HL Deb 25 January 1989 vol 503 cc768-814

7.47 p.m.

Lord Rea

My Lords, I beg to move that this Bill be now read a second time. I should like to say how delighted I am that so many distinguished noble Lords have agreed to take part in the debate. I am particularly pleased that my opening batsman will be the noble Lord, Lord Butterfield, with his maiden speech. As we all know, he has just retired from his position as Regius Professor of Physic at Cambridge University, after a long and distinguished medical career.

I have to declare an interest in the Bill as I have been a junior hospital doctor. Admittedly it was 30 odd years ago, but my memory is very vivid. One of my sons is also a junior hospital doctor, now in his third year, so I have both historical and current family experience to draw on.

When I first told the noble Lord, Lord Hesketh, that I was thinking of bringing in the Bill he said, "Ah, a well-known form of slave labour"! In one sense I would not go that far. At least junior doctors are paid for their work, though in a rather peculiar way as I shall describe. But in another sense they may be worse off than slaves. The Geneva Convention on the treatment of prisoners of war, who are surely a form of slave, forbids a working week of more than 48 hours. Junior hospital doctors are contracted on average for an 86-hour week and many do far more than that.

There has been a tremendous amount of public interest in our topic in the past six weeks since the First Reading of the Bill. That was greatly helped by the Minister, Mr. David Mellor—for which I thank him most sincerely,—when he said that accounts of long hours worked and their effects had a whiff of the fisherman's tale about them.

That had the effect of galvanising medical opinion. For example, a group of 15 doctors from St. Stephen's Hospital wrote to the Independent on 2nd January this year. They stated: Mr. Mellor insults us when he claims our statements of overworking are fishermen's tales. Doctors among us have fallen asleep at the operating table. Doctors among us have missed a crucial diagnosis late on a Sunday night. For him to accuse junior doctors of fabricating their stories is to try to protect the public from the reality of over-tired doctors treating their loved ones and perhaps making life-threatening mistakes. For too long junior doctors have kept quiet so as not to upset their bosses or damage their promotion prospects. We owe it to our patients and to ourselves to demand better working conditions so that we can provide better medical care". Similar letters appeared in other newspapers up and down the country.

The Bill has the support both of the BMA Hospital Junior Staffs committee, which represents all junior doctors, and of the Medical Practitioners' Union. They believe that 72 hours per week of contracted availability for work by 1992 is a realistic aim not requiring a large increase in medical manpower.

I shall attempt to give a brief outline of the present situation and the reasons for seeking legislation. First, who are the junior doctors? There are approximately 26,500 in Great Britain and Northern Ireland. Approximately 3,600 are pre-registration house officers doing their first year of professional work after qualifying. There are 11,500 senior house officers, who may work for several years in hospital before going into general practice or becoming registrars. There are approximately 7,500 registrars. That is the first step on the ladder to becoming a consultant. They may stay in the grade for two to four years, or even longer, before becoming senior registrars, of whom there are 3,800. Nearly all should become consultants—and I choose the word "should" advisedly—after a further four years. The average age of consultants on appointment is now 38, by which time they will have served 10 to 14 years as a junior hospital doctor.

Technically speaking, all junior hospital doctors are in training but some are not at all junior. As a group, they consist of some of the most able and highly trained people in the country. They handle most of the emergency and routine medical care in the hospitals. They are the doctors whom patients are most likely to meet when they first attend hospital and who will look after them from day to day when they are admitted to a ward. They are a group of professionals who like their work and carry it out extremely well.

Much is said about the importance of developing primary care in the community as being the key to improving health services. I agree with that statement because I am a general practitioner. However, good primary care is impossible without an effective hospital service. That must be, and it is, consultant-led. However, at present the bulk of the work is carried out by junior hospital doctors. The weekly contracted hours of work for those doctors as a whole were 86 in 1985, compared with 89 in 1981. Those figures are given in two Office of Manpower Economics surveys.

The hours consist of a 40-hour basic working week, plus 46 hours on call. The hours worked on average were 57; that is a decrease of one hour since 1981. That varied from 69 hours for pre-registration house officers in their first job—and they are the real workhorses—to 53 hours for registrars. There is a great deal of variation between specialities.

There is evidence to show that, although the total number of hours actually worked may have marginally decreased, interruptions in sleep while on call have increased in recent years because of the greatly increased throughput in hospitals and the greater use of technically sophisticated equipment for diagnosis and treatment. My son tells me that a major reason for interruption in the sleep of junior hospital doctors is the need for attention to intravenous drips and the drugs that they contain. It is a job which nurses could easily carry out. They could do it better if that were allowed and if their morale were better.

I hope that noble Lord will bear with me while I explain the implications of a one in three and one in four rota. They are stated early and long-term government aims. "One in three" means a basic 40-hour week—that is, 9 a.m. to 5 p.m., five days a week, paid at a standard rate—plus one-third of the remaining 128 hours in the week on call, which is paid at only 38 per cent. of the standard rate. It is a total of just under 83 hours.

That is not an incentive for local authorities to reduce the hours of work for junior doctors, because it costs far less to employ one doctor for 80 hours than two doctors for 40 hours. The 83-hour week of a one in three rota usually works out at 86 hours or more because, inevitably, the basic 40-hour week is unsufficient to complete day-time tasks.

A one in four rota implies a 72-hour week, as requested in the Bill. It could be achieved on a one in three basis if certain changes in working practices were made. If time permits, I hope to describe them in a little more detail. If locums are not employed and prospective cover is given for colleagues who are unwell or on holiday, the hours worked in a so-called one in three rota are much greater. They are up to 104 hours a week or more, which is equivalent to a one in two rota.

A one in three rota requires a doctor to be on call on two week nights for two weeks out of three, and for one week night with two week-end nights for the other week of the three. That is without days off after nights on call. In the busy specialties—and they are the majority—nights on call can be most arduous, especially if the firm is "on take" for new admissions that night. Then the doctor gets little or no sleep and even that is likely to be broken by bleeps and telephone calls. The benefit of such broken sleep has been shown to be little better than a night without any sleep.

The serious effect of sleep deprivation on decision-making and manipulative skills has been shown by numerous studies. Noble Lords, particularly those who served in another place, will be fully aware of the problem. While sleep-deprived subjects may be able to carry out major activities which are emotive or stimulating—for example, coping with a cardiac arrest or a major accident, behaving like troops in action—they become very inefficient at dealing with routine procedures or interpreting data. That duty is becoming increasingly important as technology advances. It is worrying to note that such skills begin to fall off at any time after the internal clock indicates that sleep is due after being awake for 15 hours or so. That would be at 1 or 2 a.m. in the morning if you got up at 7 or 8 a.m.

An increasing number of doctors in the United Kingdom are prepared to come forward and admit that they have made clinical mistakes as a result of fatigue. The results of a recent study carried out in Bristol were handed to me before the debate. They show that only 14 per cent. of those who answered the survey stated that they had made no mistakes. Twenty-two per cent. said that they had made four or more mistakes. Therefore, 85 per cent. were aware of one or more mistakes as a result of lack of sleep.

In the Confidential Enquiry into Perioperative Deaths (known as CEPOD for short), in three regions in the UK in 1985–86 it was judged that 618 deaths had avoidable elements over a one-year period. Fatigue was blamed as a possible cause in 28 cases. Extrapolated to all 15 regions, that represents 140 surgical deaths alone in one year and it is probable that fatigue in other specialties contributed to an equal or even greater number of deaths. The main problem associated with other avoidable deaths was the inexperience of the surgeon or anaesthetist; the corollary being that consultants or senior registrars should be more directly concerned with patient care.

It has been said that long hours on duty are necessary for educational purposes so that junior doctors can accumulate sufficient experience of a wide variety of clinical conditions and also because continuity of care by one doctor is highly desirable. Against that it must be asked: how valuable educationally is clinical experience if the learner's intellectual faculties are dulled by lack of sleep? Is patient care not better if tired personal doctors are relieved periodically by more alert colleagues?

A resolution of the Council of the BMA in December last year stated: Council believes that an average of 72 hours per week should be the maximum necessary for post-graduate training, and sees no reason for service needs to exceed this, save in exceptional cases". The Social Services Select Committee which reported in 1981 on medical education and medical manpower needs states: In present circumstances where many young doctors are expected to be on call for excessively long hours, not only arc they not in a position to provide a satisfactory service to the patient, but they are also not in the best position to learn and benefit from the training that is available.". We may ask how the Government have responded to that report in subsequent years. As a result of the report and other pressures, in November 1982 the DHSS announced a programme for health authorities to eliminate rotas more onerous than one in three. That was followed by three further circulars, the most recent in June 1988, in which district working parties inquiring into junior doctors' hours of work were recreated and asked to report later this year and have recently been asked for a progress report.

The most recent information shows that 12 per cent. of junior hospital doctors were still contracted to work for 99 hours or more per week. Clearly, the one in three rota aim stated in 1982 has not been achieved, let alone the 1981 Social Services Select Committee's aims of 80 hours. Even a one in three rota can be extremely onerous, as I have explained. Junior doctors want and deserve, I feel, something better for their patients' sake as well as their own mental health. However, a 72-hour week could be achieved with very little increase in manpower on a one in three basis if, for example, a day off was given after every night or weekend on call. There are a number of other ways in which hours on call could be reduced without greatly increasing staffing requirements. Schemes need to be adapted to suit local circumstances.

A good example is the model for Bath and District worked out by Dr. Ruth Gilbert and colleagues which achieves an average of 72 hours per week for 122 junior hospital doctors who are now averaging 86 hours a week by a combination of methods; namely, cross cover, flexible working, teamwork between teams in the same or similar specialties and the elimination of one tier in internal referral systems. Other ways of looking at cutting hours would be to look as split sites where two hospitals in the same district are offering acute services. One hospital could concentrate of some of those services and another on others without the necessity of closing the hospital altogether.

Further reductions beyond 72 hours would have greater manpower implications, but that does not mean employing 3,000 extra junior doctors as suggested by Mr. Mellor, further upsetting the balance between the numbers of junior training posts and career positions. However, it requires a considerable expansion of consultant numbers. The 1986 DHSS plan Achieving a Balance recommended a 2 per cent. increase per annum of consultants. In fact that has not been achieved, particularly in surgery, which is one specialty where junior doctors are most hard pressed. A 4 per cent. per annum increase, an eventual doubling of consultants, is required. In my view further permanent staffing in hospitals to buttress the consultants could be achieved by expanding the hospital practitioner grade for general practitioners who have developed skills in a particular specialty and who possibly have higher qualifications. They could come in for three sessions a week to do the work now being done by junior hospital doctors on the day which they should be having off having been on duty at night.

It has been said that a block to achieving reductions in junior doctors' hours of work should be laid at the door of those consultants who do not wish their numbers to be expanded and who are opposed to an increase in the hospital practitioner grade. However, the BMA Council now supports a 72-hour week. Many consultants who I have spoken to are aware of the problems of junior hospital doctors and are fully in favour of decreasing their working hours, increasing teamwork and becoming themselves more involved in patient care. Many are already doing that with increased job satisfaction and better patient care.

In your Lordships' House seven years ago in February 1982 a similar Bill to this was moved by my noble friend Lord Wells-Pestell arising from the then recently-published Social Services Select Committee report. The Bill was withdrawn at Second Reading because at that point the BMA Hospital Junior Staff Committee was not in favour of legislation. The Government said, in the words of the noble Lord, Lord Elton: we recognise the problem, we want to solve it and we intend to play our proper role in it … 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". My noble friend said: 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".—[Official Report, 16/2/82; col. 539.] On his behalf, I have done precisely that.

Finally, I should like to say a few words about the Bill itself. It is extremely short—hardly a page long. Clause 1 sets out the requirement of 72 hours' availability for work in any one week averaged over a one-month period. That allows for considerable flexibility from week to week. If required to work extra time because of the absence of a colleague, doctors should be given time off in lieu the following week. Clause 2 enables further reductions to be made without fresh legislation and its presence in the Bill will enable Parliament to press for further reductions in hours down to 60 if they are not made by the department. Clause 3 concerns variations in the case of emergencies and speaks for itself. Clause 4 is not intended as a let-out clause for health authorities but it enables them to make a special case to be allowed to contract for longer hours in perhaps a small remote hospital, with few staff, which is not very busy or for a registrar in a less hard-pressed specialty to be on call from home. Clause 5 allows Parliament to assess the progress of the legislation. Clause 6 allows regulation by negative instrument of Clauses 2 to 4. Clauses 7 and 8 contain definitions and the title.

I should like to conclude by further quoting the words of the noble Lord, Lord Wells-Pestell, seven years ago. He said: 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 … I shall watch for dragging feet.—[Official Report, 16/2/82; col. 539.] I believe that the Government may well develop a form of locomotor ataxia, otherwise known as creeping paralysis, so slow has progress been. That is why the Bill is both necessary and overdue. It is for the safety of the public and to prevent disillusion and a collapse in morale among a group of extremely hard-working professionals on whom our lives may literally depend. I beg to move.

Moved, That the Bill be now read a second time.—(Lord Rea.)

8.12 p.m.

Lord Butterfield

My Lords, I am most grateful to the noble Lord, Lord Rea, for his lucid explanation of the background to the Bill and particularly for introducing the Bill just at this time. It provides me with an opportunity to make this maiden speech on topics with which I am familiar, so making the occasion marginally less daunting than going in to bat for the first time at Lord's cricket ground.

I must be brief and uncontroversial. The former is a good discipline for someone like myself who recognises that he is usually too talkative; and in my work on health promotion, in recent years I have been helped in avoiding public controversy by the wise counsel of the noble Baroness, Lady Birk. I hope that I can achieve the same lack of controversy here today.

I am of that generation of doctors which has been proud to work in the National Health Service. The NHS has grown and now has a workforce of over 1 million people. We are today concerned with about 2 per cent. of that workforce—the junior hospital doctors. It is a very important 2 per cent. Those junior doctors are the future medical leaders that the service needs and I very much hope that the present difficulties about duty times and payments can be resolved without these important young people becoming embittered with the NHS administrators because that could poison relations in the NHS far into the future.

I understand—the noble Lord, Lord Rea, referred to this—that the last time your Lordships had a similar Bill before the House was in 1982. It was introduced by the noble Lord, Lord Wells-Pestell, who remarked towards the end of his introductory speech that the matter we are considering—junior doctors' working hours and on-call hours—needs careful investigation into what really happens to junior doctors. I hope I am not being too controversial when I say that in my view the same is true today.

In 1982, as I read Hansard, nine of the speakers felt that the subject was not right for legislation. The noble Lord, Lord Rea, referred to that. The noble Lord, Lord Hunter of Newington, who is so experienced in matters related to the management of the health services, reflected the views of the distinguished doctors and surgeons present at the time when he said: What is required is an urgent investigation into flexible rostering."—[Official Report, 160/82: col. 518.] He was, and remains, right.

Life for our young doctors has not eased much since 1982. There have been some slight reductions in duty hours but at the bedside it is they who have to deal with new threats to health, like AIDS. It is they who use new medicines which often need extra monitoring. Since 1982, 320 new medicines have been licenced by the Department of Health. That is a lot of new information for them to master. Moreover, our young doctors are undertaking research on ever-widening topics to keep our NHS in the forefront. We must, as the Committee of Vice-Chancellors and Principals urges, ensure that this work is not inhibited. It may be if people are too tired.

There is a further aspect. An ever-increasing number of elderly people are over the age of 75; about 600,000 more since 1982. Because they are so variable in their responses to standard medicines and so much more prone to develop side effects, they need extra vigilance. Despite all those factors, the NHS increased its throughput of patients from an average throughput of 16 patients per bed in 1982 to 20 patients in 1985, which is the most recent statistic that I have been able to trace. I suggest that most industrialists might be thinking of a staff bonus for a 25 per cent. increase in throughput in a four-year period.

I have no doubt that our junior doctors have been affected by the recent review of the salaries of their colleagues on the wards—the nurses. They must have been. They are probably wondering whether their lot will be improved by the NHS review which is about to be reported or whether even more will be expected of them.

One cannot speak with detailed knowledge about administrative changes in the working hours of junior doctors in all parts of the country. I know that it is recognised as an important and sensitive topic which is receiving attention. The noble Lord, Lord Rea, will be pleased to learn that folk at the Department of Health say that his activities are stimulating people to respond; I hope more quickly than the ataxic gait which he suggested.

At Cambridge, where I come from, and elsewhere, we have had detailed discussions involving both the hospital and the university because, your Lordships will remember, for the first year of their career after graduation our pre-registration doctors remain under the control of their medical school. I must try to make a little joke. These young people only come under the proposed Bill's authority when they finally register as medical practitioners. I very much hope that the pressures on the health service will not percolate downwards and create a class of fags, if I may so call them; that is, the students ending their period of university-supervised education and training but not yet registered.

At this time we are fortunate in Cambridge. Almost all our junior doctors, pre-registration doctors included, work one night in three and one weekend in three. However, we are concerned about the weekends. Where I come from the weekend for young doctors lasts from Friday evening to Monday morning and conscientious young people can get very short of' sleep. Our psychologists tell us that when people reach a deficit of seven hours sleep against their usual sleep pattern they make errors in tests and clinical judgments. Or course, that has been confirmed by the study referred to by the noble Lord, Lord Rea.

Your Lordships do not want from me any further discussion about the clinical history. The question is: what treatment can we find? It will not be easy. Almost all the studies that I have looked at involve finding more doctors. We cannot wave a wand and quickly produce more British doctors from the medical schools in this country. It will take at least five to seven years. Should we consider trying to recruit overseas doctors? Perhaps they will come here, in time. I know that the Royal Colleges are trying to produce good training programmes for them.

I have reached the conclusion that we probably have no alternative but to follow the advice of the noble Lord, Lord Hunter, and encourage the senior doctors in the NHS, together with the NHS administrators at hospital level, regularly to review, as the noble Lord, Lord Wells-Pestell, urged, exactly what is going on with their services at night and during the weekends and to take, individually, the best steps that they can to combat the difficulties that they find. Many senior doctors are doing that, but all of them might make sure that their hard-working young colleagues have access to some food at night and somewhere to put their feet up whenever they can.

Whatever happens to the Bill before us, the educational ethos of senior doctors caring for and helping their junior colleagues as well as their patients cannot be wrong. In that regard there is much more that must be achieved.

8.20 p.m.

Lord Trafford

My Lords, it is my pleasant duty and a great pleasure on behalf of your Lordships' House, to congratulate the noble Lord, Lord Butterfield, on his maiden speech. He brings to our debate in this field a very wide and long experience and an enormous expertise from a distinguished career. I suppose that for most people to be a professor in one institution is enough; to be a professor in three and a vice-chancellor of two universities and also a regius professor would seem to be almost excessive. We are delighted that he has contributed to our debate tonight. I hope, as I am sure do the rest of your Lordships, that the noble Lord will contribute again.

Perhaps I may add a personal reason for congratulating him particularly in a debate concerning junior doctors. Nearly 30 years ago when I was a junior doctor, one of the leaders of one of the firms for which I worked was none other than the noble Lord, Lord Butterfield. I therefore learnt early from a very high and distinguished source all the problems of slaves and masters in the medical hierarchy. More seriously, I recall those days both as pleasurable and as rewarding. We hope that we shall hear a good deal more from the noble Lord in future debates.

I now turn to the Bill introduced by the noble Lord, Lord Rea. I too am very grateful to him for introducing it because it allows us to discuss a most important subject. I agree entirely with his aim of curbing the excessive hours worked by junior doctors in the National Health Service. I am personally totally committed to the National Health Service, which I regard as one of the great institutions of this country. I also congratulate the noble Lord on introducing such a short Bill. We are used to such large and complicated ones that it is a pleasure to read one that is almost but not quite on the famous one side of the paper.

However, I qualify that by saying that I believe it is too short and too simple. For example, it is too short because it has left out senior registrars. They are a very important and most senior part of the junior doctor hierarchy. I believe that this Bill applies as much to them as to any others. The Bill is too simple because this is a much more complex problem than we have so far allowed. Not all junior doctors are the same and not all of them work excessive hours.

It is essentially in the acute services that excessive hours are worked. It is done mainly by those who operate either in what is called the preregistration field or those who then choose to operate in the acute services. They work the excessive hours. For example, there would be no problem of many night or weekend calls if one referred to specialties like pathology, haematology, dermatology, rheumatology, and so forth. There may be some occasionally, but not very often. This is totally different from working where there is intensive care work: in acute medicine or surgery, obstetrics, and so on. So not all junior doctors are the same.

Not all junior doctors have the same aims. The preregistration year is compulsory but thereafter their objectives in taking any particular post may vary considerably. They may wish to get on to a training scheme for general practice; they may wish to continue in the specialty of hospital medicine of one kind or another. Some junior doctors may be aiming for a specific specialty which may or may not require excessive hours. Therefore, we are speaking about a largely different population within this group of junior doctors.

Their work practices are also totally different. I believe we heard from the noble Lord, Lord Rea (or it may have been from the noble Lord, Lord Butterfield) that the population is growing older and there is greater demand for the elderly. Whoever said it, it is quite accurate. The work in a geriatric department or for the care of the elderly is generally speaking quite different. Many people choosing a career in this field are, as I say, on their way to something different. They may work for only a very limited period in this field where excessive hours may be worked. It is a matter for consideration but it is not in any way an exclusion of the fact that even then they should not he working excessive hours.

I firmly believe that it is not necessary to introduce legislation for this purpose when the problem can be solved in present circumstances almost with existing resources if there is a will so to do. It is the will and not the means that is lacking. We have to remember that there are a number of different considerations that we have to balance. We have heard about the significance and importance of the continuity of care with patients. Patients can be very confused by seeing four, five or six different doctors. We have to bear this in mind. I am very glad that in introducing his Bill the noble Lord, Lord Rea, mentioned this point and the question of patients. It is often forgotten when talking about the working practices of doctors.

Another factor is that there are certain experience requirements that must be obtained. I shall tell you a silly story. The other night on leaving this House I returned to the hospital to find a registrar working at a very late hour. He was not supposed to be on duty. When I asked why he was doing this and why he was there, he said to me, "On the present rotas that you are operating I am supposed to have experience of transplant surgery. I have missed four out of the last six simply because they have not occurred when I was on rota". We need to take this kind of factor into consideration. This man was perfectly voluntarily but quite unnecessarily staying on. In these circumstances this proposed legislation is too simple because it does not take into account the complexity of the situation, the innumerable considerations.

The Bill does not mention service requirements. I have deliberately left that subject out of my initial comments simply because the moment one uses the term "service requirements" one always feels that whoever is using it is falling into the trap of bureaucracy or else is referring to money. I am not referring to either, but to that predominant function of all doctors of all types, which is the delivery of health care to the patient at the time he needs it. I believe that this legislation is only attacking part of a much larger problem and only a part of that larger problem.

To change by law the working practices or the hours worked of one particular group, albeit a very important one, affects the working practices of all others who work within that context or in relation to it. Incidentally, that includes nurses. To my mind there is no reason why nurses should not be far more widely used in terms of what they are allowed to do. They are perfectly capable. In the unit in which I have the privilege to operate our nurses do far more of this kind of work. None of our doctors in that unit would be raised from his sleep to deal with the question of an intravenous drip. I suspect that the nurses do it rather better. They are very practised at doing it in this unit. They give about 1,500 intravenous injections a week. By that I mean putting people on kidney machines and taking them off. So the nurses are perfectly capable of doing a great many of these things. Very often it is a restrictive practice that does not allow them to do it. It is only part of a problem of part of a wider context affecting a good many other people that this Bill proposes to tackle. That is what worries me about it as part of legislation.

I have said that there are ways of dealing with this problem. If there is a will there are the means. There is also the consideration that it is the essence of a profession that it should regulate its own practices and standards. This, I think, the profession should do. Unfortunately I have to concede that over the years all this has failed to happen. Perhaps I may say one or two words about why it has failed to happen and what we should do. I shall do so under four headings.

First, there are the problems of the juniors themselves. We heard about the Monday to Friday weekend at Cambridge, to which the noble Lord, Lord Butterfield, referred. In my hospital we would not allow that for the simple reason that if a man or a woman worked on Saturday and Sunday he or she would not work on Friday on take and would not work on Monday on take. If one runs weekends from Friday to Monday, one is asking for trouble for reasons of sleep, exhaustion and so on. That is wrong. It needs a certain amount of fiddling with rotas and great attention to detail to make sure that the same consultants, registrars, SHOs, junior doctors and so on are on at the same time and that if by chance they are on on Friday they are not on on a Saturday or a Sunday and vice versa. It needs the consultant who leads the team to remember when he sees them on Monday that if they have been on take on Saturday and Sunday it is time that they were off.

That is the leadership the consultant should give. He should not just swan in and swan out. He should pay great attention, as the noble Lord, Lord Butterfield, pointed out, to the needs not only of his junior doctors but of his nurses, his ancillaries, his clerks and his domestics, for nowadays medicine is teamwork. Medicine is not the individual, high and mighty, one and only consultant who knows all the answers. Such consultants should be locked up in a psychiatric institution if they believe that. It is teamwork. Part of leadership of a team requires attention to the details not only of the consultant's immediate junior doctors, his colleagues, but of the other staff as well.

Juniors have problems. They want a social life. They have problems requiring longer weekends. If one turned round and said "shift system" to them and suggested 12-hour shifts, they would be the first to object to losing a full Saturday and Sunday. This point must be taken into consideration. Equally, there is the problem that large numbers of juniors are not involved in this way. Shift systems can be operated in certain places. In most casualty departments shift systems are already operating. We have heard how general practitioners, as clinical assistants, as hospital practitioners or in many of the different ways in which they can help, could help, but again that would affect the working practices of general practitioners. Do we have so many of them that we can spare them to take the places of junior doctors? Do we have so many trained consultants that they could take the places of junior doctors? These questions need to be addressed before we tackle part of part of part of a larger problem.

I say sincerely and with no criticism of junior doctors that nobody teaches them how to work. They are taught what to do and how to treat patients but not to organise that treatment and how to use their time and skills efficiently. The result is that a massive amount of time is wasted by their wandering, phoning, getting the wrong things and so on. This is why we need to look into the working practices of junior doctors and the related specialities, whether consultants or even in some respects nurses. We need to look into what they do. We must ask whether they need to do it and whether they or somebody else should be doing it. I shall not cover the question of what is a reasonable working week in this respect because I believe that there should be flexibility, proper leadership, proper organisation and rota and consultation with the junior doctors, to whom I shall come in a moment.

The second major problem is with the health authorities. With due respect to most members of health authorities—I do not refer to the professional members—they do not have knowledge, the experience or the understanding of this complicated question. Those who listened just now to the noble Lord, Lord Rea, talking about the complications of the hours and the one in three, one in four and one in five rotas will understand that it is not easy. I hope I have illustrated some of the problems. Health authorities are reluctant to interfere in a purely professional matter. Many of them regard this as a problem for doctors (in the widest use of that term) and not as a matter for health authority diktat. By and large that is another reason why, if they do not drag their feet, at least they do not take too much direct action.

The Department of Health has come in for a good deal of stick and during the rest of the debate will undoubtedly come in for a good deal more stick. In actual fact I would not hold the Department of Health very responsible in this respect. It has shown an interest. It has issued guidelines and has required the setting up of district working parties and so on. Perhaps it has not put as much shove behind it as it could have done. But for many reasons similar to those which I have just mentioned with regard to district health authorities, there is a reluctance for it to become involved in what it sees as primarily a professional matter. I am afraid to say, mea culpa.

The real roadblock lies with the profession and with the consultants themselves. They take a view of the service needs and of the practice and delivery of health care in their districts and then they try to fit things in according to that. Unfortunately, the junior doctors are not always considered when these plans are made. For example, when another consultant or two consultants are appointed to a unit with two junior doctors, the juniors may not be asked about the appointment. It would be unusual if they were. Yet the very arrival of these people would probably mean two more rounds each week, different practices and foibles for them to learn and perhaps two more outpatient sessions. The last person to be asked when the job description of the new consultant is laid down is the junior doctor. This may be the last straw which breaks the proverbial camel's back. There is a lack of consultation.

Another example, which may be regarded as an ego trip, is that many consultants insist on all their junior staff attending upon them for much if not all of the time. This is unnecessary but it is a restrictive practice for some consultants. Occasionally it is necessary, but by and large it is not. It is the working practices not only of the junior doctors but of the consultants that play the large part in the problem. The consultants need to look also at their own working practices as well as the working practices of junior doctors. Taken together one could get a good picture of what needs to happen and what does happen in hospitals.

I began by saying that I thought that the problem could be solved without legislation and was more appropriately solved without legislation. I think that with due respect to the noble Lord, Lord Rea, who introduced the Bill. Nonetheless I am obliged to him for doing so for he has raised an important question. It has given prominence to the question, has pushed people into thinking about it and will no doubt make people take further action. It is for the profession to organise the system, but it should be done with the Department of Health driving it along with specific time-scale targets. It is a question of will. The sanctions are there to ensure that all parts of the profession co-operate and act to reduce these excessive hours. If it is wished to be done it can he done.

8.38 p.m.

Lord Winstanley

My Lords, having heard the noble Lord, Lord Butterfield, speak on many occasions before, I was greatly looking forward to his maiden speech. I was not disappointed. Our House will be enriched by his presence and I very much look forward to hearing him speak on many occasions in the future. Incidentally, in addition to enjoying the noble Lord's maiden speech, I also agreed with a great deal of it, which is not quite the same thing.

I should also like to say that I agreed substantially with the speech made by the noble Lord, Lord Trafford. I am afraid that I find increasingly often that I am in agreement with him. I hope that nothing political will be read into that statement, but I agreed very much with what he said. I especially agreed with his general implication that the only people who can solve the problem are the consultants and the junior hospital doctors themselves. It is not the kind of matter which can be dealt with by hospital managers, nor can it be dealt with by importing the shop floor philosophy of industry into professional work. However, the problem must be dealt with by someone.

Had I had any doubts whatever about the reality, or indeed the seriousness of the problem, they would all have been dispelled by the letters which I have received from many junior hospital doctors. Indeed, I know that many noble Lords have received many such letters. I shall quote from but one of them. It was sent to me by Dr. Lamorna Osborne, a doctor who qualified in this country, trained as an anaesthetist then worked abroad and finally returned here. In her letter she says: I was on duty as the anaesthetist at St. Thomas's on a weekend early three years ago… I had enjoyed my work until my return to London when I discovered that I would be required to work continuously for three or four days at a time … On that weekend I remember a fit, 69 year-old man being admitted with a ruptured aortic aneurysm at 2 a.m. on the Monday morning". Dr. Osborne had told me earlier in a letter that she had in fact been on duty since the Friday morning, and this case arose at two o'clock on the Monday morning. The letter continues: "As I pressed the plunger of the Thiopentone syringe, I thought, 'if I just squeeze this two more inches I can go to my bed'. It is a moment that I shall never forget, weighing up the fact that this operation had 50% mortality anyway, so nobody would query a death and the fact that I was so tired". She then says: I suppose the patient in question could have been my grandfather, or even yourself. In any event, I carried on; the patient did survive. I vowed there and then never to allow myself to be placed in that situation again. I almost gave up medicine. I decided instead that I would try,… to get the message of the juniors across. If this was happening to me, it was happening to many other people, who were too tired and too afraid, because of the reference problem, to voice their view". Those were her views. However, I think that the problem of references, to which she referred, and the fear of juniors voicing their opinions, has now largely gone because consultants now tell us that they agree on this matter. So, if they agree, then they can do something about it. Indeed, they can do much more than they have already done and I think that they should get on with the job.

Like many other noble Lords I entered this debate today with a feeling of déjà vu. I spoke, as did so many who are speaking today, in that earlier debate which took place on 16th February 1982 on the Bill introduced by the noble Lord, Lord Wells-Pestell. The Bill was very similar to this one and that rather raises the question as to why the noble Lord, Lord Wells-Pestell, did not deal with this urgent problem during the years when he was a Minister in the department and, indeed, when the noble Lord, Lord Ennals, was Secretary of State. However, to be fair to the noble Lord, Lord Ennals—who will be speaking later—I think that he genuinely thought that he had dealt with it, or that he had set in train various steps which would in fact deal with the matter.

As I said, I spoke in that earlier debate and I have no wish to repeat the speech which I made on that occasion save to say, as I said then, that we appear to be proceeding with the inevitability of gradualness. On that occasion I quite wrongly attributed those words to Winston Churchill. Perhaps I may therefore now make amends by acknowledging that they were in fact the words of Sidney Webb. But to realise how gradual is our progress, one only has to look at the end of that earlier debate on the Bill introduced by the noble Lord, Lord Wells-Pestell.

I disagree marginally with the noble Lord, Lord Rea, in that the noble Lord, Lord Wells-Pestell, did not withdraw the Bill solely because the BMA, and perhaps the junior doctors were opposed to legislation at that time, although they have changed their minds now. He withdrew the Bill in part because of assurances which were then given by the Minister who replied; namely, the noble Lord, Lord Elton. I think it would be helpful if I were to look at those words now because the noble Lord, Lord WellsPestell, listened carefully to the Minister's reply and was wondering whether to withdraw, but instead he intervened at the end of the Minister's reply and said this: 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 he something emerging". He then said: I do not know whether the noble Lord would like to intervene". and the noble Lord, Lord Elton, did intervene saying this: 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".—[Official Report, 16.2.82; col. 539.] That of course was a long time ago. I think it is right that I should say that we are indeed proceeding extremely gradually.

The problem cannot be solved just by the Bill. In view of the complexity of the whole question—the noble Lord, Lord Trafford, illustrated this point, as indeed did the noble Lord, Lord Rea—I should like to see a Select Committee set up to investigate the whole subject fully so that we have all the facts. I am not quite sure that we have all the facts at present. We do not quite know in which hospitals the problem is the greatest. I suspect that when we get those full facts we may find that the hospitals in which the doctors work the most outrageous hours are very often teaching hospitals which are well staffed, whereas some of the hospitals which are badly staffed somehow seem to manage rather better.

I recollect my experience when I qualified during the war at a time when staffs had largely disappeared and everyone was very much understaffed. In those days we managed. It is true that we cut some corners, some of which perhaps should not have been cut; but I think we managed without working absolutely outrageous hours. We managed in many ways by doing the kind of things at that time which the noble Lord, Lord Trafford, has already suggested. For example, nurses did things which it was necessary for them to do because there was not a doctor available to do them. Those are the kind of adjustments which will have to be made and I believe that the problems will not be solved by the Bill. I would welcome a Select Committee to look at the matter as a whole, but the department itself will somehow have to take active steps to assist the consultants and the junior hospital doctors to take on the issue in the kind of way suggested and thereby solve it.

I believe that the problem can be solved now that the parties say that they agree. The consultants say that they agree and the BMA as a whole says it agrees, so why on earth do they not get down to it and really solve it here and now? Further, why does the department not assist them so to do? I repeat that the matter is an extremely complex one, but I shall mention only one other point and it is one which I mentioned in my speech in that debate all those years ago. I think that it illustrates in a way the complexity of the problem. The point has already been hinted at and it is this. In looking at the hours of junior hospital doctors, one has to remember the whole question of continuity of care within a hospital for a patient. It is very often with the junior hospital doctor that the patients establish a relationship. They get used to the junior hospital doctor and they like to see the same one. On that occasion at col. 515 I said: 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 have never seen befor at all during their hospital period". That is an important point. We must go on to consider the importance of continuity of care on a daily and continuing basis for patients in hospital. I am speaking of care not only by the nurses, but also by the junior hospital doctors whose relationship with the patient is so much closer than is the relationship of perhaps even the consultant who has the overall clinical responsibility for the case.

I, too, am most grateful to the noble Lord, Lord Rea, for bringing the matter forward. It is most important that we should have had this debate. However, it is also most important that the debate should be followed by action, and not inaction. Everyone is now aware of the problem and everyone is calling for it to be solved. I believe that it could be solved. I believe, with the noble Lord, Lord Trafford, that if the consultants think that it should be solved, then they should get down to the job with the junior hospital doctors and solve it. I hope that the noble Lord's Bill and this Second Reading debate will help towards that end.

I hope that the Bill is carried, that it proceeds on its passage and that we may go further into the matter. However, I also hope that during that period other things will happen and that the department will see to it that something is done and that some of the hopes expressed by the noble Lord, Lord Wells-Pestell, all those years ago—and some of the promises made by the noble Lord, Lord Elton—will be kept, but carried out perhaps a little more speedily than appears to have been the case so far.

8.50 p.m.

Lord Richardson

My Lords, I too have had the privilege of knowing the noble Lord, Lord Butterfield, for 30 years. I was mildly interested when he spoke about going in to bat. My interest was considerably increased when he mentioned Cambridge more than once, because he used to go in to bat for an Oxford cricket XI. We all hope that we shall hear a great deal from him in the future. Knowing him, I know that he will be eloquent.

I am extremely grateful to the noble Lord, Lord Rea, for bringing up this subject, but at the same time I feel a considerable degree of sadness that it has to come up at all. It was a living problem over 30 years ago, so much so that the then recently formed Association for the Study of Medical Education did a special study of the educational effects of the time that junior and younger doctors spent at work and of their over-long hours. It was a sufficiently serious problem for the very much respected and highly regarded Minister for Health, Mr., now Sir, Kenneth Robinson, to set up a working party to examine the whole of the work of doctors in hospitals.

That working party divided into two. The Minister took a great personal interest in it and chaired as many meetings as he could. The two parts dealt with consultants' work and the junior doctors' work. The junior doctors' committee reported after the consultants because the Department of Health, together with the Joint Consultants Committee, had commissioned a study of the junior hospital doctors' work. It was a detailed study. If I remember rightly, the work of 83 doctors was examined. 'Over 7.000 hours' work were watched and records made at half-minute intervals. Nine hospitals of different kinds were under scrutiny. They found that the doctors worked about the same time as they do now. At that time it was felt that that was not excessive. They wanted to have the experience, and there is nothing much to be said about that.

However, the committee was greatly disturbed by the fact that time on call was added to the total of 86 hours worked. The solution then was what has been suggested tonight and may well come from speaker after speaker. The noble Lord, Lord Trafford, went into the matter in detail. The solution was that there should be proper organisation of the doctors' work by doctors (consultants primarily) and by the junior doctors themselves, who of course are under a disadvantage. They are inexperienced. They are anxious. It weighs heavier on their spirits and their bodies to have great responsibilities. However, at that time there was evidence that they could save themselves a great deal of trouble by using their common sense as well as their increasing medical knowledge. That was all that time ago. We are now discussing again what we discussed in 1982.

There are various considerations about the limitation of hours. They were touched upon by the noble Lord, Lord Trafford, who pointed out the educational implications that are different at the different stages of a so-called junior doctor's career towards consultancy. There must be careful consideration if there is to be such a thing as a statutory limitation of hours. A senior registrar, shortly to be a consultant, would be greatly offended if his time of work were to be legislated for.

Another factor is the inflation in the number of doctors. That matter needs looking at carefully because over the years there has been tremendous anxiety in the medical profession about the question of numbers, not only because it could lead to medical unemployment under-employment—that is not a myth; it is something of substance—but because it could lead to the alarming situation where the boys and girls who are practising in their junior capacity have the whole of their future distorted by the terrible problem of the staffing structure. If one has more juniors, one will to some extent vitiate the already not terribly successful attempts described by the noble Lord, Lord Rea, to produce a staffing structure balance by increasing the ratio of consultants to junior staff. That has been a running sore since the beginning of the health service. It is the future of the juniors that we are talking about, because, if there are too many juniors chasing too few senior jobs, that will surely be very much to their disadvantage.

What about the question of a profession having its hours of work controlled by the law of the land? I cannot help feeling strongly that that is profoundly against the basic professional ethos. Medicine is one of the three original professions of mediaeval days. To it were added the armed forces, but of course in the past 20 years—longer perhaps—the number of so-called professionals has increased enormously. Many have had their circumstances controlled by legislation.

It would be a sad thing for what I choose to call the true professions if their professionalism were in any way invaded. It is the hallmark of a profession that it controls its education, its discipline and its responsibilities. There is another aspect to this matter. It concerns the attitude of the young entering the medical profession and their enjoyment of it. It is an exciting period to be a junior doctor in hospital. One is beginning to feel one's strength as a doctor. It is a tragedy if that time is blighted and turned into a nightmare by an excessive amount of work, but it is a very great tragedy if by having one's hours of work controlled one loses the sense of adventure, the sense of obligation to the patient, the sense that the patient is the person who matters. One loses the realisation that in the profession the patients or the clients must come before one's own interests. If we lose that feeling we shall lose a great deal of the satisfaction that comes from learning about looking after patients and feeling our responsibilities towards them.

Patients know when a doctor is dedicated. Any doctor at this moment in your Lordships' House will feel grateful, remembering patients who have put up with his inadequacies, as I do, because that doctor and all of us who are doctors were really trying and were in a sense dedicated. That is the way to happiness in medicine and the way to make patients feel that they are getting what they deserve.

I cannot join the noble Lord, Lord Winstanley, in hoping that the Bill will pass. However, I hope with the greatest possible intensity that it will lead to real action, administrative action, all the way up, with proper and rigid monitoring of results. It is disgraceful that such a problem as this should have been spread over 30 years and no solution evolved, although the solution lies in proper administration.

9.2 p.m.

Lord Kilmarnock

My Lords, I think am the first layman to speak in this debate. That is perhaps a rather daunting prospect since all five previous speakers have been luminaries of the medical profession. Of course this Bill concerns us all as members of the general public.

The Bill of the noble Lord, Lord Rea, which is before us performs a very useful service in drawing attention to a profoundly unsatisfactory situation which has hardly changed or has changed very little since the noble Lord, Lord Wells-Pestell, moved a similar Motion on 1st February 1982. That has already been referred to and he later withdrew it in circumstances which were explained by the noble Lord, Lord Winstanley. I shall not use the same quotation as was used by the noble Lord, Lord Rea, and others, but on that occasion the noble Lord, Lord Elton, speaking for the Government, accepted, that the hours of work of some junior hospital stalls arc excessive. Indeed, the average junior doctor is contracted for nearly 90 hours a week. Although contracted hours include both time spent on-call and hours actually worked, we consider this figure is too high. We are anxious that it should be reduced and have started to consider steps to do so".—[Official Report, 1/2/82; col. 532.] Later on at col. 536 he said that there was general recognition that there was a real problem to which a solution must be found. At that time there was considerable evidence of government interest in the whole matter.

Whatever steps have been taken have not got very far because today, seven years later, the average still stands at 86 hours according to BMA figures and as the noble Lord, Lord Rea, has also told us. It might therefore be thought that I should give an unconditional welcome to the Bill. However, I am afraid that, while I appreciate the motives by which the noble Lord, Lord Rea, is animated, I have a number of reservations. In the first place we have a shrewd suspicion that the Government will not give the Bill any help. It goes against Mr. Mellor's declared objective of reaching a maximum one in three rota or 84 hours a week of time on duty. So we know or are pretty sure that it will not reach the statute book. That is not to condemn it out of hand. Many good Bills do not reach the statute book. But we know it is a non-starter in terms of achieving its main objective.

Next I am unhappy with its blanket approach to the problem. There are undoubtedly some staggering abuses of junior doctors' staying power. A number of instances have been given this evening and I recently heard one of a junior house officer contracted for a one in two rota working from 8 a.m. on a Friday morning until 7 p.m. on a Tuesday night and then from 8 a.m. on Wednesday until 7 p.m. on Thursday; and finally from 8 a.m. until 7 p.m. on Friday evening, a total of 142 hours in that week. That is quite unacceptable.

However I venture to suggest that there is another side to the coin. All doctors going into general practice must do a minimum of one year as a junior house officer, as we have heard, and two as a senior house officer. That may be prolonged if no suitable practice opening occurs, but in most cases they are out of the hospital system in three or four years. During this period they not only need, but some actively desire, to get as much experience in as many specialties as they possibly can. In pursuit of this end, intensive on-the-job training at that age is probably sustainable over a relatively short period. I think the noble Lord, Lord Trafford, touched on this.

The Bill as drafted might well inhibit that kind of zeal for knowledge and experience and in this respect I think frankly that it is a little too prescriptive. The real problem surely, at any rate in a layman's eyes, is that the term "junior doctors" somewhat absurdly covers the whole hospital careers structure up to and including senior registrar, who may be someone with 14 or 15 years' experience, waiting for a consultant post to be vacated. What can be sustainable for a few years in the mid to late 20s takes on quite another colour when prolonged into middle life.

What alarms me here is that although the average weekly hours on duty of all hospital doctors are the same as in 1981, those of senior registrars within that aggregate have risen from 78 to 87 hours. These are people quite literally at the cutting edge who make many of the big decisions. When that is coupled with a not very attractive pay scale and with family commitments, it might seem that these are the people with whom we should be concerned no less than those further down the scale. Yet the Bill appears to exclude them, unless they are intended to be subsumed under the generic word "registrar".

In these circumstances one might think the Bill would have done better to go for greater flexibility—say, a maximum of 84 hours for all grades and a lower maximum for the higher responsibilities carried out by more senior junior doctors, who in a saner world would no longer be so described. They are the equivalent of experienced middle managers in industry. I have to note that the noble Lord, Lord Richardson, thought there should be no restraints at that level, which goes to show the many dimensions involved in a doctor's working life.

As the noble Lord, Lord Porritt—I am delighted to see that he is speaking this evening—said during a debate on 16th February 1982 (col. 528 of Hansard): There are so many sidelines connected wth this problem that it merits very long and detailed consideration". That is obviously true. You cannot consider registrars and senior registrars without considering consultants, and this brings a number of additional factors into play. In the first place, the Government's undertaking to expand consultant posts by 2 per cent. per annum is not being met; so I understand. The noble Lord, Lord Rea, mentioned that. Nor do the plans in the joint statement of Ministers, consultants and health authorities of July 1986, entitled Achieving a Balance, appear to have made much progress.

There is then the interesting suggestion made by the Medical Practitioners' Union that there ought to he more cross-cover between consultant "firms". This, over time, would inevitably lead to the replacement of these so-called firms by a system of speciality teams. Something along these lines would presumably be needed if the present level of cover were to he provided on reduced hours without a very substantial increase in the number of doctors and thus of the hospitals' salary bills. Yet if such a reform were implemented it would have profound consequences for the whole consultant system.

I could go on. I have hardly touched on the critical question of pay; but I will not do so because the whole purpose of the remarks I have made so far is to show that the question is much more complex—here I am entirely in agreement with what the noble Lord, Lord Trafford, said—than appears from the Bill as drafted. I suggest that we lack much of the objective information, as opposed to impassioned advocacy, that we need if we are to make sensible improvements to this Bill in Committee. Of course we can have an interesting Committee stage, to which eminent members of the medical profession will undoubtedly contribute from the great store of their knowledge and experience. The Government will no doubt thank us politely for our labours and say that our valuable opinions will be taken into account, but I doubt whether it will go very much further than that.

Alternatively, I suggest—the noble Lord, Lord Winstanley, has already partly floated this—that we could produce something much more authoritative and make a real contribution to an eventual solution if we were to send the Bill to a Select Committee, where evidence could be taken and weighed, the facts properly established and different interests heard, including those of the junior doctors and those I like to call the middle doctors, the consultants, the Royal Colleges, the hospital managers, the BMA and the department itself. We would then have an extremely thorough report produced with the agreement of all parties and none, which is the only proper way to proceed on an issue of this kind which is not basically of a party political nature.

When a Private Member's Bill is sent to a Select Committee, that committee can do various important things. First, it calls for evidence, as I have already outlined; it can then redraft the Bill and produce something more acceptable in terms of feasibility. It can even make a useful report with positive proposals but recommend that the Bill itself should not proceed, thus saving time on the Floor of the House. Whatever course it chooses, its report is a document of considerable value which the Government find difficult to dismiss even if the Bill itself fails—which, as I have already pointed out, in this case it is almost bound to do. I think it is no secret that some of us wanted such a Motion to be moved this evening so that in the event of the Bill receiving a Second Reading, as I hope it does, it would go to a Select Committee before being brought back to the Floor of the House at Committee stage.

Other noble Lords, while accepting the attraction of this approach, wondered whether this was the right way to proceed before listening to the Government's response and in particular with the Prime Minister's National Health Service review due to be published, we understand, on 3Ist January. Personally, I doubt whether a broad brush White Paper is likely to tackle these intricate details. We shall see. Caution prevails; but I must say that if the Government have nothing much to tell us this evening, apart from invoking the regional working parties Mr. Mellor has set up, and if the White Paper is silent on the matter, as I think it probably will be, I still believe there would be a strong case for tabling a Motion for the Bill to go to a Select Committee during the course of next week.

I should add that there is no procedural barrier to doing this, provided it is done prior to an order of commitment to a Committee of the Whole House. The Select Committee route has been taken on eight occasions since 1975. In that year the noble Lord, Lord Denham, no less, speaking then from the Opposition Front Bench, moved that the Hare Coursing Bill be sent to a Select Committee. That was a government-mandated Bill. We would not of course be prolonging consideration of government legislation in such a way.

The most recent instance was the Infant Life (Preservation) Bill, interrupted by the last general election, and on that account sent twice to a Select Committee in that year. If the argument is invoked that such a move places an unwarranted strain on the resources of the House, the answer must be that that is to place the cart before the horse. Our prior duty is to ensure that matters like this of legitimate public interest receive proper scrutiny. We are, incidentally, probably the cheapest and most cost-effective second chamber in the Western world, and the resource implications in this instance would not be very great.

I hope I have not steered the debate off course. Naturally I look forward to the other contributions and await with interest the Government's reply. But I hope that other noble Lords in the course of their speeches will agree with me that we should not dismiss the option of a Select Committee just because a Motion to that effect has not been moved tonight. In the meantime, my Lords, I support the Second Reading of the Bill.

9.15 p.m.

Lord Pitt of Hampstead

My Lords, I too am grateful to my noble friend Lord Rea for introducing this Bill, and it has my support. I must apologise to him for not being here for the early part of his speech. Unfortunately I am doing a locum for a colleague of mine at the moment and I was doing his evening surgery.

Last Friday I read an article in the Independent indicating the desire of the authorities further to tighten the controls in the number of hours worked by airline pilots. In the same paper there was an article indicating that the health Minister was suggesting to health authorities that they should get junior doctors to cover for colleagues while on leave or unwell rather than employ locums. Your Lordships will realise that this will further increase the number of hours that junior doctors will have to work.

An airline pilot can work for a maximum of 50 hours a week, with no more than seven consecutive days on duty without a rest of at least one day and two nights. The long-distance lorry driver can drive for a maximum of 56 hours a week, with 45 minutes' rest every 44 hours and a weekly rest period of 45 consecutive hours. Junior doctors face much greater demands. They often have to work an 80-hour weekend when they are on duty from 9 a.m. on Friday to 5 p.m. on Monday.

I well remember when I was a house physician at the San Fernando Hospital in Trinidad forcing the medical superintendent to do casualty duty from Sunday afternoon to Monday morning, because I was on duty from 8 a.m. on Friday and the weekend was busy, so I had very little sleep. He looked at me and decided that I was much too exhausted to carry on, and told me to go to bed and he carried on doing the job himself. But there are no medical superintendents in British hospitals any more, so I do not know who would do for any house physician in this country what Dr. Rostart did for me.

Concern about the long hours worked by some junior doctors has been a regular issue coming to the BMA juniors' committee for debate over many years. Following a conference organised by the Chief Medical Officer in 1981, lengthy negotiations have taken place and have managed only a minimal reduction in hours worked. The junior doctors believe that something more needs to be done now to force the health authorities to act, and agree with them.

The present contract was introduced in the mid-1970s, with junior doctors feeling that if they had to work such long hours they should at least be paid for them, because up till then they were not paid at all. Even now their "overtime" is paid at only 30 per cent. to 38 per cent. of their base rate. In other words, for every hour's "overtime" a house officer earns £1.75. In late 1981—nearly eight years ago£the BMA opened negotiations with the Department of Health to ban one in one rotas, which means working or being on call for 24 hours a day, seven days a week, and to get a maximum one in three rota, which is still an 84-hour week. That means that, in addition to the 40-hour basic week, one night in every three and every third weekend is also worked.

Those measures have produced very little success. The average hours worked by junior doctors fell by only three hours between 1980 and 1986. In 1987 about 12 per cent. of junior doctors were still contracted to work over 101 hours a week. I suspect that there are still junior doctors—admittedly only a few—working the one in one rota (24 hours a day) despite it having been banned by the Department of Health. I suspect that if one did some careful research one would find that that was so.

I know that many of the older generation of doctors are not convinced that for junior doctors life should be easier than it was for them. However, as a result of advances in technology more and more junior doctors are having to use complex equipment which was not available in my days as a junior doctor. There is also a vast increase in day cases, which puts particular pressure on junior doctors who have to check the patients in and see them onto the wards. Patients survive now with diseases which were previously untreatable. There is no comparison between being a junior doctor 30 years ago—or 40 years ago in my case—and now.

I read an article written for the BMA News Review by Sir Christopher Booth, who is a former head of the Clinical Research Centre at the Northwick Park Hospital and was my successor as President of the British Medical Association. Sir Christopher was sent by the editor of the magazine to spend a night on duty with two junior doctors in a hospital in the North of England. Initially he was not convinced by the junior doctors' argument that their work is now much more complicated. After following the junior doctors around for a whole night, as well as being shattered by the next morning, his views had changed dramatically. He now concludes that the situation faced by junior doctors is "monstrous". That is his term.

Sir Christopher tells of how the whole practice of medicine is more complex and more stressful than in his day. For example, 30 or 40 years ago a heart attack victim would have been left in bed to rest and recover or die. Nowadays patients are linked to ECG machines which need to be monitored constantly. Doctors have to be alert enough to respond immediately to any abnormality in the hearbeat rhythms. Within a couple of minutes the doctor has to make the decision as to whether or which drug needs to be administered, and if so in what dosage. He needs to monitor the patient's reaction and continue to act if necessary. A tired junior doctor cannot do that properly. It is necessary to face that fact.

I am convinced that the experiences of the junior doctors which we read in the press are not exaggerated. The time has come for the Government to act to reduce the hours worked by junior doctors. I would regard this legislation as just one important step. I hope that your Lordships will give this Bill a Second Reading. I agree with the noble Lord, Lord Kilmarnock, that it should be sent to a Select Committee. I hope that the approach of the House will be that we should give the Bill a Second Reading and send it to a Select Committee.

9.24 p.m.

Baroness Masham of Ilton

My Lords, in welcoming the noble Lord, Lord Butterfield, I should like to say how good it is to hear that he is interested in health promotion. I hope that he will promote it in your Lordships' House.

On one occasion when travelling back from abroad the aeroplane broke down and I went for almost two nights without sleep. I am fortunate in that I do not need a great deal of sleep. My noble kinsman the noble Earl, Lord Swinton, needs far more sleep than I, as he will tell any of your Lordships. On our return we had an engagement to fulfil near Cambridge. I was driving and this was the third day with little sleep. Suddenly my noble kinsman shouted at me and I opened my eyes to find that we were heading straight for a bluebell wood.

There is a point when without sleep one's system cannot operate. I have learnt my lesson about the danger of driving when lacking sleep. I am convinced that doctors, who have the responsibility of patients' lives and deaths in their hands should work within safe limits of sleep. In the cause of the safety of patients and the wellbeing of junior doctors I thank the noble Lord, Lord Rea, for bringing this timely Bill to your Lordships' House.

I should like to ask the Minister a few questions. I have always felt that an expert is a person who continues to learn. The field of medicine has now become very specialised with many different drugs and high technology equipment which need great skill and understanding. I asked several consultants how they feel about the situation of junior doctors and several of them said. "We had to do long hours; we lived through it".

But hospitals were different then. The throughput of patients was much slower, the technology and skill needed to keep tiny babies alive was not there; the knowledge and skill to transplant organs did not exist. Moreover, the expectations of patients were not so great; the elderly did not live so long and the pace of life outside the hospital was also slower.

The medical situation has changed because society has changed. All doctors, however senior, have to keep up with new developments. When a doctor is given the status of a junior doctor, does it not mean that he is an apprentice to the consultant? Is too much responsibility being placed on junior doctors? Do they have enough time to study? Are they being drained of energy because those who are on call for too many hours work constantly both night and day so that they end up exhausted? They must become edgy and difficult to live with and the patients worry when they have to depend on young, tired doctors.

Are we taking too much out of the junior doctors and not enough out of the senior doctors or do we not employ enough doctors? We employ fewer than do several European countries or America. Some senior doctors work very hard indeed. I know several of them. But can that be said of all senior doctors? Would it be possible for some of them to share with some of their juniors some of the load of routine work? I feel that such a move would be unpopular.

However, the situation could be made more flexible in many ways. Senior doctors need time to do research and keep pace with progress. We are lucky to have some splendid and excellent consultants but can that be said of all of them? I have heard of consultants who have not turned up on ward rounds and not informed the sister in charge when they did not attend clinic. What kind of example is that to a junior doctor?

We must not fall into mercenary ways wherein monetary interest rules all, as is so well described in the book The Citadel. It is a wise practice to have two nurses checking when they dispense drugs to patients. Many people throughout the country are now worried, having read the recent Sunday Times article on overtired junior doctors and their prescribing of the wrong quantity of a drug which unfortunately killed the patient. Doctors are covered by insurance but the life of the patient cannot be brought back. It would help to abate fears if when a junior doctor prescribes a drug the system is that a senior nurse checks the quantity. There is always a senior nurse on duty in any hospital for acute cases. I would appreciate the view of the Minister on this point.

The question of junior doctors' hours is not a new issue. In November 1982 Ministers announced a programme of action for health authorities to work towards the elimination of regular rota commitments requiring junior staff to be on duty on average more than one night and one weekend in three—a one in three rota—where resources and the needs of patients permitted. Measures taken included the setting up of district working parties to review rota commitments and the establishment of a ban on regular rota commitments more onerous than one in two. Despite this, there still remains in the Yorkshire region, which is the authority on which I serve, a considerable number of rotas that involve junior staff being on call more than one night and one weekend in three. One of the main reasons for this is that the Department of Health exercises strict manpower controls on the number of junior doctors and there is an embargo on the appointment of additional senior house officers and registrars. This clearly makes the reduction of existing rotas difficult so long as existing working arrangements continue.

Not all junior medical staff are anxious for their on-call commitment to be reduced because they regard the exposure to medical emergencies that being on call gives them as a valuable part of their training and because a reduction in their on-call commitment will mean a decrease in salary. Because of this, would it be possible to give junior doctors a choice of working more hours than those stated in the Bill if they so wished? I have often heard it said that the amount of work which being on call entails depends very much on the specialty. Junior staff working a one in three rota in hard pressed specialties such as general surgery and paediatrics may have a more onerous on-call burden than those working a one in two rota in less hard pressed specialties such as ENT, ophthalmology and dermatology. If there were more cross cover within clinical units, this might help to spread the load. However, many consultants are reluctant about this and if the junior doctor is serving an apprenticeship in a specialty one can understand the argument. But the wider cover might also be good experience for the doctor. That illustrates the difficulties of overcoming these problems.

We have heard in the region that the Government wish to reduce the number of junior doctors. This would be pulling in the opposite direction when trying to reduce junior doctors' hours. I do not see that it is possible to reduce the number of junior doctors unless senior doctors undertake considerably more work than they now undertake. I shall have to get up at 6 a.m. tomorrow to catch a train to go to my regional health authority meeting. We have 17 health districts. I hope when the Minister replies that he will give some encouraging messages that I can take up North with me. In some of our districts it is difficult to fill some posts with good quality doctors.

We have on paper at region and at districts further planned rota reductions for our districts and those which have already been achieved. What is written on paper is not always what happens in practice because there are absences due to illness and other reasons. With doctors, as with nurses, one needs some extra cover if the targets are to be achieved. There must be a safety net.

It seems that this matter of junior doctors' hours has come to a head. I hope that your Lordships will give the Bill a Second Reading. If improvements are to be made we can make them in the further stages of the Bill or perhaps, as has been said by other noble Lords, the Bill will go to a Select Committee. But something positive must happen. I do not believe that overtired and overstressed junior doctors who have a great deal of responsibility can give of their best to their patients or their employers or find for themselves the much-needed job satisfaction. We need an efficient but caring health service. The junior doctors are a very important part of it.

There is nothing as important as the good health of our nation and for this we need enthusiastic, well-trained, committed doctors.

9.37 p.m.

Lord Auckland

My Lords, this is a very timely debate. I should like to add my thanks to the noble Lord, Lord Rea, for moving this Second Reading, unfortunately at a very late hour. The debate coincides with the forthcoming National Health Review. Whether or not anything relevant to the problem which is the subject of this debate will be contained in the review we shall have to wait to see.

One of the fascinations about this Second Reading is that there are almost as many, if not more, distinguished members of the medical profession taking part than there are lay people. In many ways that is a tribute to the noble Lord, Lord Rea, for his consistency in this matter. Inevitably those who are outside the profession must be very careful not to tread on professional corns. I do not propose to go into a kind of ping-pong match between consultants and junior doctors.

I have had very few spells in hospital, but just over two and half years ago I parted company with my gall-bladder in my local district hospital in Epsom where I am president of the Friends. I was operated on by a consultant of outstanding ability as was his registrar. They made an excellent team. Undoubtedly there are times when consultants could put in more time, but on the whole I believe the teamwork between consultants and junior doctor is admirable. I do not believe that that is the root of the problem.

Just over a week ago I talked to some of the junior doctors in our local district hospital over lunch. What I should really have liked to have done—and I hope that I shall sometime—is to have experienced a round with them. I should have liked to have experienced the hours that they work on any one shift and seen what happened. Conditions vary from hospital to hospital and one might think that the London teaching hospitals do not have the same problems as, for example, the West Cornwall Hospital in Penzance which, according to a recent television programme, has major problems.

There are London teaching hospitals where major problems exist. There was an admirable article in last weeks's Sunday Times colour supplement. It is sad to note that the doctors who took part incurred the displeasure of the regional health authority. Under the Hypocratic Oath doctors have certain constraints upon them. However, having read the article carefully I thought that their observations were sound and restrained. Often those who go into hospital for treatment are the best judges of the extent to which a junior hospital doctor's abilities are tried. There are occasions when they are tried considerably.

The Bill obviously excludes a national emergency and major accident. For example, the recent crash on the M I motorway, when at least three major hospitals were alerted, would be excluded from the Bill and one would expect that. I hope that the country will not take for granted the fact that such junior doctors who took part in the rescue work and treatment will work for 90 or 100 hours each shift on such an occasion. Accidents of that kind involve a great deal of work.

It has been suggested that nurses could take over some of the duties which junior doctors carry out. I speak as a layman among the medical talent taking part in the debate so I use my words carefully. In theory that is a good idea but I look at the suggestion from another angle. Let us suppose that something goes wrong and, hypothetically, a nurse gives the wrong injection. In the case of a doctor one presumes that the British Medical Association or an allied organisation will deal with the matter. If the mistake should happen in the case of a nurse or a nursing sister, would the same apply to the Royal College of Nursing?

An important matter which could be resolved as a result of the Second Reading debate is that there should be more consultation between the British Medical Association and the Royal College of Nursing in order to devise some kind of working practice. My noble friend Lord Trafford has said that in his professional experience there is a tendency to see simple solutions in the Bill. Of course, it is a fact that not in every single hospital do junior doctors work these very long shifts. However, I believe that it is equally the case—and it is certainly so if some of the journals including the British Medical Association journals are to be believed, as undoubtedly they are—that there are all too many hospitals where that takes place.

Of course, with modern technology doctors, be they housemen, registrars or senior registrars, have to take on very much more responsibility. They need training. I believe that it is equally important to point out that the National Health Service caters for some 50 million people today. Twenty or 30 years ago when a junior doctor may well have been told by his senior consultant to get on with it because he had had to do the same work, there may have been some justification because there were fewer patients to treat, albeit with less technology then. Nowadays both nurses and doctors have to cope with many more technological complications. They obviously have to treat more and different kinds of patients. A gall-bladder operation 20 years ago may have necessitated a patient being in hospital for a month. In many cases today he is in hospital for just over a week. Whoever performs the operation— whether it be a senior registrar or consultant—has the added responsibility of modern technology and ensuring that the operation is carried out as expeditiously as possible due to the availability of beds.

What is the solution? A Select Committee has obvious attractions because one can have those with considerable knowledge of the health service and other matters to take part and give evidence. My reservation is the time which that takes. I believe that this is a very urgent matter, whether or not this is the right Bill. I believe that very much more urgent consultation must take place between the various medical organisations including, possibly, the Royal College of Nursing because co-operation between nurses and junior doctors is all-important. However, that is for those far more expert than I to solve.

Meanwhile, I end by saying that the noble Lord, Lord Rea, whatever happens to this Bill, has given the House the opportunity to think very carefully about a very major subject.

9.48 p.m.

Lord Hunter of Newington

My Lords, in the first instance it is a great pleasure to congratulate the noble Lord, Lord Butterfield, on his maiden speech, which I enjoyed enormously. That is not unexpected. Having known him for some 40 years, I am sure that it is exactly the sort of speech which the House will enjoy from him on many occasions to come. It has been said that one should sit through a debate and make up one's mind listening to it. Almost every conceivable aspect of this topic has been dealt with except for one question which arose in my mind when I read some of the recommendations of the Social Services Select Committee. One recommendation was: We believe that the reduction of the doctor's contract week initially to a maximum of 80 hours should be one of the top priorities". In 1982 the noble Lord, Lord Wells-Pestell, said: The number of junior doctors on call could be reduced", and so on. I listened with great interest to the brief account given by the noble Lord, Lord Richardson, of the problems that arose in the training of doctors in the 1970s when I was privileged to be associated with him. There were problems regarding the career structure and consultants posts within the health service with which we struggled for many months at the time.

In listening to the debate, and reading of all this, the thought occurred to me that the Government must have had some good reason for what has or has not happened. Therefore, one looks forward to the Minister's reply with particular anxiety. We want to know whether there have been difficulties of one kind or another. The department is well known to me and therefore I feel I must make that point.

As has been said, this is not simply a matter of reducing the working hours of junior doctors. The whole concept of the delivery of medical care and its administration is involved. As the noble Lord, Lord Richardson, said, the situation is complicated by trying to combine three roles: experience, responsibility for patients and training for the professional posts, with time being allowed for teaching and research.

One aspect that urgently needs to be examined, and perhaps the Government have examined it, is the nature of being on call. As has been said, it is so different in the casualty department from, say, the department of dermatology. Suggestions were made in 1982. What happened to them? At that time the junior hospital doctors said: The Hospital Junior Staff Committee is opposed to any legislation seeking to reduce the hours of work of junior doctors at the present time". We still have the same problem of organisation and management and the sharing between specialties of' similar skills, as was mentioned by the noble Lord, Lord Trafford.

In 1982 the noble Lord, Lord Elton, said that the Government were concerned that the average doctors were contracted for nearly 90 hours and that the Government were anxious to reduce that. In his perceptive speech the noble Lord said that the average doctor could be on call or on stand-by for 50 hours per week and that this of course was inconvenient but it was not necessarily very tiring; so we are back to organisation and sharing as suggested by Dr. Ruth Gilbert, deputy chairman of the Junior Staff Committee of the BMA. She states, rightly, that the current arrangements are inefficient of doctors' time.

In 1972 I chaired a committee of the department concerned with the role of medical managers. This report was largely ignored and the government of the day instead introduced consensus management. I wonder how much consensus management is responsible for the present situation. Now we have general managers. Are general managers beginning to make any real contribution to solving the problem we have been discussing?

As has been said, the medical managers of clinical units are by tradition senior consultants. How many of them have ever attended a management course, or do they believe that any doctor can be a good manager? On making some inquiries, as others have done, I find that it is not exceptional to have a first-class team of consultants, registrars and house officers with the consultant prepared to do his share of on-call cover, particularly if he is worried about the welfare of his juniors. We have not heard much about these people but perhaps we should because they are the backbone of the National Health Service.

Management is not enough. There has been a substantial increase in technology and there are demands on staff. The Government have exerted constant pressure for improved turnover—that has been referred to and the details given—with maximum use of beds. Nowadays patients do not need to be kept in bed so much. Undoubtedly the consequence is that more staff are required to meet a more intensive regime. It would be wasteful of resources to do this until the whole question of the management and organisation has been sorted out.

9.55 p.m.

Lord Blease

My Lords, I find it somewhat daunting to follow the noble Lord, Lord Hunter of Newington, and other noble Lords who have spoken in this debate who are so widely experienced and knowledgeable in the matters we are considering. The complexity of the subject and the solutions have been mentioned by all noble Lords who have spoken. I will not resist the temptation to expand this debate into the wider critical issues as regards the present and future state of the National Health Service. In my opinion the issues that we are debating today are closely related to the basic reasons for this Bill.

I support the general principles of the Bill that are designed to regulate and improve by statute the working hours of junior hospital doctors. Mention has been made of the long-standing professional approaches to the medical ethos. I greatly respect this personal commitment when it is freely given by doctors at all levels. There are vast areas of professional medical conduct that are already subject to statutory regulation. I do not see that the question of hours of work should be omitted. I believe that the adoption of the principle of statutorily regulated hours of work for junior hospital doctors is basic to the achievement of the declared objectives of the national hospital service. These objectives are to ensure the highest possible quality of patient treatment and medical care.

In my opinion the principle of statutorily regulated hours is consistent also with the recognised needs of working conditions which suitably protect the health, safety and quality of life of all junior hospital doctors. I listened with great interest to the very thoughtful speech made by the noble Lord, Lord Trafford. He expressed the opinion that the will is needed to bring about the necessary change. He dealt also with the question of the number of hours of work, which vary from a few hours to much longer periods.

In my opinion, if one junior hospital doctor has to work the hours that have been expressed here, it is worthwhile to go down the line to correct it. No doctor should be put under the stress and strain of the kind that has been suggested. I believe that the figures relate to many who are in this category. I repeat to some extent what has already been said. How can our hospital doctors be expected to provide the highest standards of medical and surgical treatment when all too often their duties involve such long periods without sleep? In such conditions of fatigue doctors on first call have to make decisions vital to the wellbeing, the life and death of patients under their care.

Much has been said in this debate about patient care. It is a matter which is of supreme importance. But what about the quality of life of junior hospital doctors? How can we expect them to be intelligently aware and involved in the cultural, economic and political life of the community when their social life is so drastically restricted by long hours in dealing with human ailments in life in hospital wards? I know that some noble Lords have already told us they came up through the ranks of junior doctors to consultant level. They are acutely aware of the problem and are deeply involved in the social life of our community.

Two matters arise from the text of the Bill which at Second Reading should be clarified. The first relates to the constitutional scope of the Bill, which I believe should embrace the whole of the United Kingdom. The second relates to the practical measures required to implement the statutory regulation of working hours.

As I understand it, the Bill proposes to amend the National Health Service Act 1977. That Act makes provision for the health service for England and Wales only but gives certain powers to the Secretary of State to extend the provisions to Scotland and Northern Ireland. I have been lobbied about the Bill by junior hospital doctors and others directly concerned in Northern Ireland. From the information given to me it is evident that junior hospital doctors in Northern Ireland are subjected to hardships regarding contracted hours of work similar to those in England and Wales. I am given to understand that the position in Scotland is the same.

It is important that I should make reference to the standing of the hospital service in Northern Ireland in case it is thought that I am making derogatory remarks about the general personnel in that service. The people of Northern Ireland arc justifiably proud of the high standards of their health and personal social services. Over the years the services have been quick to adopt new and better methods of treatment and care for victims of disease, illness, accident or social disability. The capacity of the services to cope with new developments and changes demanded of our society is a tribute to the skill and dedication of staff at all levels in our hospital services. Whatever changes may be made for England and Wales, the same measures should be applied to junior hospital doctors in Northern Ireland. I wish also to stress the point made earlier by the noble Lord, Lord Trafford. There is a will at all levels of the medical profession to adopt change.

I should like to turn now to the practical measures required to implement the proposed statutory regulation of working hours. We are dealing with a wide variation of hours and working practices in the different hospitals across the areas, the regions and the districts. It is a complex subject and one which I would not attempt to debate simplistically. In promoting any change we must consider the implications for existing manpower ratios in regard to hospital medical arrangements, the working practices under the consultants "firm" system, the hospital service management relationships and the procedures already being practised at various levels.

In addition, factors such as the maintenance and improvement of the efficiency and effectiveness of the various medical specialties within the national hospital service must be considered. Any change must not bring about a deterioration or a further deterioration in the national hospital service.

We note that in the past eight years numerous attempts have failed to bring about any effective change in the reduction of hours for junior hospital doctors. It is evident that legislation is urgently required to limit the hours worked by junior hospital doctors. If this is so, a code of work practice is also required. While the elements of such a code of work practice could not be effectively framed in a parliamentary debate of this nature, it is important that such a measure should be enshrined in any proposed changes or legislation. It may he that a Select Committee would be the most useful means of bringing forward recommendations that could bring together the measures to implement such changes.

In conclusion, I must say that this Bill, which was so ably promoted by the noble Lord, Lord Rea, has generated considerable public interest and indeed concern. The outcome of this evening's debate is keenly awaited, not only by the junior hospital doctors. Therefore I hope that the Government will be earnest and generous in their consideration of the time factor and other factors which made it necessary to bring the Bill into creation. I also hope that we shall have some action that will bring about agreed change. Having said that, I support the Second Reading of the Bill.

10.6 p.m.

Lord Porritt

My Lords, for what seemed to me two very good reasons, I had not originally intended to take part in the debate. First, long before the date of the Second Reading was announced, I had accepted an invitation to a very interesting medico-pharmaceutical occasion which I imagine is now pretty well over. Secondly, and much more to the point, my medical status is now at best that of a Rip van Winkle and at worst that of a Methuselah. Further, whatever I may say will probably be considered miles out of date.

However, as noble Lords can see, I have decided to change my mind on both counts, despite the fact that it is certainly well over 60 years since I could reasonably be called a junior hospital doctor. I have changed my mind following the old cliché that if one cannot change one's mind then one probably does not have a mind to change. So I have changed my mind as regards speaking and also, more importantly, I have changed my mind on the subject under discussion. Therefore my speech is by way of being a pseudo-confession.

I am glad that I changed my mind in regard to speaking because it gives me an opportunity warmly to congratulate the noble Lord, Lord Butterfield, whom I have also known for some time. His was a tour de force in making a non-controversial speech on a controversial subject. But that is typical of him; he can manage the most difficult situations with consummate ease, and believe me, your Lordships have not even begun to experience his repertoire yet— although I hope you will.

However, perhaps I may resume with the main subject. When I first came into contact with the issue of overworked junior doctors I realised that it had very definite importance because questions were being asked all the time and, similarly, receiving no answers all the time. My first reaction, from what I have already said, was simply that of a very grown-up junior hospital doctor of the 'twenties'—you can imagine what that was. However, I wanted to say what I felt at first.

In those faraway days we worked as we were required to work. We worked without remuneration for our board and lodging and we worked for as long as it took. It was a privilege to be involved in emergency work at the hospital— in fact in any work at all—which gave us personal experience and the opportunity of learning from our elders and betters.

Words such as "contract" and "overtime" still make me shudder. Paid holidays, rotas and remuneration did not exist in our vocabulary. We vied with one another to do long stints of work. If at the end of it we were tired, that was a state of which we were rather jealous as regards each other. That makes me think of the extremely good speech made by the noble Lord, Lord Richardson. It moved me because it took me back to those days which showed that there was another side of being a junior hospital doctor.

Those were days where there was a sort of ethos to it; where there was a joy to it; where there was fun to it; and where there was great companionship. Those things do not add up with what we are talking about tonight but they very definitely exist.

In the intervening years, the whole face of medicine has changed dramatically. The present face is just a little stern, materialistic, and businesslike compared with the face of pre-war days, which was kindly, personal, and perhaps almost happy-go-lucky. It was a very different atmosphere.

On more than one occasion, even in your Lordships' House, I have recently been guilty of saying that in the past 30 to 40 years we have developed an entirely new type of doctor, a very good doctor; a well-trained doctor; an efficient doctor; a hard-working doctor; and a doctor conversant with the advances in modern Medicine. But, in view of the circumstances in which he has to work today, his motivation is different from that of his predecessors. His motivation is, to a considerable extent, more material, more technical and more financial. That has nothing to do with his personality; it has to do with his environment. In all fairness one should say that there has also developed a new type of patient with whom the doctor has to deal—a patient who is well aware of his rights and, sadly, not quite so well aware of his responsibilities. It is a case of the chicken and the egg.

Your Lordships well know the causes of that change in medicine in Britain. The first is the advent of the National Health Service, with its complex statutory regulations; its bureaucracy: its financial limitations; and its restrictions. The second, and far more important cause, is the gigantic strides that have been made in technical and scientific knowledge. In other words—I want to make this point because I do not believe that it has been made tonight— the whole question of overworked junior hospital doctors might well be interpreted as yet another manifestation of the exceptional progress that has been achieved in modern medicine. It is another success story. It may be a backward way of looking at it, but it is one way of looking at it. It brings in a little optimism, and we have not had much of that tonight.

It is for those reasons that I have changed my mind. I have talked to a number of the younger doctors over the years. Please, we should not classify senior registrars with junior hospital doctors. At a pinch, one can include registrars, but I would not do so. We are not talking about them. We are talking about genuine juniors, not people with 14 years of training. I have talked to a number of them; I have talked to a number of their more senior colleagues who are still in active practice, and I have also talked to some of the rather more broad-minded of my contemporaries who still exist.

I am now willing to believe that such is the intensity and complexity of today's therapeutic measures, and incidentally the concomitant responsibility that goes with them, that the junior officer today has more stress and more fatigue than we had. Probably mathematically he works more hours, but there was nothing like the organisational arrangements in our day that exist now. If that is so, if he has more stress and fatigue, it is quite right that we should look at some limitation of his hours of work. The extent of that limitation is very much open to discussion. In his excellent and succinct explanation of this little Bill, the noble Lord, Lord Rea, mentioned 72 hours. So does the BMA, I think, but this is by no means a set figure. There are many others that could be discussed.

Like the noble Lord, Lord Trafford, I had very much hoped that this would not require legislation. It does not seem to me a matter for laying down the law, as we are trying to do tonight. One should remember that these young doctors are essentially on call, I suppose, to the ubiquitous bleep that they take round with them. That may mean very strenuous periods at work; it may also mean periods without excessive work but with loss of sleep. It may also mean periods of relative inactivity, periods of no work. We should remember that.

Furthermore, changes in the type of hospital and the type of work done in that hospital will make an enormous difference to the hours and frequency of work, so that has to be discussed. It is a much more complicated problem than one thinks.

The whole problem seems to be an ideal occasion for getting together the departmental sides and the professional side and trying to agree on an arrangement that suits both sides. I know that this has been mooted for the last eight years and nothing has happened. But if we have shown by tonight's discussion that it is now a really urgent problem, it might be possible to achieve something without the rigmarole of legislation.

There were two further points which I wanted to make but they have been made so I wish just to underline them. One is that the younger doctor in post is not only there for his service but to be trained. I underline "trained". If we are going to keep up the reputation of the British doctor all over the world, this is the stage at which he must receive that training. He must gain more confidence and, we hope, more knowledge and he must certainly gain more experience.

The last point I want to make is quite a simple one. It has been said in different ways by many noble Lords in this discussion. If we are to talk about the hours of work of a junior hospital doctor, we should talk about the hours of work of every doctor in the hospital. The senior levels, the consultants, are automatically bound up in any discussions that we have on junior doctors and we must remember that. For these reasons I have given my support to the Bill in principle, but I feel that it opens up an enormous problem of which we have dealt with only a very small part. I support the Bill but not very enthusiastically I am afraid.

10.20 p.m.

Lord Brain

My Lords, it is late and I shall be as brief as I can because I do not want to give an overdose of the medicine we have already received. The noble Lords, Lord Trafford and Lord Pitt of Hampstead, have made many of the points I have in my notes and I shall not repeat them. I would just emphasise the question of experience through my daughters who are both junior hospital doctors; the need to get the complete co-operation of the team when fixing rotas; and also the need to get the cooperation of the staffing department of the hospital, because it is no use trying to organise a rota if the staffing department says, "You cannot have a locum on this occasion: it is not allowed." It may make all the difference to a really effective rota.

I also support the comments made by the noble Lord, Lord Pitt. I shall make two further points. One is that everybody thinks of the hospital doctor problem as being a problem related to the wards. However, a tremendous amount of the hospital problem relates to clinics, which occur in addition to the ward work; and it is staffing those clinics that very often makes the rotas and allowing time off a difficult matter and much more complicated than might appear to the average person.

The other point is that I support the Bill in principle but a lot of work will need to be done either in Committee or Select Committee. It talks about "required hours of work" but, as has been said, the medical profession does not know about required hours of work: it wants to give service. I shall here pick up a point made by the noble Lord, Lord Trafford, that care of the elderly or geriatrics might be thought to be a simple profession. I remember an occasion when one of my daughters was due to leave the hospital for the weekend at 5.30 and she rang at 9 o'clock saying, "I've just left the hospital: I had a difficult case."

It is not easy to rule for difficult cases. I support the Bill. I think it is easier to support it by being brief, and so I shall finish.

10.22 p.m.

The Earl of Halsbury

My Lords, speaking towards the end of the list, I shall be brief, albeit anecdotal. For me the wells of memory go back nigh on 20 years to when I became chairman of the Doctors' and Dentists' Pay Review Body. I listened to many witnesses and my noble friend Lord Richardson was one of them. A lot of what I listened to was not directly relevant to my remit. Nevertheless, I naturally formulated my thoughts on what I listened to and I fed them forward via the Office of Manpower Economics in the hope that they would reach the lords and masters of the National Health Service in due course.

Junior doctors were tired, stale and overworked then, as now. Nothing appears to have changed. Morale was at a low ebb then, as now. Oh dear! This is where I came in nearly 20 years ago. There were too few junior doctors because they had every incentive to leave hospital service as soon as they possibly could and go into general practice. The remedy was to declare a minimum number of years' hospital service before they would qualify to enter general practice in the National Health Service.

I thought one might be able to compensate for the temporary reduction in recruitment to general practice by encouraging general practitioners to postpone their retirement for a few years. The effect of course would have been to raise the standard of general practitioners by appropriate registrarships in hospitals. A registrarship should be held in every specialism that on a statistical basis they were bound to encounter in general practice: for example, paediatrics, geriatrics, psychiatrics, cardiac conditions, rheumatic conditions and so on. They are bound to encounter all these, and the better trained they are the better. But the recruitment of registrars was a shambles, with the lack of any form of planning beyond the current post held by a registrar for six months' tenure.

The noble Lord, Lord Rea, in private conversation, assures me that a lot of that has in fact taken place, though not necessarily by the means that I advocated. My last suspicion was that firms worked in too watertight compartments, with a floating population of house officers and registrars, so that the firm on a long-term basis consisted of one consultant plus one senior registrar training to be a consultant. I was strongly influenced by the views of the noble Lord, Lord Trafford. We need the will to organise properly. Nothing gets done in this world without some tough, strong, driving individual will behind it.

How then do we achieve it? By legislation? Certainly I shall vote for the Second Reading of the Bill, but I must not allow the noble Lord, Lord Rea, to suppose that a Private Member's Bill launched here as late as this can get on to the statute book without government support in the other place. Unless the government spokesman this evening supports the Bill here and now, it is unlikely to get on to the statute book.

It might be a good vehicle for initiating reference to a Select Committee, but this might not be the occasion on which to move that because the Select Committee bottleneck is caused by a a lack of clerks and rooms. If not legislation, then what else? By what other means are men governed? By stick and carrot: no more merit awards for hospitals where the consultants and the junior doctors do not get together to solve this problem—the job that the noble Lord, Lord Trafford, seeks to assign to them. Stick and carrot; stick and carrot.

If other ranks are demoralised, blame their officers whose first duty it is to raise the morale of the regiment. What incentives are there to join the medical profession at all if the other ranks express public dissatisfaction with their working conditions? That appears to be the view of the noble Lord, Lord Trafford. It is also mine.

10.27 p.m.

The Lord Bishop of Southwark

My Lords, I must first apologise for inserting myself into this debate unexpectedly at this late hour, and I am sorry to do it. Unfortunately my name was not sent forward through the usual channels due to some oversight and I was unaware of the fact until I arrived in the House this afternoon. One consequence of course is that I find myself in an unusual position on the list for a Bishop. It has been a salutary and I must say stimulating experience to listen to the considerable array of wisdom that has been deployed here this evening on this important subject. I have also had the experience for once of watching my speech quietly disintegrate. But I want to say just a few things briefly, and I shall try to be as quick as I can.

My primary intention was, and still is, to focus on the question of training rather than or safety, which has already been well covered, since the majority of junior doctors are still in some kind of clinical training as well as providing a service. That is a point already made strongly by some of your Lordships. They are the people on whom the future of the health service depends.

It may be helpful to underline this from some of the evidence that I have been gathering in my diocese, which contains four of the best-known London teaching hospitals, and to come at it from the angle of another profession. When you require someone to work exceedingly long hours not only do you impose a physical strain on them which may easily impair their judgment; you also reduce their capacity to learn at other points in the week when they are at the receiving end of specific teaching or involved in other forms of learning.

Someone was giving a talk to a group of young doctors recently on how to break bad news. One fell asleep during the talk, most were obviously on the brink of doing so and one of them said at the end, "Thank you for what should have been a very helpful talk on an important subject. Not everything that doctors do is simply clinical medicine, and I wish we could have taken it in properly bul we are all exhausted".

There appears to be very little provision so far as I can gather for the kind of in-service training that enables people to stand back from the demands of sick people and emergencies for at least a couple of days at a time: that is to say, to concentrate on the task of taking in rather than giving out and to reflect on what they have been doing and the experience they have been gaining. As clergy numbers drop and pressures actually increase, more and more we find the need to do just that.

I noticed that a number of speakers tonight almost appeared to equate training with the amount of time you spend on the wards or in the clinics, rather like a pilot clocking up hours of flying time. I recognise that that is a very important dimension of medical training but I do not think that it can be as simple or as restricted as that.

What has struck me tonight is the frank recognition on the part of many distinguished speakers, led by the noble Lord, Lord Trafford, that the reason why the training dimension has remained unsatisfactory is that some of those directly responsible have not yet taken into account the extent of the changes which have taken place over the past 25 or 35 years, nor faced the organisational changes that are needed.

I have been told again and again in the past few weeks that the "We had to do it, so can you" syndrome is still around, and the noble Baroness confirmed that. That cannot be right on safety grounds, given modern drugs and technology. Everyone is agreed on that. It cannot be right either on training grounds.

A hospital chaplain talked with four new junior doctors a few weeks ago and found them all frightened by the responsibilities thrust on them and feeling that they were not supported by senior colleagues. I find that worrying. Instead of a training relationship which encourages people to share their difficulties and their doubts in order to become more effective at a deeper level, there is the fear of saying anything which might be interpreted as an inability to cope. I suspect that that is one reason why the present unhappiness and low morale has not surfaced earlier.

It is not a sin, nor is it always a sign of weakness, to say that one cannot cope with life and death decisions without sleep or that one's learning curve is likely to drop out of sight in such circumstances. There is an image of efficiency nowadays which holds up the excessive workaholic for our admiration and expects the rest of us to conform. We have it in the Church too, with God pictured as relentlessly demanding more and more of us. But it is not a good or true image and it can have tragic consequences.

The Bill is about the hours which junior doctors will he allowed to work in future. I have listened with great interest to the difficulties expressed by those who know much more about it than I do, and I have no opinion to offer on that subject. The only comment I should want to make tonight is that I get a little worried when professionals say that this is a matter which is not a fit subject for legislation; "leave it to us". The whole subject was raised seven or eight years ago. According to the statistics the matter is in the same difficult state.

Behind the Bill there is the equally important question of how people work together in a profession and how well newcomers are supported and cared for by their more experienced seniors. Those are, as many have said, questions for the medical profession itself, not for government. I hope that there may be real co-operation, honesty and a willingness in some cases to change attitudes in addressing this very urgent problem together.

10.33 p.m.

Lord Ennals

My Lords, I am grateful to the right reverend Prelate for having filled the gap. What he had to say was most relevant and provided a useful way of bringing this debate to an end.

First, I want to say how grateful the House is to my noble friend Lord Rea for bringing the issue before us today. He chose a very good time to do so, a time when the issue has been much debated in the press and when there is deep feeling among junior hospital doctors.

I know that, having just completed a successful stay in hospital. This was an issue which was being much debated by those, both patients and doctors, who were at my side. I want to say a word or two about that later because I believe that I owe a great debt of gratitude to the consultants, doctors and nurses and all the others who work in the health service for the fact that I am here and able to make a speech, albeit a poor speech. So I am grateful to my noble friend.

Secondly, on behalf of us all, I want to give a very warm welcome to our new arrival, the noble Lord, Lord Butterfield. I have had the privilege of knowing him for a considerable time and admire his talents. I was delighted when he was invited to come to this House.

His first speech was a very warm reminder to us of his many talents. "Many talents" have been the feature of today's debate. An extraordinary combination of medical talents has come before us and given us advice. The vast majority of those who have spoken are or have been doctors. I think in particular of the noble Lords, Lord Porritt, Lord Richardson, Lord Hunter, Lord Trafford and Lord Butterfield, who are among the most distinguished men of our time—or their time, whichever it may be. They have shown tremendous distinction. That is not to underplay the significance of the noble Earl, Lord Halsbury, and my noble friends sitting behind me, both of whom are from the medical profession.

In a sense we are in an interesting situation. The majority of speakers quite clearly favour legislation; only two or three speakers hoped that matters could be settled in some other way. As I have said, the doctors, who are in the majority today, are divided. Some favour the concept of self-regulation which was first advocated in today's debate by the noble Lord, Lord Trafford. There is much weight in what he had to say. There is no need to legislate if there is a will.

I believe that there has been a will for some time, but change has not come about. I do not know whether we should criticise any one section and say that the blame lies on the consultants or the politicians or the administrators. I do not think that it is easy to say who is to blame. But what we know and what the junior hospital doctors know is that change has not happened. We can go back over many years of activity in which initiatives have been taken, but it has not happened.

However, there has been a very important change of attitude. It was an issue in 1978 when I was Secretary of State for Social Services, but the junior doctors were against legislation. We say "junior", but as your Lordships have been reminded, many of them are men and women of great distinction and have years of very considerable experience which is of great value to the health service. I think that sometimes we write them off by using the word "junior". There is tremendous sympathy for them and for the case that they are making today. However, in my time they were absolutely against legislation. The BMA was against legislation and so too was the Hospital Junior Staffs Committee of the BMA. There was hardly any argument put forward by the medical profession.

I was involved in the negotiations about how to put a new price tag on units of medical time, to put a limit on the number of UMTs that could be paid for by the health authority and to set a target for the maximum number of hours that could be worked. It was my impression—and this was referred to by the noble Lord, Lord Winstanley—that there was a great will and enthusiasm. I thought that we had produced a pattern and that change would come about in 1978, but the next attempt was made in 1981—and the pattern has been repeated every two years between then and now. Each time an attempt has been made to get something done to make sure that doctors do not work the intolerable hours that they are now expected to work.

So we have to ask ourselves how we can deal with this intolerable position in which the doctors find themselves. It is not just an intolerable position for the doctors concerned; it is an intolerable position for society. As we were reminded by the noble Lord. Lord Pitt, we take powers to regulate the hours of many workers. The noble Lord referred in particular to airline pilots. I must say that junior hospital doctors would welcome the kind of pay that is received by airline pilots. Junior hospital doctors work several times as many hours as airline pilots for a fraction of the pay achieved by them. As a result, the attitude of the doctors has been transformed. Of those who have spoken in today's debate, there are those who have changed their attitude, including the noble Lord, Lord Porritt, who said that he had altered his approach.

How do we resolve the problem? I do not think that anyone can say that legislation alone will do so. It is true that eventually it has to be resolved by agreement, by administrative pattern, and by determination between juniors, consultants, the health authorities and the department. After all, the department has been seeking a solution, with such energy as it could put into it over a period of successive governments; so there should be no doubt about its intention.

First, we can give this Bill a Second Reading and, I hope, send it to another place. I am not arguing that the idea of a Select Committee ought not to be considered. Are the Government and Members on all sides of the House prepared to accept the concept of a Select Committee which might be able to report in, let us say, nine months? It could take evidence from all those involved and come up with a solution which legislation could not provide. Legislation simply provides a requirement for a solution to be found. But that is important since other methods have not so far succeeded.

I agree with the view that was taken by the Select Committee in 1981. I was a member of the Social Services Select Committee in another place which recommended in 1981 that, The reduction of the doctor's contracted week, initially to a maximum of 80 hours, should be one of Government's top priorities and the existing agreement to achieve this for junior doctors should be enforced. To this end, the Health Departments should study different patterns of shift work and work-sharing between different firms in a district". I assume that the initiatives that have been taken by the department seek to bring about the same aims that were set out by the Select Committee at that time.

The BMA's hospital junior staffs committee believes that this pattern would be greatly strengthened by legislation. I take that view myself. There is no doubt that legislation would help the situation. The medical practitioners' union also agrees that it is essential a solution be found.

I say that it is essential because there are some very disturbing factors. I have recently come out of hospital. The registrar who was responsible for my health, under the consultant Mr. James, Dr. Andrew Liddle, has prepared a very significant document that I asked him to prepare on the matter as it affected him. I shall not go through the details but he has given me two examples of circumstances in which, after tremendously long hours of work and pressure, he was in a situation where he could have caused loss of life. It was only because of the intervention of someone else that it was possible to see the patient safely through.

There is a great danger that inevitably results from the conditions of work under which doctors labour at the present time. We must remember that junior doctors in the United Kingdom work more than 40 per cent. longer hours than their counterparts in every other EC country except the Republic of Ireland. While United Kingdom juniors average 86 hours a week, in EC countries the average is 60 hours or less. If the problem can be resolved in other countries, it can and must be resolved in Britain. I believe that it is not only bad for the doctors' morale—some of them are leaving and taking their skills to other countries—but it is disturbing for the patients.

In conclusion, the passing of a law will not solve the problem. It must be solved by those in the professions, with the leadership of the department. However, the passing of a law will create a requirement for a solution. I hope that is what will happen. I am most grateful to my noble friend Lord Rea for having initiated this debate and for giving us the opportunity of passing legislation.

10.45 p.m.

Lord Hesketh

My Lords, first, let me humbly say how much I appreciated the speech of the noble Lord, Lord Butterfield—more than that, how illuminating I found it. Also I agree with what he said about there being no magic wand. This evening has demonstrated that he is entirely correct in that supposition.

It might be of help to your Lordships if, before outlining the Government's views on the Bill—for that is all that the Government can do—I explained the basis of junior hospital doctors' contracts and gave some background to what has happened about their hours of work over the last few years.

Junior hospital doctors contract for a basic working week of 40 hours. This is usually from Monday to Friday. In order to provide 24-hour cover most juniors additionally have a contractual duty to be on-call for a further number of hours on a rota basis. Average weekly contracted hours for all grades is approximately 83. However, and this is an important point which is not always fully understood, not all this time is spent working. Some will be spent on-call in hospital or at home. Average hours spent actually working are 57, and this varies accordingly to specialty, ranging from 46.4 hours in mental illness and psychiatry to 66.9 hours in general surgery.

The Government have long been concerned at the hours some juniors have to work. No easy answers exist. Government initiatives between 1982 and 1985 were largely instrumental in a reduction in the number of doctors on rotas more onerous than one night and one weekend in three being cut by some 30 per cent.—from 5,000 to 3,500 doctors. Juniors' hours of duty were on average 91.3 in 1976, 87.7 in 1982 and 83 in 1987. Independent surveys show that average hours of work in 1981 were 58.3 but, as I said earlier, by 1985 they were 57. Progress has, therefore, been made but there is still a long way to go.

A departmental survey in 1987 showed that there were a significant number of people working a one in two rota. The problem was considered by a working party consisting of representatives of the health departments, the National Health Service, the Royal colleges, consultants and juniors. Their recommendations led to health authorities being asked, last June, to re-convene district working parties including managers to advise on the elimination, wherever possible, of regular commitments for juniors to be on duty on average more than one in three. Particular reference was made to those first on call in the hard-pressed posts. Authorities are due to report to the department on the final results of this initiative in October. However, because of recent public concern about the long hours worked by some junior doctors and because of the timing of this debate, my right honourable friend the Secretary of State for Health earlier this month called for urgent interim reports from health authorities.

Your Lordships may know that my right honourable friend the Secretary of State together with my honourable friend the Minister for Health met representatives of the British Medical Association on 9th January about the problem of juniors' hours. All present at that meeting agreed that it was a complex and long-standing issue to which a solution must be found, although no simple solution is available. It was further agreed that all parties concerned at national, regional and local level must throw their weight behind the initiative launched last June to make it a success. My honourable friend the Minister for Health is to chair shortly a further meeting with the representatives of the BMA to discuss the picture which emerges from the interim reports to which I have already referred and to consider what further action may he required.

Your Lordships will wish to know that by the end of last week interim reports had been received from every regional health authority. The content of these reports will need to be carefully analysed and discussed within the department and with the NHS as well as at the meeting that is to be held with the BMA. Although the progress has been different from region to region, I am pleased to say that all have confirmed that the programme will be completed by the end of September. The reports show that some districts have been able to reduce rota commitments already and plans for further reductions are envisaged. The evidence exists of the willingness of regions to look at the whole problem and to make suggestions for improving the situation. These suggestions will be given close attention. But the reports also confirm what Ministers and representatives of the BMA agreed. This is a problem with no easy answers, but the willingness to tackle it is something that we must build on.

I turn now to the Government's views on the Bill that is before us tonight. Noble Lords will be aware, from what I have said so far, of the Government's concern at the excessive hours worked by some junior hospital doctors. The objective of the Bill is to make the hours they should work or be available for work no more than 72 in any one working week, averaged over a one-month period. The Government are committed to a further reduction in junior doctors' hours wherever possible and believe that an average week of duty of 72 hours is a target which we should work towards. But there are a number of reasons why the Government have grave reservations on the effect that statutory limitation on hours proposed in this Bill would produce.

First, the Government's initiative announced last June, with, as I have said, the agreement of all interested parties, has a programme of action which is partly completed and which envisages reports to the department in October this year.

Secondly, the pattern of work of junior hospital doctors cannot—and should not—be determined centrally. Rota commitments can only sensibly be worked out locally. They are influenced by a number of factors: speciality, training needs. the organisation of hospital services locally, the needs of individual consultants and. most important of all, the need to ensure satisfactory medical cover for patients throughout the year.

Thirdly, to implement the Bill with conventional staffing patterns would require a very substantial increase in the number of junior doctors, especially in the senior house officer grade. It is far from clear that we could recruit these extra doctors, at least in the short-term, given that there are already difficulties in filling the existing number of senior house officer posts.

Fourthly, any increase in the number of junior doctors would run entirely counter to our current efforts to reform the hospital staffing structure. The main thrust of Achieving a Balance, published in 1987, in agreement with professional and health authority interests, is to increase the number of consultants while limiting the number of junior doctor posts to the number required to fill future career vacancies. The effect of increasing the number of juniors would be to increase the length of time which juniors spend in training—which is already widely recognised to be excessive—and could mean that some juniors never attain the career post for which their skill and expertise would fit them.

The regrettable fact is that no one has yet come forward with a generally applicable scheme which would enable hours to be reduced but would safeguard career prospects. Various suggestions have been put forward, but they would either require a big increase in junior numbers, or would involve novel patterns of medical care such as shift-working. I am aware that specific innovations of this kind have been proposed and in some cases even implemented successfully, but I do not sense that the profession at large is ready to adopt these on a wide scale. In this connection I was encouraged to see the recent comments of the president of the Royal College of Surgeons; that the solution is not more junior doctors but more consultants. I should like to see the medical profession work through the implications of this remark and bring forward specific proposals for ways in which consultants could help to take over some of junior doctors' existing workload. For the time being, however, I believe it would be irresponsible for the Government to make firm plans for a maximim of 72 hours, however desirable that may be in itself, without a clear and agreed view in the medical profession on how that could be achieved.

To conclude, I repeat that the Government are firmly committed to seeing a further reduction in hours. We wish to see the current initiative work and, as I have said, my honourable friend the Minister for Health will next month be examining progress on this with BMA representatives and discussing with them any alternative action that may be necessary.

I must emphasise that the department is committed to assist with the professions as and when asked. However, as I explained to your Lordships earlier, we are not convinced that statutory limitations and the timetable proposed in the Bill is the practical way to achieve the reductions which we all want.

Finally, a number of noble Lords mentioned a Select Committee. That is not for me but is a matter for the usual channels.

10.55 p.m.

Lord Rea

My Lords, I should very much like to thank all noble Lords who have spoken and who have stayed so very late. I have found the contributions from all sides to be of great interest and I should particularly like to thank the noble Lord, Lord Butterfield, for his very supportive, though of course completely non-controversial, maiden speech.

I welcome the comments and criticism of the noble Lord, Lord Trafford, and appreciate many points which he made. I hope that he will be able to put some of his ideas into the form of amendments if we reach a Committee stage. That also applies to many other noble Lords who have put forward suggestions for improving the Bill.

As always, I was very interested in the remarks of the noble Lord, Lord Porritt, and delighted that he realises that circumstances have changed in the past half century. He spoke of the hard, materialistic doctor of today, but talking to junior doctors I am repeatedly told that the first thing which suffers with exhaustion is the patient. Caring doctors become automatons like the correspondent of the noble Lord, Lord Winstanley.

I very much welcome the contribution of the right reverend Prelate the Bishop of Southwark who eloquently touched on the more human dimensions of medical care and showed how they elude exhausted doctors.

Referring to the remarks of the noble Lord, Lord Hesketh, I am delighted that the Government are working towards a 72-hour limit on contracted working hours for junior doctors. I am also delighted that the department wishes to assist the profession in reaching that end. Of course he pointed out that there has been a reduction in contracted hours over the past decade. However, I am not convinced that that represents the whole truth. For example, what about the possibility of work outside contracted hours? I have evidence that there is more work being done than is demonstrated by the statistics. I also believe that the decision to cut back on the use of agencies to provide locums will inevitably increase the hours worked by some junior doctors and that may not be included in the statistics which the noble Lord has to hand.

I do not believe that there is enough in his remarks to convince me that there will shortly be a significant improvement in the situation. He certainly mentioned that there should be more consultants, but I did not hear any commitment that that was a good idea. However, he put the responsibility for that onto the consultants themselves. I shall read his remarks. but that seemed to me to be what he said. I did not hear any commitment from him to double the increase in consultant numbers, which many authorities to which I have spoken feel is necessary as a permanent solution to the situation.

Referral to a Select Committee was suggested by several noble Lords. I believe that the House as a whole is quite interested in that idea. At this stage I will merely say that I shall take this away and give it very serious thought. If the Bill is given a Second Reading, I shall inquire into the possibility through the usual channels.

I believe that this has been a very successful debate and the time has now come to put the Question to the House.

On Question, Bill read a second time, and committed to a Committee of the Whole House.