§ 4.41 p.m.
The Earl of Caithness
My Lords, with the leave of the House, I will now repeat a Statement on medical and dental manpower being made in another place by my right honourable friend the Secretary of State for Social Services. The Statement is as follows:
"With permission, Mr. Speaker, I should like to make a statement about medical and dental manpower.
"Following the report of the Royal Commission on Medical Education in 1968 and the earlier McNair Report on dental manpower, a decision was taken to embark on a major programme of medical and dental school expansion. The purpose of that expansion programme was to achieve a position in which we are training, in this country, enough doctors and dentists to meet our own needs. The health service had already become heavily dependent upon doctors and dentists from other countries, to whom we owe a considerable debt. They have enabled us to make good the shortfall in supply which arose from the inadequate number of graduates from our own medical and dental schools.
"The expansion programme begun in the late 1960s is now largely complete. The Government therefore have a responsibility to re-examine the supply and demand position for doctors and dentists. A review of dental manpower was completed in 1983 and led us to conclude that the output from dental schools was in danger of leading to an over-supply. We accordingly agreed, following discussions with the profession, to reduce the intake to dental schools by 10 per cent.
"I am today publishing a report by the Advisory Committee for Medical Manpower Planning, which comprised officials from the Health Departments and representatives of the main professional bodies. The report contains different projections of the likely future pattern of supply of and demand for 900 doctors. There are many factors which will affect the future balance, including the level of output from medical schools, the extent to which women doctors remain in active practice and the number of overseas doctors coming here. I will want to discuss with the medical profession the implications of the report for the intake to medical schools, for the medical staffing of hospitals and for postgraduate training.
"The Government have, however, concluded that it is now necessary to prepare for the position which the expansion programme was intended to achieve: that is, where the United Kingdom is essentially self-sufficient in its supply of doctors and dentists. At present, overseas doctors and dentists have almost unrestricted access to this country. We have therefore decided to bring them more into line with the immigration rules applying to other groups. But we will wish to retain the important role which this country has traditionally fulfilled of providing postgraduate training to doctors and dentists from other countries who can come here for the period of specialist training before returning to put those specialist skills into practice.
"To give effect to this policy, my right honourable and learned friend the Home Secretary is today laying before the House a statement of the necessary changes to the immigration rules. Briefly, these changes will have the following effects from 1st April: doctors and dentists from overseas who wish to become general medical or dental practitioners will need to comply with the relevant entry provisions for the self-employed. All other doctors and dentists, with the exception of those intending to undertake a period of postgraduate training, will be subject to normal work permit arrangements. Doctors and dentists seeking entry for the purpose of postgraduate training in hospitals will be admitted for a period of up to four years. After four years in this country they will be able to stay only if extensions of stay are granted under the normal immigration and employment provisions. A similar permit-free provision of postgraduate training will be available to overseas nationals graduating here. The changes will not apply to the doctors and dentists from the European Community, who have free entry to this country for employment.
"Mr. Speaker, the changes are, I believe, a sensible step for us to take at this stage. They do not in any way affect the position of overseas doctors and dentists currently working here. They will, however, make clear to those who come in the future the basis on which they are being admitted and they will ensure that we do not encourage doctors and dentists to come here with expectations that the health service cannot fulfil. They will also enable the health service to plan its use of medical and dental manpower more effectively".
My Lords, that concludes the Statement.
§ Lord Ennals
My Lords, perhaps I may first thank the noble Earl for repeating the Statement which was made in another place by his right honourable friend the Secretary of State. I broadly welcome this Statement. I want to say that we owe a very great debt of gratitude to those doctors and dentists who came to 901 this country from overseas, perhaps for training, and who have stayed here, for all that they have done to sustain the National Health Service. There is no doubt that their contribution, particularly in the less popular specialties, has been of very great importance to the National Health Service. I think there have been times when, without them, we should have been hard pressed to provide the service which has been provided.
I am glad that the position of those already practising here has been in no way affected by the decisions that have been taken by the Government and the provisions of the Statement which is made today. I also agree with that part of the Statement which referred to the need to reduce the intake to dental schools. I know that was in conformity with the views of the British Dental Association and the working group which reported some two years ago.
Thirdly—and I hate to go on agreeing with the Government this much—I agree with the decision that we should not deprive developing countries of their supply of medical manpower. During the whole period when I was Secretary of State I was well aware that, while the National Health Service was benefiting from doctors from overseas, overseas countries were at a disadvantage because those doctors stayed here for an easier life when they were very much needed in the countries from which they came. I welcome also the decision to retain the facilities for postgraduate training for doctors and dentists from other countries.
My regrets concern what has not been said in the Statement, which is a Statement which I thought was going to go rather more broadly on medical and dental manpower. The first point about which I had hoped to hear—and about which I hope that the noble Earl will feel he can say some words—is the very important issue which was taken up by the Select Committee on Social Services in another place, of which I was a member, which dealt with the very serious shortage of consultants and the very serious bottleneck, because of the excess, of those in the training grades. The noble Earl will recall that the Select Committee suggested that over a period of years there should be a doubling of the number of consultants and thus an end to the bottleneck for those in the training grades. I hope that he will be able to say something on this issue.
If it is not too unseemly to do so, may I finally give a warning to the noble Earl and perhaps to his right honourable friend? Last year for the first time the Government themselves imposed manpower cuts in the National Health Service. There was one result: that there are now an increasing number of doctors who are unemployed. I know there is pressure to reduce the number of doctors and therefore to reduce the number of doctors who enter for training. In my view, this is misguided. I do not believe that there is in a general sense a surplus of doctors to meet the nation's need. Looking at the field of primary health care, which concerns us all, I believe that there are too few doctors and that the GPs we have are unable to give enough time to their patients, have too little opportunity for home visits and too little time for health education. This is very much a question of medical manpower. I hope that the noble Earl may care to make a comment on this second point.
§ Lord McNair
My Lords, I, too, would like to thank the noble Earl for repeating the Statement. May I ask him, first, on average how many patients per GP list are the Government aiming at?—because, clearly, until you have decided that, you cannot decide how many doctors you need. I believe the average figure is about 2,100 and there is a view that a figure of 1,700 would be better. Can the noble Earl, when he replies, tell us whether the Government have a particular figure in mind?
Secondly, may I ask for an assurance that the Government do still recognise that training doctors for the third world is not just an act of altruism?—though, even if it were, that would not seem to me to render it necessarily undesirable. Surely, one of the best things that we can do for the third world is to improve the general level of health.
Finally, may I make a comment and put a question on the procedure of this Statement? Some of your Lordships may not realise that this Statement is quite meaningless without being read in conjunction with this document, which only appeared about half an hour ago. It is a statement of changes in the immigration rules and it makes, so far as I can see, 10 quite substantial amendments to the earlier statement of changes in immigration rules. It has been impossible for me, in the time available, to work out all the implications. Is this Statement by the Home Secretary of the changes in the rules an authoritarian fiat that we have got to accept, like it or not, or may we have an opportunity of debating it at the earliest possible moment?
§ 4.51 p.m.
The Earl of Caithness
My Lords, I am most grateful to the noble Lords, Lord Ennals and Lord McNair, for their reception of the Statement. I am particularly grateful to the noble Lord, Lord Ennals. On the last occasion or on the occasion before that when we discussed matters across the Floor of the House, I accused him of being too party-politically-orientated, but today I think that we share much more common ground than we did at that stage.
I am even more convinced now that what we are doing is the right thing. The noble Lord asked me about medical employment. I, too, am not convinced that there is substantial medical unemployment. In fact that is borne out by the Hospital Junior Staffs Committee's own survey, which showed that no more than 3 per cent. of junior doctors experienced transitional unemployment between short-term training posts. As the noble Lord is aware, there is to be a Green Paper on this matter later in the year and perhaps that would be a better time to discuss this aspect more fully.
The same would apply also to the comment of the noble Lord, Lord McNair, with regard to the numbers on the GP's list. I would say, from memory, yes it is about 2,100 but of course it does vary. Perhaps when we are discussing the Green Paper we ought to look into whether the figure should be a little lower, but at present the aim is about 2,000. The noble Lord asked for an assurance that training doctors from overseas countries was not just another form of altruism for this country. No, my Lords, we consider it to be an 903 extremely important part of helping them as much as we can by giving them a first-class training using the facilities of this country.
With regard to the immigration rules, I can inform the noble Lord that these are not statutory instruments but statements of the practice and administration of the Home Secretary. However, the Immigration Act requires changes to be laid before Parliament and I understand that they can be prayed against.
§ Lord Hunter of Newington
My Lords, may I ask the Minister to say a little more about doctors and dentists from Europe? He told us that of course they have free access, but my information (which is out of date) is that there has been very little movement of doctors from Europe to this country. However, perhaps Spain and Portugal will be in the Community one of these days. Will the noble Earl please tell us how many doctors have come from Europe in the last year?
The Earl of Caithness
My Lords, I am very grateful to the noble Lord, Lord Hunter of Newington, for his question. I understand that the figure is just under 100 and that most of these come from the Republic of Ireland. As regards dentists, the figure seems to be about 10 a year. It is not very many: but, equally, if they can come here without any restrictions, our people can also go to the EEC.
§ Lord Hunter of Newington
My Lords, would the Minister not agree that in fact there were large numbers of doctors coming from Ireland before we entered Europe? There has been a very small flow of doctors coming from the main European countries since we joined. I think one should note that, for some reason, doctors have not come in large numbers to this country.
§ Baroness Gardner of Parkes
My Lords, does the Minister think this is an adequate protection to meet the present under-employment of doctors and dentists or does he think, as I do, that this is only a small drop in the ocean? As an elected member of the General Dental Council, of course I welcome the restriction on free entry, because we are educating dentists who cannot get employment in this country. But does he not think that it is time we looked at the other end of the scale much more thoroughly and encouraged those doctors who are well over retiring age to retire and indeed to consider the early retirement of some general dental practitioners?
Is he aware that with the complete new type of structuring of dental fees from the 1st April the estimate of too many dentists may be well below what will really be the situation, as many more dentists may be unemployed due to an entirely different and much more expensive system of patient charges? Does he not think it is time to look at both ends? Also, when he says he is not aware of too much under-employment in medicine, is he aware that, as regards new young doctors at the moment applying to get on to a vocational training course as a general practitioner, 904 there are 200 applications for every two posts advertised, and that many of these young doctors are finding it very discouraging?
The Earl of Caithness
My Lords, I think my noble friend Lady Gardner of Parkes has put her finger on a very relevant matter. Successive Governments since the 1960s, including the Government of which the noble Lord, Lord Ennals, was proud to be a member, have been aiming at self-sufficiency as regards dentists and doctors. This is not something that can be achieved overnight and it has taken a good 20 years so far, but we are getting there. The Statement is merely an indication of the Government's continuing policy in one area—perhaps not all the areas that my noble friend would like to see acted upon, but certainly in one very important area.
As regards dentists, I can confirm, as I confirmed only the other day in this House, that the number of people attending dentists has gone up regularly. The number went up again last year and, as she will be only too well aware, I think that about half the population hardly go to a dentist at all; so there is a huge market still left for her.
§ Lord Ennals
My Lords, in answer to an earlier question, the noble Earl referred to the Green Paper on primary care which is still to come. In my more aggressive moods—and he will have noted I am not in such a mood today—I have been pressing the noble Earl to say when we are going to get this long-awaited Green Paper. Presumably he knows a little more than he did last time. Can he perhaps divulge some information to this House?
The Earl of Caithness
My Lords, I do not know the exact date, but I do not think it will be in the too-distant future. Perhaps the noble Lord will be kind enough to wait just a little bit longer.