must go home with the niggling thought that perhaps they have not given of their best. Would be it that all other professions were as conscientious as those who work in this noble profession. It has been submitted to me, for example, that even the work associated with the administration of drugs has changed dramatically in the past 20 years; the junior doctor has to be on his toes at all times because the tiniest slip can mean disaster. A slip on the part of a bricklayer, engineer or motor mechanic can be despairing, but in this profession an error can have the most bitter effects.
For those reasons we have every right, wherever we see a possibility of removing an element of risk, to do so. That is why, unlike the noble Lord, Lord Perry, I believe my noble friend has pointed the way for us to follow. After all, it can sometimes happen in the work of a hospital doctor that a patient with whom he has a close relationship—the noble Lord, Lord Winstanley, mentioned this—can arrive at a particular crisis and then, within the heart of the young doctor, there is a crisis because he knows he is suffering the effects of overwork. Thus, all factors must be taken into consideration.
It seems almost a paradox to have to talk in this way, and it may be that the Safety at Work Act, now the law of the land, should look very closely at the way in which some of our hospitals are administered. Let us remember that the tiredness and strain that goes on in a hospital sometimes goes right through an entire staff shift, affecting not only the junior doctor but nurses, sisters and staff nurses; they may all be aware that the doctor in charge "is not up to it tonight" in that he is not fully in charge. Conversely, the junior doctor may know that his assistant staff nurse—and remember, we are talking about very important people, particularly when the results of the genius of our 521 doctors often depends on the equal ability of our nurses to nurse—is under added strain, and anything of that sort can mean an increase in risk.
My noble friend also mentioned the strain in the private life of junior doctors, and of course that too can have a great effect. He gave the example of a junior doctor who was involved in an accident, and unfortunately in the case he cited there was loss of life in a motor-car accident. That was an extreme case, but how many other cases are there in between, even those involving unhappiness at home? One sees some of that as one moves among those working in this noble profession. As a parliamentary assistant—not an adviser, although perhaps as an adviser in terms of legislation—to the great Confederation of Health Service Employees, one becomes acquainted with matters of that kind. They may not even be on the periphery of medicine, but they are bound to be related; and I believe that if the strain of the job is carried into the home, we have a responsibility to remove it. If we do not, our National Health Service will be stained by administrative insouciance.
I regret to say that it has always been stained by meanness. Since its inception, Governments have never given it all that it should have, and to a degree the nation, through Parliament, has taken advantage of the great medical profession, its loyalty and its devotion. We should take whatever opportunity there is to remove some of the things that irritate people in this great profession, whether they be nurses, doctors, even administrators or ancillary staff, and of course the junior doctors, who can make the most fatal error of all. If our National Health Service is still a golden achievement in the field of medicine, for the world to witness, we cannot allow in that great service any element of risk that we can administratively remove.
But there is another point that we must examine. In this new age of technology we are moving very rapidly towards a situation where a junior doctor will have to be part mechanic, part scientist, as well as a doctor. So, paradoxically, the risk through tiredness will increase, because of the new technology. These points must be looked at, bearing in mind that perhaps not so many young people will be going to university to read medicine, unless the policy relating to that is reversed. There will be fewer people entering the medical profession, fewer junior doctors, and ergo there will be more possibility of strain.
I hope that your Lordships will approve of the Bill presented by my noble friend. I hope, too, that we can make our contribution to removing strain from the junior doctors, which would also remove strain from nurses and ancillary staff, because they are all inter-linked. It would also remove apprehensiveness from those people who are ill and their relatives. If we can do that, we shall make a valid contribution to this great service. If we can do that by means of the initiative of my noble friend Lord Wells-Pestell in presenting the Bill to us, we shall make a contribution not only to the junior doctors but to the entire health service, thereby providing an even finer, better service for all the people of our nation.
§ 7.33 p.m.
§ Lord Richardson
My Lords, I cannot avoid a feeling of sadness over the fact that the noble Lord, Lord 522 Wells-Pestell, said that he was slightly hurt because he did not know about the conference that took place last Friday. So many of us—the noble Lord, Lord Hunter of Newington, referred to this—have many reasons to be grateful to him for what he has done for the medical profession. Thus each one of us feels—I certainly feel—that we might well have pointed out to the noble Lord what was announced in the British Medical Journal before Christmas; namely, that on the initiative of the CMO at the Department of Health there was to be this conference, and within our profession it has been widely known that it was to take place.
It was a closed, private conference, but statements that could be announced publicly were agreed, and the noble Lord the Minister will tell us about that, if he so chooses. But I am most reputably informed —and this is remarkable—that it was agreed by all the doctors there, whatever their rank and whatever their particular interest, that some limitation in hours of work for junior staff should be implemented as swiftly as possible. It was also agreed that the so-called one-in-two—that means 24 hours on the whole time, a day's work, then a night in bed, and then starting again—should be phased out immediately, with a one-in-three system being introduced very shortly, and that the objective should be one-in-four. So there was achieved a unanimity of purpose.
The noble Lord, Lord Wells-Pestell, pointed out that there were no junior doctors in this House. I am afraid that I could not convince your Lordships if I posed as one, even for the purpose of advocacy, but I have with me a letter, which I received this morning, from the chairman of the Hospital Junior Staff Committee of the British Medical Association, a body that was, of course, much concerned with, and highly active at, the recent conference.
At the beginning of his speech, the noble Lord, Lord Wells-Pestell, said that, had he known about the conference, he might not have brought the Bill before us in the form that he has done. He then went on to speak most valuably, so I felt, about the importance of looking at the whole problem of the junior hospital doctors' work, their working hours and circumstances. In other words, there were two aspects: first, the numerical one contained in the Bill; and the other, the wider considerations of the problems and the needs of the junior hospital doctors.
I can, at any rate, speak for the particular body that represents the junior hospital doctors of the British Medical Association, and which is an autonomous body within the association. They say that there is general support throughout the whole of the medical profession to reduce the hours worked by junior doctors to a reasonable level. They go on to say that a maximum of 80 hours a week is what they feel is a reasonable level, taking into account (as we have heard this evening) the question of on-call time.
They then go on to talk about a large-scale reduction in hours, and they come to a point about which I wish to speak principally; namely, the training of junior doctors. They say:The large-scale reduction in hours proposed in the Bill would eliminate all the training content from juniors' posts.…That is probably true. If it should come about, it would be very serious indeed; it would have enormous implications for the whole of the medical profession, 523 the health service and the public. The Hospital Junior Staff Committee goes on to say:They do not believe that the current problem can be resolved by legislation at the present time although legislation may be required if satisfactory progress cannot be made in discussions with the DHSS".We all agree that prolonged hours of duty and strain are dangerous and undesirable. After nearly 50 years in hospitals, having worked with almost 200 junior staff who were directly responsible to me, I cannot go all the way with the noble Lord, Lord Molloy, in the awful pictures that he drew, though I found much of interest in many of the points that he made about the things that nowadays contribute to the strain of being a junior doctor. If I may say so, he made a very good point when he said that increasing technology, the increasing application of science, adds to, rather than detracts from, the mental effort and perhaps the necessity for physical dexterity among junior doctors. Certainly his point about drugs was extremely important—something with which my generation, at our beginnings, was hardly concerned.
Again, mention was made of nursing staff. The junior doctors make the interesting remark (which is slightly contrary to how it was put in this debate this evening) that because of the rota of times that nurses now follow, and the reduction in their hours and the alteration in their structure following the Salmon Report, they cannot rely in the same way on wards always having a senior nurse experienced and well-trained, as was the case when I was a young man. I have always maintained that only two women have in fact made me run—I am a lazy man. One, of course, is my wife and the other was my ward sister. If she rang me and said, "Dr. Richardson, such-and-such a patient is very ill", I ran.
My Lords, we agree, then, that something should be done. But I want to come to the real purpose of the lives of these junior doctors. Their real purpose is to convert their long years of academic training, teaching and learning, into practical activities. The junior doctors cannot be lumped together when we are thinking about their hours of work and their type of work, because there exist different levels. There is the pre-registration house job, to which the noble Lord, Lord Winstanley, referred. I greatly hope that there is no shortfall of pre-registration posts. At one time it looked as if there might be a danger of that, and it was averted without very great trouble. It would be an appalling scandal, and quite intolerable, if it were to happen, because unless these people can do their pre-registration job they cannot pass on to full registration and the privileges that follow from it.
I must not be too wordy, my Lords, but to these young men and young women, in the first year of their experience, when they are really feeling their power and the possibilities of their profession, the hours that they work are less important than the experience that they get. I have no doubt at all that most of them feel—in fact, some of them have actually said this to me-" If my job is duplicated with another, with two doing the work that I am doing, it will be so much less a good job that I would not like to recommend it to my friends". They need the experience. As they go up the ladder various other factors enter into their training, such as 524 clinical research work, more basic research work, work in intensive care, the follow-up of patients, the follow-up of patients in hours which are socially acceptable to the patient but may be socially difficult for the doctor. All these times that they have to work, and the varying periods for which they may be working—and research is, indeed, work—are really not susceptible to any rigid limitation of time, any more than is the practice of medicine itself.
My Lords, doctors do work long hours. They expect, and should expect, to work long hours. This does not mean that I am going back for one moment on my belief that round about 80 hours, give or take, is the correct number for the junior doctors, and within that sort of timing they ought to be able to fit in the requirements of the different levels. I agree with the idea that a great contribution could be made by organisation, by putting aside the rigid concept of "my" house physician; "He sees 'my' patients, he does not see anybody else's", and so on. This could contribute quite considerably to leading to intelligent and workable rosters that could give these young men and women their proper training and their proper experience and, at the same time, not exhaust them.
I feel that by initiating this debate the noble Lord has done a great deal of good, because your Lordships may be able to urge forward the process of reducing the hours of work of the juniors, which may lead to an examination—and the noble Lord, Lord Hunter of Newington, hinted at this—of the contracts that these young men and women hold. In some instances noble Lords would be very surprised at the type of discipline that is said to be standing, straining to rush off to see an emergency—the type of discipline that has probably never seen an emergency since being a student, with somebody else demonstrating it. These things need looking at; and their type of work needs looking at. It is so different. Dermatology has been mentioned—a very good example—between specialties.
So I feel that one of the purposes of the noble Lord, Lord Wells-Pestell, has been most amply served by this evening's debate, but I also feel that the junior hospital staff were absolutely right when, on January 19th of this year, they issued this statement:The Hospital Junior Staff Committee is opposed to any legislation seeking to reduce the hours of work of junior doctors at the present time".I hope your Lordships will agree with them.
§ 7.47 p.m.
§ Lord Davies of Leek
My Lords, we have had an interesting debate, and undoubtedly we have had the privilege of listening to people who know what they are talking about in this area of social work and social legislation. The House will be glad to hear that I do not intend to talk for very many minutes. Nevertheless, there are some caveats that I should like to enter. I do not know whether my noble friend is going to push this Second Reading to a Division, but first of all I want to pay a tribute to him for the years and years of work that he has given to social medicine, to hospitalisation and to social welfare. Not knowing how many people were going to speak on this, and being a layman in this direction, nevertheless as soon as I saw that my noble friend was moving this I was willing to come in and support him. 525 I also then read in the Guardian, and listened at the weekend, about the changes that have been made. But because I have been privileged to listen to practising medicos who have worked in hospitals for many years I understand better now what that message meant. Nevertheless, despite the privacy, I think my noble friend Lord Wells-Pestell would have been entitled to some direct line to him to let him know exactly what was going on; and the Minister said when he interrupted that an explanation will be made.
Having said that, what are my caveats? A rolling rate of change is happening not only in the medical profession: it is happening in engineering, in micro-technology and in my own profession of teaching. There were people in my profession who were not as dedicated as they may have been, and there may be people in medicine who are not so dedicated. But whatever we may think about it, the overall thing in this change is that now we have something that Aneurin Bevan did not envisage. We have the growth of private hospitals side by side with the National Health system, of which I am very proud. It was one of my great moments, at Princetown University some years ago, to talk about the growth of our National Health system when America was having her great debates. I know that many Americans came over and they had free operations. I remember one American lady in tears of gratitude at my own home when, having been struck down by appendicitis she was operated upon freely, when in Chicago it would have cost that lady a small fortune.
We are now looking at two echelons of medicine. Private medicine is developing. I do not want to pass any party remarks about it now, but I want to ask whether regulations apply to private entry into medicine as well as into the National Health Service. What would happen to the legislation if we make legislation? Would we be better off if we took note of what we have just heard? Apparently, the junior medical men have said, "Look, we don't want masses of legislation about this". I have spoken to one or two hospitals about the different centres of administration that have been set up. I much regret the change that was made in the administration of the hospitals some years ago; and many of our specialist consultants and general doctors were looked upon as leaders in the chain of responsibility. From the lower echelons to the higher, they were spending and wasting much of their time on committees discussing, sometimes aridly, administration. That we want to avoid. Over-administration is one of the things which is ruining much of Britain's initiative at the present time. My first question therefore is this. Would the same controls activate in the private hospitals as in the National Health Hospitals or the public hospitals, or would the private zones have the right to be free from any controls at all? Would that be the situation?
There are two other points. The point is well made that in, say, engineering and in anything in which people desire to achieve success, application is essential. Long hours of work, if it does not upset the health, is part of that dedication of learning a job. To get into one's own being. The whole gamut of the profession in which one is entering means dedication. At one time, when somebody took up medicine, it was considered a calling—just as in teaching and on the religious side. 526 You cannot make medicine and you cannot make teaching the same as a day-to-day job. People who enter it must have some drive and some desire. With some levity, may I say that I regret sometimes overworking among those junior hospital doctors who have been privileged to play Rugby for my own country. I do not want them to be kept too busy on the days when we are playing against France, Scotland, or England at Twickenham. I should like to see flexibility there. I am prepared to recognise that, because of the profession, the regulations should be made inside their profession itself.
My Lords, I would wish to pay tribute to the nursing profession. To the nursing profession, the young junior doctor also owes a great deal. I myself unluckily—although I seem to be healthy enough now—have been in hospital many times, sometimes through accidents and sometimes through thinking I was stronger than I was. At those times, I was grateful for the attention I had night and day on special occasions by the junior doctors and to see how well the nurse in charge helped the doctor. This is the opportunity for the reassessment of the whole of the services of the junior doctors to medicine. I think the debate tonight has been worthwhile.
§ 7.55 p.m.
§ Lord Hill of Luton
My Lords, we are all grateful to the noble Lord, Lord Wells-Pestell, for provoking the very useful discussion that we have had today. I am particularly grateful to him for having provoked that superb speech from the noble Lord, Lord Richardson, which brought to us a wealth of experience and judgment and so raised the level of the debate.
I am going to limit my remarks to two points. I know that it is said that yesterday can teach us nothing. I took my first house job rather more than 55 years ago. We were not paid, we competed strongly for those appointments, we wanted them for the completion of our education, for the responsibility it brought us. For most weeks of that time, we were on duty, if by "duty "one means hours worked and hours waiting on call, I suppose, for 168 hours a week. We rarely went out and when we did so we arranged with a colleague to stand in for us. We enjoyed it enormously. We felt that it was essential to our professional life. It was also the centre of a very lively enjoyable, professional, community.
I do not remember, I confess, being dog-tired. It may be that one remembers only the more pleasant things and forgets the nights of exhaustion. I do not believe that for a moment; they were great days and when we finished one job we put down our names for another. I would not have it believed that to be on duty for 24 hours is as destroying as it sounds. We worked hard on duty, we played cards, we played billiards, we read, we worked, we even occasionally went to a neighbouring hostelry, having arranged with the porter to call us if we were needed. Do not let the picture of the past be forgotten even though it is now defined as the bad old days. I doubt whether the young house officers—and I am speaking only of the house officers and not of the higher grades covered by this Bill—are very different from those days. Nevertheless, the world is different. We accept that there is a problem whether we like it or not. It is no good 527 quoting 50 years ago in an attempt to pretend it is not here.
My second point is that I do not think this Bill is workable. Its objective—and I know that it has to be approached by stages—is 35 hours a week, working and waiting to work. I do not know what the proportions would be; but the total is 35 hours a week including 10 hours for refreshment. That is what the Bill says. What possible use is 25 hours a week in the educative process? How many changes of doctor does it involve for the individual patients? It seems to me that, however hard we try to solve this problem, it is not by legislation that the solution will be found.
It contains some absurdities when one examines the figures involved. What happens at the end of the 25 hours? Mind you, there is an exemption clause. If there is a state of emergency proclaimed by Her Majesty, then all bets are off and hours limitations go. If there is a major accident procedure or its equivalent being put into operation—I am not certain what that is, but it does not cover an outbreak of infectious disease —what is the young medical officer of the infectious diseases hospital to do when his limit has been reached? What is a hospital to do?
My mind goes back to my first house job as house physician to the children's department of a teaching hospital. In those days—thank God not now—every summer brought a great wave of children, babies, suffering from what is politely called D and V—a killing disease demanding immediate treatment to replace lost fluids. What was one to do having reached the limit of the day, to throw down the work and go? I am sorry, but this is inconsistent with proper care of patients.
Therefore, I say, though there is a problem to be solved—and some progress is being made, as the noble Lord, Lord Richardson, told us—for Heaven's sake do not let us pretend to solve it by legislative clauses that name hours of work. In other words, when you must stop and give up. That means great discontinuity of treatment for patients. I am afraid that his way of doing it has all the properties of a nightmare. I accept the arguments for the existence of a problem; I do not feel competent to express a view as to the size of the problem for my contract with hospitals has hardly existed for almost 50 years. But I know that to try to solve this kind of problem involving patients by legislation, by Act of Parliament, is a nonsense.
We are grateful to the noble Lord, Lord WellsPestell, for introducing the subject and usefully opening up this discussion; but do not let us believe for one moment that by passing an Act of Parliament we can solve a complicated problem of this kind. It is a problem which involves human beings, patients and doctors, in circumstances which would need to have that degree of elasticity that would permit the best medical service to be rendered and not a reference to an Act of Parliament to see whether you have reached your 25 hours or other limit, whatever it may be.
§ 8.3 p.m.
§ Lord Porritt
My Lords, like my noble friend Lord Richardson, I feel I must declare an interest, in that I speak to you as an ex-junior hospital doctor—very 528 "ex" I admit—but rather like my noble friend Lord Hill with still a very keen remembrance of those days. And how good they were! If they were that good—or bad as you may think today—it is rather extraordinary that here are we three still standing up despite the life that we lived as junior hospital doctors all that time ago. It perhaps speaks a little for the old régime.
I will deliberately refrain from any comparison between the junior hospital staff—very definitely overworked in pre-NHS days—and the junior hospital staff of today, apparently still overworked. I do not think that it would achieve anything at this moment, although I believe that the comparison would raise some very fascinating questions about the practical and cost-efficient care of patients. I think the comparison would still be worth making. It might be conducive to a pretty radical rethink of methods of achieving what we have been talking about so much: maximum patient care.
I too should like to thank my noble friend Lord Wells-Pestell because—I will be frank—he has opened up this extremely interesting discussion much more than I expected. I was very disappointed when I saw the form of this Bill. I hoped that I should be able to support it, but when I saw its shape I realised that I could not possibly do so. This did not mean that we did not all agree with the principle behind it all, the principle of improved patient care, and the Bill as it stands—and I agree with my noble friend Lord Hill that it is impracticable and I do not think can possibly go much further—has opened up an extremely interesting periphery and vista.
There are so many sidelines connected with this problem that it merits very long and detailed consideration. There are certain aspects, most of which have been mentioned, which appeal to me enormously, one of which the noble Lord, Lord Richardson, mentioned but did not go into. That is the education side of the matter. If we cut down the working hours of these young men to the bone, not only will they have no time to give continued service to patients, but they will certainly have no time to learn, to be taught, to be trained and to get experience. Those are vital parts of a doctor's activities at that stage in his life.
That is one point that I should like to stress. Another is this. It is a waste of time to consider the Bill as it stands. My noble friend Lord Hill has already given your Lordships a little mathematics and it seems quite ridiculous that a doctor will get full pay—whatever the pay is—for doing half a day's work. That is what it boils down to. If we fulfil this scheme, we will have to treble our junior hospital staff to keep going with these reduced hours. That would be so even if we doubled our consultants, which the DHSS has apparently rather vaguely suggested might happen at the end of the 1980s. We should still need twice as many junior hospital officers as we have now.
Who is going to pay for that? At the present moment, the personnel side of the NHS costs considerably more than the whole of the cost of the rest of the service put together. If you are going to put up that personnel bill by hundreds of new hospital doctors and consultants, you are going to increase that bill to an impossible extent. That is why I do not think that the Bill as it stands is practicable. We have been 529 very lucky and we ought to thank the noble Lord, Lord Wells-Pestell, for opening up this discussion. I hope that it is not finished by a long way.
We have heard of the most fascinating discussion at the DHSS between the young doctors themselves and their committee at the BMA, and the practical results that appear to have come out. I hope that we shall hear a little more shortly. This is the way in which this problem should be tackled, by mutual agreement. It is not 35 hours: they are talking round a figure of 80 hours. That is practical. Something could be managed around that figure, but certainly not around 60, 40 or 35 hours. That is just not on from a practical point of view. I hope that this get-together between the department and the junior doctors will continue and will produce results.
It has been thought that, if we are to get better service and not work our young doctors so much, we ought to work the consultants more. That is an interesting thought. There is no reason why the consultants should not work more if they have time to do so. But, is it not a terrific waste of time for a highly trained and a specialised consultant to do routine work? That is not his job. He is wasted if he does that. He is there to train his juniors—and juniors go up to quite a senior level, I can tell your Lordships. He is there to be the leader, to be the teacher and to do the bigger work. To bring him in to do routine work in the wards is not good medicine.
The other point which my noble friend Lord Hill so rightly brought up is that the junior doctor must be given a little sense of competitiveness; a little incentive. He must be pushed to some extent to get the best out of him and, equally, to do the best for him. That is why I think the number of junior hospital staff must be such that it does not automatically open up the higher ranks. He must have to work for his promotion and he must feel competitive with his contemporaries. So, while I cannot in any sense support this Bill as such, I very much wish to join those who have thanked the noble Lord, Lord WellsPestell, for initiating this debate, whatever happens to his Bill, because I believe and hope that this will lead to much greater things on a much wider scale inside the NHS.
§ 8.11 p.m.
§ Baroness Stewart of Alvechurch
My Lords, as a former chairman of governors at a London teaching hospital, I welcome the opportunity my noble friend's Bill has given us to consider the heavy responsibilities and long hours of work of junior hospital doctors. I do not recall, when I was in the hospital, any complaints being made by them, but I am sure that their exacting duties, which were of such great importance to their patients, left many of them worn out at the end of many working days. I am sure, too, that the majority of hospital patients are deeply grateful to the hospital doctors and to their nurses for the treatment they receive. When considering my noble friend's Bill, we must bear in mind that fatigue can be a dangerous symptom and it may affect a doctor's judgment relating to his patient's needs. Doctors, of course, are aware of this and will normally avoid snap decisions.
In considering this Bill, we must also bear in mind that even today the medical schools find it difficult to 530 produce the numbers of doctors which are required to cover all the work that is expected of them, and allowance has to be made for sick leave and for study leave which may be required by young doctors in order to pursue higher examinations. We shall undoubtedly need more medical school doctors, and I hope that improved working conditions for doctors in the hospitals may lead to an increase in the number of young men and women wishing to train as doctors.
Although a reduction in the hours of work of junior hospital doctors is essential, it must be achieved with the full co-operation of the medical profession and, even more importantly, it must not lead to a deterioration in the service given by junior hospital doctors to their patients. I think we all agree that continuity of patient care is of very great importance. I understand that the medical profession would agree on moving from the 88.3 hours average working week to a one-in-three rota, which would represent about 80 hours a week. That would be a very considerable improvement on the present position and I hope that it will come about in the not-too-distant future. I hope, too, that all the proposals made in my noble friend's Bill will be given careful consideration.
§ 8.14 p.m.
§ Lord Hunt of Fawley
My Lords, perhaps I might just tell a very short story against myself, bearing in mind what the noble Lord, Lord Wells-Pestell, and others have said so well about the effect of a severe lack of sleep on almost everything one does. Some years ago, I was a house surgeon in a teaching hospital in London. I had been on duty and up for two nights without any sleep at all. On the third morning, full of coffee, I felt full of beans. I went down to the surgery, where a lady was sitting on a bench with her skirts drawn up, her varicose veins very prominent and with her notes on the table. I wanted to say: "Are these your notes?" but what I actually said, after this lack of sleep, was: "Good morning, madam; are those your legs?"
I am quite sure that I could never have said such a fatuous thing as that had I had a good night's sleep the night before.
§ 8.16 p.m.
§ Baroness Jeger
My Lords, this has been a very informed and useful debate and we are all grateful to my noble friend Lord Wells-Pestell for making it possible for us to take part. I was particularly interested to hear the remarks of some, if I may so call them, older doctors, because I do not remember in my young days those junior doctors always being so exhausted that we never had any good times at all; and I am very sorry that occasionally a note of gloom has come into the debate about the lack of resilience and staying-power of many of the young men and women who are working with such dedication in our hospitals. I say that not because we ought to take advantage of them, but because I think it is very important to try to get a "wide focus" look at this problem.
In the first place, I must say that, whatever the noble Lord the Minister is going to tell us about the conference last Friday and the report in the Guardian, there seems to me to have been some lack of courtesy somewhere—and I am not saying where—in that nobody thought fit, either in the department or in the House, to inform my noble friend about this matter which so closely affected 531 his Bill. We cannot all read the British Medical Journal and it seems to me that it would have been helpful had we known more about that conference. Now, I feel that things have largely been put right because we have heard so much about it from the most informed source, and we are all better qualified now to discuss the matter.
I must say to your Lordships that I feel this is largely a matter for the profession. There are all sorts of things wrong in the way we use medical manpower and nursing man and woman-power. For one thing, the very name "junior doctor" is misleading because to the general public it usually means someone who is just qualified. The fact that it includes all doctors in the hospital up to registrar level is not well understood outside, and it really is not a felicitous or accurate description.
I should like to make one point that has not so far been mentioned about the hours that the so-called junior doctors are working in hospitals. I have found among many women doctor friends that the hours of hospital work are a serious disincentive to their staying on that ladder of promotion. I am sure that one of the reasons why we have comparatively few women consultants—and that is true in some specialties more than others—is that a woman doctor, however well qualified, wanting to have children and to have some time with her family, will feel that the hospital situation is not compatible with that sort of life because of the long hours. Therefore she is more likely to go into part-time work or perhaps into general practice, which may perhaps be the best thing that any doctor can do. It really is a very strenuous time either for a young man or a young woman—a time when this is not just a kind of student phase in their lives but might go on for many years, because there are certainly always going to be many more junior hospital doctors than there are registrars or consultants.
I should like to follow up a question which was raised by the noble Lord, Lord Winstanley. I, too, had heard about the increase in consultant posts, but is it a fact that there has been a reduction in the preregistration posts? At one time, there was quite a log-jam and there was a great deal of discontent among doctors in several hospitals.
What we have to do is to go carefully through the report of this debate. No Government have solved these problems. I am not introducing any party points at all; we could have a very "party" debate on the National Health Service, but that is not for tonight. We need to put our heads together, to think more about how we use our doctors and about the whole set-up of hospitals in this modern age. Hospitals are very complicated workplaces. If they had not existed, I am not sure whether we should have invented them. One thinks of the multiplicity of disciplines that have to go on, such as cooking, washing, laundering and operating places of skilled technology, places of asylum—and I use the word "asylum" carefully, because it is often under-estimated especially in our mental hospitals.
A doctor must deal with such a variety of situations that more thought about the redistribution of the work burden is as essential as the shortening of hours—and I say this with great respect to my noble friend Lord Wells-Pestell, who I know will agree with me. In any work situation, what you do in the time you are at work is as important as how long you are there. You 532 can feel that you are wasting your time when the hours drag, and there is not half the stimulus that there often is in working quite hard for a different number of hours.
I should like to ask the noble Lord the Minister whether he can tell us tonight anything about the number of doctors who are unemployed or underemployed in this country. I do not have any figures with me, because it is not easy to get them, but I have heard of the difficulties that some young men and women are finding, and I know that often it is because it is difficult to move around the country. I am sure that there is always a vacancy somewhere for somebody, but it is not always in the place where you want to work.
The arguments have been very interesting and very serious, and I would end by saying this. It seems to me that the challenge is with those who say that my noble friend's Bill is not workable; that we cannot improve by legislation a situation which we all agree is serious; to say how we can do it. It is not good enough to use as a "get-out" the fact that there are statutory difficulties. So everyone who said to my noble friend that this is not possible by legislation, now owes it to him and to the House to get up and say how it should be done, because the whole mood of this debate is that this should be done.
§ 8.24 p.m.
§ Lord Elton
My Lords, I think I should start by saying that the Government very much share the concern of the noble Lord, Lord Wells-Pestell. My colleagues and I fully accept that the hours of work of some junior hospital staff are excessive. Indeed, the average junior doctor is contracted for nearly 90 hours a week. Although, as has been made very clear this evening, contracted hours include both time spent on-call and hours actually worked, we consider that this figure is too high. We are anxious that it should be reduced and have started to consider steps to do so.
That brings me to the conference and, in retrospect, I regret that I did not mention this to the noble Lord, Lord Wells-Pestell, in conversations that we had prior to this Bill. But I must make it clear that the people attending the conference, although they came from a representative range of institutions—and I shall later be speaking about those—attended as individuals. Contrary to what I believe the noble Lord, Lord Richardson, who made a most admirable speech, believes, there was no agreed outcome, though the chief medical officer said that he would produce an account of the conference which would be circulated, and I think it will be found that what is circulated bears a close resemblance to what I shall tell your Lordships.
But I regret that I did not mention this only for this reason: that the success of the conference and its prestige were greater than I had supposed, and therefore I shall have to give it slightly more weight than I would otherwise have done in this speech. But the fact remains that it was, in no sense, a bargaining or negotiating conference. The people were not plenipotentiaries and the speculative account, which was as surprising to me as it was to the noble Lord, Lord Wells-Pestell, has perhaps given an apprehension and and understanding of the conference which is, frankly, misleading. 533 I very much hope that I have not unwittingly caused offence, because I value the open relationships which it is possible to keep in this House, particularly on matters which we do not treat as straight politics. I should not like it to be thought that I deliberately withheld from the noble Lord information about the conference which, it is true, was known in the profession, but which, none the less, seems to have been built up to appear to be something which it was not. I do not want to belittle its importance and I shall return to the conference.
But, first, let me say that our argument in this debate is not, therefore, with the spirit of this Bill, that juniors' hours should be reduced from excessive levels, but with the way in which this should be achieved. Some noble Lords have made it clear that they are very familiar with the way in which junior doctors work and how their hours are determined, and I must say that some noble Lords seem to have taken great pleasure in the experience. Junior hospital staff are contracted to work a basic 40-hour week. Generally, although not exclusively, this will be from Monday to Friday. Thereafter, they are contracted to perform stand-by or on-call duties. A doctor who is contracted for 90 hours a week will, therefore, spend 50 hours a week on-call or on stand-by. Being on-call or on stand-by can be very inconvenient, but it is not necessarily very tiring.
The amount of time which doctors actually spend working when they are on-call varies between grades, specialties and "firms"—and, as your Lordships will know, in this context a "firm" is a group of doctors led by a consultant. However, various surveys—and the subject has been surveyed—have suggested that an average of about 30 to 35 per cent. of on-call and stand-by time is spent in working. In some specialties it can be considerably less than this. For example, I think that the number of urgent turn-outs in dermatology or, indeed, neurology in the middle of the night are minimal, but we are not, of course, looking only at dermatologists and neurologists.
On average, then, junior doctors will actually be working for perhaps 62 hours a week, which sounds a lot and by comparison with other sorts of work it certainly is a lot. But medicine is not, as noble Lords have already said, just a job like any other. Doctors, whatever we consider to be the maximum they can work, cannot simply work from nine to five. Patients need round-the-clock care and they need it from doctors who are familiar with their case. The noble Lord, Lord Winstanley, emphasised the benefits that result from that. Long hours are part of the practice of medicine. I doubt whether there is anyone who enters medical school who does not realise this fact before he goes in, and I am certain that he knows it when he comes out.
Medicine is more than a trade. As the noble Lord, Lord Davies of Leek, put it with his customary eloquence, those who answer its call do not expect an easy life while they acquire their skill. This has a great deal to do with the profound respect in which the profession is held by other people in the community. Fatigue, however, is, without doubt, experienced by some doctors, with results such as those mentioned by the noble Lord, Lord Hunter of Newington, and others.
534 I ought, however, to point out that every patient in a National Health Service hospital is under the care of a named consultant. It is the responsibility of that consultant to ensure that the medical care provided for that patient is adequate and, in particular, to decide whether treatment can safely be left to the junior doctor on duty. Equally, it is the responsibility of the junior doctor to call in a more senior doctor or the consultant if he feels he is unable to cope. It is this which provides the safeguard for patients from junior doctors who, unlike the noble Lord, Lord Hill of Luton, are not entirely indefatigable.
I do not want, none the less, to suggest that no improvement is possible. Indeed, I have already referred to the steps which we have taken to look for improvements. However, I must stress that the kind of figures mentioned in the Bill are quite impracticable, even as a distant target. This is not because we wish to exploit young men and women but simply because an adequate standard of care cannot be provided by doctors who go off duty at a fixed time, regardless of the needs of their patients. The noble Lord, Lord Hill of Luton, was very precise about that. That is no more today in the nature of their chosen profession than it was 50 years ago.
There is another important point which I ought to emphasise. Junior doctors are doctors in training and the course of training which they follow is laid down, not by Government but by completely independent professional bodies: the General Medical Council and the Royal Colleges. Posts limited in the way proposed in the Bill would not, I believe, be recognised by these bodies as providing adequate training. To become masters of their craft, doctors need to see a wide range of different cases. They need to see individual cases develop over a time-scale which has to be set not by the clock, or by regulations, but by the patient. The clock has an apparently malevolent influence of its own. I understand that in medicine, as in some other professions, the most interesting as well as the most urgent developments have an uncanny habit of turning up in the wee small hours of the night.
There is another consideration, by no means the least. Doctors need to learn to make crucial decisions at inconvenient and uncomfortable times because that is very often the condition, when they are trained, in which they are going to have to operate. They have to learn to respond to emergencies, even though they have just woken up or have been on duty for a long time. This is what they will be called upon to do when they are fully trained. So I do not think that it is an exaggeration to say that, if the Bill were passed, postgraduate training in this country would fail to reach the standards of which we are now justly proud.
The Bill also seems to me to have a number of other rather serious defects. There would, for example, seem to be no restriction upon a doctor contracting, of his own choice, separately with two different health authorities to work for longer than the stipulated periods, thus defeating the Bill's objective. Clause 1(b) and (c) seek to put defined limits upon the amount of work which may be done in any one day and the amount of time which may be given for refreshment.
This seems to me—and others have pointed it out—to be similar to the way we deal with safety in transport. The noble Lord himself drew on that analogy. But 535 it is not so easy as that and the analogy is not so straightforward. Driving rosters can take account of the need for scheduled stops, but you cannot do that for doctors. A patient cannot always be left at the end of a 10-hour day. The result would be that doctors would then be required by their professional undertakings to put in "voluntary"—and I use the word in quotation marks—overtime, for which no payment could be provided. I do not think that this was the intention of the Bill. However, it seems to me to be an unseen but unavoidable consequence which would be neither right nor fair.
I hope I have made it clear that the Government recognise the very real problem to which the noble Lord's Bill is addressed, but they do not regard it as a practical solution. As the noble Lord, Lord Richardson, himself said—and he put it much more trenchantly than can I—the Hospital Junior Staff Committee, by far the largest of the various bodies which speak for junior doctors, recently considered this Bill and passed the motion which he read out: That it was opposed to any legislation seeking to reduce the hours of work of junior doctors at the present time.
So what is the way forward? I agree entirely that we cannot simply say that this legislation is not suitable and duck out of the responsibility. To a layman, the obvious solution would be to employ more junior doctors so that each worked fewer hours. The problem with that is that these doctors are training for consultant posts. To employ more, without creating more consultant posts pro rata, would produce ever larger numbers of doctors with highly specialised skills, acquired at great expense, and with no opportunity to use these skills. The junior doctors themselves have expressed very strongly their support for our policy of reducing the number of junior posts while increasing the number of consultants. They have done so in their evidence to the Social Services Committee, in their comments on the report of the Social Services Committee and in letters to the Secretary of State. This policy will improve their career prospects and I am convinced that it will improve the quality of patient care.
This brings me to the point at which I should reassure the noble Lord, Lord Winstanley, and others (including the noble Baroness, Lady Jeger) that the number of pre-registration posts is not in process of reduction. It is carefully controlled to relate to the number of our medical school graduates. As the latter has increased, so has the former. As to the moratorium on junior posts, certainly there is a moratorium on junior posts, but the overall numbers in the profession are planned to expand—but by consultant, not junior, expansion because of the distortion of the career pattern of doctors in hospitals and of the inordinate length of time that it takes juniors to reach consultant appointments under the present system.
The answer to the problem lies in a careful examination of the organisation of medical work in hospitals, I quite agree—in making more efficient use of all doctors. In some cases, juniors may be able to take out-of-hours cover for more patients, but for a shorter time. In others, the burden of out-of-hours work may be redistributed between juniors and consultants. 536 In some cases, the work involved may be so specialised that only a very few doctors in any hospital are capable of providing the necessary cover. Sometimes a consultant may disagree with the noble Lord, Lord Richardson, and judge it right that only the doctors within his "firm" should give cover to his patients—though if he has read the noble Lord's speech with care 1 think he will take very careful thought before he disagrees with him about anything. These doctors know the patients best. This again was the point made by the noble Lord, Lord Winstanley. In other cases, a doctor from one "firm" may be able to cover for several.
The situation is not clear-cut. It is not susceptible to uniform, cut-and-dried solutions. It follows from this that any approach is likely to be piecemeal and not across the board. There must be flexibility to allow for the particular circumstances of individual specialties and individual hospitals. This is basically a task for the profession itself. Legislation is too blunt an instrument. There must be preparation in the way of seeing what is going on now. On the question of the study of doctors' hours, we hope to see published later this year a full survey of the working of junior hospital doctors undertaken by the Office of Manpower Economics on behalf of the Doctors and Dentists Review Body.
The question of the distribution of doctors also arises. At this point may I say that, while it is true that some posts are less attractive than others, this is not the main reason for the disparity in staffing between teaching, hospitals and others. Junior doctors are, let us again remind ourselves, in training, and inevitably training in the more specialised and recondite areas of the subject is available only in the specialised teaching hospitals. For this reason, the training bodies generally expect a fair part of the training to be spent in such hospitals, and therefore there is bound to be some sort of concentration in them.
I said that I would return to the matter of the conference which was arranged by the chief medical officer on the subject and was held last Friday. I myself was not present, but I have received a full report. I hope that noble Lords will find a brief account of the proceedings helpful. It does not include an agreed statement, but I have already said that an account will be prepared and circulated. In summary, I believe that it will say that the participants came from all sections of the medical profession and in NHS management, but they spoke as individuals rather than as representatives—and that is really rather crucial to my position on this. I am told that their discussion was frank and realistic for precisely that reason. It means, of course, that neither Government nor any other organisation are committed by the conclusions of the conference. Certain themes attracted such general support, however, that they might lead to a fair degree of consensus in the profession at large, and this is the factor of which I was not aware last week.
First, there was general recognition that there is a real problem to which a solution must be found. As one speaker put it, the conference was not about whether something needed to be done but what needed to be done. There was also wide agreement as to what the immediate aim of any such action should be. Virtually without dissent, I understand, the partici- 537 pants felt that the first step should be the abolition of the so-called "one-in-two" rota in the acute specialties; that is, the arrangement whereby a doctor is on duty every second night and evey second weekend. For the longer term, the goal might be no rota more onerous than one-in-four, although most of those present felt that one-in-three rotas would be acceptable as an interim target. This bears out what was said by the noble Baroness, Lady Stewart of Alvechurch.
To translate this into more familiar language, this interim target of a one-in-three rota corresponds to slightly more than 80 hours per week on duty, while the long-term target of one-in-four rotas corresponds to 72 hours per week on duty. The face of the noble Lord, Lord Wells-Pestell, may be lengthening at the disparity between that target and his own, but at least this is the profession speaking. I should repeat that these targets are for the acute specialties—those where emergencies are common and rapid action is essential. Another point to emerge was that not all specialties are like this. There are those when the demands on a doctor out of hours amount to little more than an occasional request for advice over the telephone. With these specialties, even a one-in-one rota—that is, notionally being on call for all 168 hours a week—is not an onerous responsibility.
If I may draw a conclusion from all this, it is that the concept of excessive hours for a doctor is a very different one from that for most other workers. The reason for this is perhaps the second major theme to arise from the conference. British medicine is based on the concept of continuity of care; the idea that an individual doctor accepts personal responsibility for a patient throughout the patient's treatment. Certainly that is how many patients see it. To the layman, the importance of this may not be apparent, but I am told that speaker after speaker stressed that if this concept was lost it would be the patients who would lose out and that the loss would be very real.
The final theme was that targets can be set nationally but that implementation must be very much a local matter. Noble Lords have already referred to the unevenness of distribution of resources, both between types of hospital and between different parts of the country. Arrangements that will work in a large hospital, moreover, will not work in a small hospital. Even hospital geography—the arrangements of the wards and the placement of the doctors—can be relevant.
Most important of all, it was felt that changes in the present arrangements must be discussed fully and agreed among the doctors concerned. In brief, the conference has identified the difficulties and has even suggested a way forward. Above all, I believe it has built up a head of steam in this matter which has been compounded and multiplied by the noble Lord, Lord Wells-Pestell, in introducing this very timely debate on the Bill. Further progress is a matter for discussion in a number of places; within professional organisations such as the Royal Colleges, in the negotiating meetings between the department and the profession, and locally in National Health Service hospitals.
I should at this stage pay tribute to the distinction of the contributors to this debate. It is one of the more alarming things about coming to the Government's Despatch Box, which one regards as a pinnacle of unassailable virtue and authority, suddenly to 538 discover that one is dwarfed by the experience and stature of those with whom one engages in debate thereafter.
The noble Lord, Lord Wells-Pestell, has drawn your Lordships' attention to an issue of very great importance in a timely and forceful manner. At one time or another, almost all of us spend a part of our lives in hospital in the hands of doctors. The trust with which we do so depends on the character of those who work in the profession and also upon their skills. The conditions under which those skills are acquired are not satisfactory. They do place very great strains on those who train for the profession. The Government recognise this problem and are already addressing themselves to it, This useful debate has thrown further light on the subject. It has highlighted the need to look at the distribution of doctors, both geographically and between specialisms, and the distribution of work between specialisms. It has evoked from the noble Lord, Lord Hunter of Newington, statistics that will be read with great interest in the colums of Hansard tomorrow, and it has evoked from other noble Lords speeches of interest and authority which it would be difficult for any other Chamber to have concentrated in one period. This debate will be noted with interest both by my colleagues and by professional and other members of the department whose concern it is to reduce the hours at present worked by junior doctors to a more statisfactory level. They also will be indebted to the noble Lord, Lord Wells-Pestell, for the service he has done in introducing the Bill and calling for this very useful discussion.
None the less, in view of the practical difficulties inherent in the Bill itself, and more particularly in view of the fact that it will pre-empt a full and proper discussion of this problem and attempt to solve it with an instrument which I fear, whatever was done with it in later stages, would remain inappropriately rigid, I hope the noble Lord will feel that the service he has done to the profession and to your Lordships' House is sufficient and that it will not be necessary to proceed further.
§ 8.48 p.m.
§ Lord Wells-Pestell
My Lords, I am grateful to everyone who has taken part in this debate on the Second Reading today. I believe that this is the wrong time to deal with matters which have been raised by various individuals but I am grateful to everybody. I did not know that my noble friend Lord Molloy was intervening, but I am glad to hear him because of his experience with the Federation of Hospital Service Employees —and sometimes we forget that they have a point of view.
If there is anyone I should like to have done battle with it would by my old friend the noble Lord, Lord Hill of Luton. I would like to take him to task for a number of things he said but, as 1 have said, I do not believe it will serve any useful purpose. I am grateful because we have been given a lot of specific information which is new to many of us, but which is of supreme importance to the understanding of this particular problem.
The one thing I feel very strongly about is the number of times it was said by people, including the Minister, that legislation is not the way to do this. I agree with 539 the noble Lord, Lord Richardson, that we ought to do this by arrangement. But what I want to say very strongly is that if it cannot be done by arrangement, then there is a responsibility upon Parliament to see that patients are protected. The best way of protecting patients is to see that junior hospital doctors do not work extraordinarily long hours. If they do and the department cannot deal with it, the BMA cannot deal with it and the doctors themselves cannot deal with it, then I believe it is a matter for legislation, and I would have no hesitation in coming back again if this was necessary.
I am grateful to the noble Lord, Lord Elton, for his opening remarks. I would not accuse him at any time of not treating one fairly; I have had a long enough experience and association with him to know that he would not do this deliberately. But I did feel that, knowing as much as we do now, it might have been possible to deal with this matter in some other way.
I think the only other thing I want to say is this, that I am not, even now, convinced in my own mind that there is going to be a consistent, well-thought-out, determined policy to bring down hours. I do not think it is good enough for the department to say there will be discussions going on here, discussions going on there, discussions going on somewhere else. I do not know whether the noble Lord can give an assurance that this matter will be co-ordinated by the department, because in the last analysis it will be the department who will have to agree to any reduction in hours. I would like to feel that this is going forward, not haphazardly, not when various groups decide to meet, but under the leadership and guidance of the department, so that within a comparatively short space of time there will be something emerging. I do not know whether the noble Lord would like to intervene before I finish.
§ Lord Elton
My Lords, with some temerity, I would say that I have experience of predicting the length of time things take in Government and have been wrong. I would not like to come to the House and say that this problem will be solved in a particular span of time. I have said that we recognise the problem, we want to solve it and we intend to play our proper role in it. I have tried to make it clear that it is not entirely the Government's role to solve it, because standards of training and so on are matters for other bodies than Government and the Government should not issue edicts to them. But we shall certainly be at the centre of the operation, and with Lord Wells-Pestell's riding whip to it, we shall not be able to spend a long time about it.
§ Lord Wells-Pestell
My Lords, I am obliged to the noble Lord for those comments. We do know that if a Government department is not enthusiastic about something there is nothing like a Government department for dragging its feet, and it does it extraordinarily well, as the noble Lord knows. I shall watch for the dragging feet. Meanwhile, with the approval of your Lordships' House, I therefore beg leave to withdraw the Motion for Second Reading.
§ Motion for Second Reading, by leave, withdrawn.