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Health Service (Consultants And Specialists)

Volume 481: debated on Wednesday 22 November 1950

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10.3 p.m.

The subject which I desire to raise in the third Adjournment Debate is, I confess, of less importance than the subject which has been under consideration for the last two hours. At the same time, it is not an unimportant topic, relating to the Health Service and the provision of consultant and specialist services for the people of this country.

May I quite briefly bring to the notice of the House certain facts? The hospital and consultant service in this country is provided in the main by three groups of doctors—the specialist at the one end, the junior house officers at the other, and, in between, that body of practitioners under training for specialist status, known as registrars. In this country there are some 5,200 specialists. In the training group which comprises the two senior groups of registrars, there are some 2,800 practitioners at one or another level of the uncertain ladder of specialist status.

The Ministers—if I may use that term, although I had in my mind the position in England and Wales in particular—had decided that as an act of future policy the number of practitioners under training in the registrar groups shall be regulated by the probable number of vacancies in the specialist ranks. That I believe to be a perfectly sound and reasonable proposition, and I am not challenging that fundamental proposition. This has been done, and I give the figures for England and Wales. It has been calculated, partly on the basis of the age of existing specialists—no doubt calculations have been made as to the prospective mortality rates of the specialists—that 150 vacancies will arise each year for the next few years in the specialist ranks. There are 5,200 specialists and 150 vacancies that will arise—100 deaths and retirements, and 30 additional specialist appointments.

When the National Health Service was in its earlier and promotion stages, the prospect of real hope held out was that there would be available in all parts of the country a comprehensive specialist service. A modest beginning, but a very modest beginning, has been made. What seems to me to be tragic is that the calculated annual increase in the number of specialists to meet this demand is 30 specialists a year. I have no doubt that that will make no more than an infinitesimal contribution to the satisfaction of the original objectives. One of the results of leaving the number of specialists approximately where it is has been that the ranks of the registrars—those under training—are to be massacred.

There are 2,800 practitioners training to be specialists at this moment, and in order to fit in with this policy of a tiny annual increase in the specialist establishment, 1,100 of those trained and semi-trained men are to be swept out of the registrar ranks. I believe the policy to be sound to adapt the number of specialist training posts to the prospect of promotion, so as to make it a reasonable training to undergo, but I suggest that what is happening now—no doubt for financial reasons—is a freezing of the specialist establishment at this present level, apart from this modest increase.

In a circular sent to all regional boards and boards of governors, they have been, as it were, given their share of registrar posts under the new arrangement. In the case of the only region I have examined—other Members will have seen it in relation to their regions—it means that three-quarters of the senior registrars will have to go as soon as possible after 1st January, and two-thirds of the registrars—that is the intermediate group. I agree that under special circumstances some senior registrars can be kept on, but, in general, they have to go. This arises largely because of this timid attitude in relation to the future expansion of the consultant services.

What is the position? It means that 1,100 practitioners in various stages of training for specialist services to the community are to be told to leave the specialist ranks. I do not want to exaggerate it, for some of them might not have made the grade in the consulting ranks. But much of this training is being thrown away. There is also a serious practical difficulty, that in hospitals the registrars are not only under training for consultant status, but are doing an important part of the work I the hospital. The Ministry's circular puts forward the suggestion that the gap which their departure creates should be filled by utilisation, part-time, of the services of general practitioners.

I should be the last to suggest that the general practitioner has not an important place in a hospital—indeed, that his position in hospital should be stronger—but to suggest that the general practitioner on a part-time basis can undertake the kind of specialist work that many of these senior registrars and these senior consultants have been undertaking, is sheer nonsense. Therefore, I urge that this whole position be re-examined. I have not put it mainly on the basis of these 1,100 registrars who are asked, as it were, to leave the consultant's ladder.

I do not desire to put it on a narrow personal basis, although I am bound to say that the registrar ranks have been swollen since the war out of the belief fostered by the Government that there would be an expansion of the consultant service. Many are men of 32 to 35 who served in His Majesty's Forces during the war, and they have been training for specialist status ever since. It is not only on that personal basis that I put it. I put it, firstly, on the basis that if the implied undertaking that there would be a consultant service everywhere is to be carried out, then an increase of establishment of 30 consultants a year is insignificant in extreme in relation to the problem. Secondly, the revised establishment of registrars has been too drastic, and to act upon the Ministry's circular and take away these registrars from the hospitals will lower the quality of service in these hospitals for some time to come.

I put this issue upon a broad public basis, for I believe that in trying to observe a sound principle of regulation of establishments we are in danger of an injustice being done to a large number of practitioners and of wasting their experience. Let us bear in mind that once we have got into the new position it will be years before we can so expand the training ranks as to get an increase in the number of specialists.

I would add that the Ministry has calculated that the country needs 7,500 whole-time specialists; yet we have 5200, the majority of whom are part-time, and our progress to the goal is to be at the rate of 30 specialists a year. I believe that that timid attitude, combined with unwisdom in the mode of applying this policy, is not only dangerous in relation to future hospital policy but will be damaging to the hospitals of this country from the early part of next year.

10.14 p.m.

I am very glad that the hon. Member for Luton (Dr. Hill) has raised this subject, because the Minister's circular has come as a very severe shock to all the hospital services in the country. I am sorry that the Minister is not on the Front Bench, but I quite understand why. I noticed that the Joint Under-Secretary of State for Scotland is there, but I do not think the circular applies to Scotland.

I read it very carefully in the supplement to the British Medical Journal this week. I confess that I was shocked at its ruthless treatment of the registrars. They are blandly told that there is no promotion for them although they have served an apprenticeship of first year, second year and third year, much of which has even been financed by the Government. Many of them have taken their diplomas in the specialised branches which they are pursuing, and a great deal of the expense of taking those diplomas has been borne by the Government. These registrars have been encouraged to go on by the undoubted statements of the Minister and of a great many of us on these benches that the service was expanding, that everyone would be entitled to have a specialist's attention, and that we should not have nearly enough consultants and specialists to conduct the new services.

I have scrutinised the memorandum very carefully, and I notice that the third-year registrar is completely abolished. If I understand the memorandum correctly, he does not go on unless the hospital can do with his services for one year, but if the hospital can find a general practitioner who has a little clinical experience the general practitioner has to be taken on instead of the registrar. Many of these young men have started off in early married life. We all understand what has to be borne nowadays by young men who embark upon married life. The purchase of a house and furniture is a heavy liability about their necks for years.

Now they are to be thrown out o their work. It should be remembered that they cannot say that they have had experience in general practise. They have not. They have been hospital men all their days and they have been trained for hospital work, and the general practitioner does not want that type. Indeed, I am told that, having had no experience in G.P., they are not allowed to go into it unless they start again as trainees. Probably it is different in England, but in Scotland the ordinary G.P. has no connection with the Scottish hospitals. What G.Ps. ever go into the great Glasgow infirmaries, the Western, the Victoria and the Royal, with their patients? They have no experience of the inside of those hospitals. Where are we to get the general practitioners with the expert knowledge which the senior registrars have? I notice also that the first-year registrar is abolished.

I agree with the hon. Member for Luton that we must ask where the specialists are to come from. It looks as if the Ministry anticipate a complete closing down within the next five or six years. We have been told that we have 894 consultants, specialists and senior hospital medical officers in Scotland, that last year the openings were 92, that it is anticipated that the openings will only be 30 per annum from now onwards, and that there are long lists of senior registrars waiting for that promotion. If the service is expanding at all, and if the G.P.'s are really taking advantage of the specialist service, most of these senior registrars will be very valuable to the community in the very near future. We are imperilling the service by dismissing them in this arbitrary manner.

I do not like the memorandum, which refers them to the Colonial Service or to the Forces without at the same time telling them what remuneration they may have either in the Forces or in the Colonial Service. We used to feel in Scotland that we were exporting our doctors to England and we were very glad that we were able to do so. We do not feel so pleased at being only able to say to them: "You have to get out of the country altogether." I believe that there has not been such a memorandum sent to the Scottish registrars. If there has, I hope they will set the heather on fire when they receive it. I hope the English ones will do likewise. Indeed, I hope that the Minister will reconsider the whole scheme.

10.21 p.m.

The hon. Lady has just said that she does not know whether the memorandum applies to Scotland. I hope that the Under-Secretary of State will be able to enlighten us. Last week-end I heard that it does apply, if not from January, at least in the course of the year. I would also like to draw attention to the fact that the hon. Member for Luton (Dr. Hill) gave notice last night that he was going to raise this Debate, that the Minister was aware of it and that he did not come.

I say this in the Minister's favour, that last night I had no proof that the notice reached him. It is different tonight, because I gave notice at half-past two today and I know that the notice reached him.

I withdraw what I said. My hon. Friend now says that he did give notice at half-past two today. Neither the Minister nor his Parliamentary Secretary is here to reply to the Debate. The hon. Member for Coatbridge (Mrs. Mann) has pointed out the position. We have senior registrars and registrars who have been training for several years. Now they have no future to look forward to at all, if it were not for one thing alone in the course of the memorandum that was sent out. It is just at the end, where it is suggested, in a rather callous way, that these surgeons and embryo surgeons who have for so long been serving in the Forces in many cases, are now invited to go back into the Forces at a much lower rate of pay than they could have looked forward to if they had been able to get further appointments. They are also being invited to go into the Colonial Service, which is not remunerated on the same scale.

I cannot think that this is fair. It represents a very definite change of plan on the part of the Ministry and seems to show once again how light-heartedly the Minister of Health embarked upon the whole of the health scheme without due and proper planning. It is a great condemnation of the health scheme that we can get to this point and suddenly find that those who we have been training for further appointments are not wanted. For example, I find that in Scotland there are only four jobs likely to be found, on a retirement basis, next year, only four vacancies to fill in the senior consultant staffs. If that is so, it is a great condemnation of the whole of the health service.

10.25 p.m.

I trust that the Joint Under-Secretary of State for Scotland is not going to allow the Debate to close without a word of reply. He was asked a most definite question by the hon. Member for Coatbridge and Airdrie (Mrs. Mann) whether this circular applied to Scotland. It may be that he is not in a position to reply for his right hon. Friend the Minister of Health, but he could certainly reply from the Scottish point of view. We are entitled to have an answer to the question which has been put to him not only from our side of the House but from his own side. We wish to know it this circular applies to Scotland, and if not do the same general conditions which have been published in the circular apply in Scotland as in England?

10.26 p.m.

It would be wrong for this Debate to continue without the whole of the facts being put forward. It would also be wrong for an insufficient reply to be given, because matters that have been raised by the hon. Member for Luton (Dr. Hill) are of some consequence. We have to remember first of all that a lot of the difficulties of the Health Service were created when the hon. Member was in an important position in the British Medical Association before he came to this House. The difficulties have been due to the fact his organisation laid it down most emphatically that there should be no full-time medical service provided by the Bill. They opposed full-time service for specialists, general practitioners and in the hospital service.

I am a little concerned to know who is advising the Minister. I have it at the back of my mind that one of the difficulties we are facing in the hospital service is the almost complete taking over of the advisory services and the hospital services by the specialists themselves. The powers of the hospital management committees are gradually being filched away by the regional hospital boards, arising out of the advice given by these special advisory committees set up by the Minister.

On the question of the registrars and the training of registrars, I find that the questions concerning them are coming from those who were connected with the university training of medical students. The university of the governing body of which I have the honour to be a member, are very concerned about this position, and when it was discussed only last Friday at an executive meeting, it was suggested that they should ask permission for a deputation to wait on the Minister. I told them that they would have to be particularly accurate in the statements they put forward to get the Minister down to the matters in the circular which has been issued.

The suggestions that have been made tonight by hon. Members opposite and by the hon. Member for Coatbridge and Airdrie (Mrs. Mann) should be answered specifically, and I am certain that the Minister has a full and perfect answer to them, which will convince even the hon. Member for Luton, who took such a very great part in opposing in every way many of the general services which were to be given under the Health Scheme.

It is not a question of who told me, for everybody knows it. Everyone knows of the threats which were made by the hon. Gentleman and the organisation with which he was connected. They said that they would not take part in the Health Service of the country unless certain schemes were laid down in their particular interests. I followed the matter very carefully, and I know that a lot of the difficulties now created have arisen from the recommendations and the decisions of the British Medical Association, whose secretary was the hon. Member for Luton.

I believe the matter could be dealt with if the Minister were here. I appreciate the concern there is about it, but I believe there is a perfect answer to it. We ought to wait until the Minister is in a position—

The Question having been proposed at Ten o'Clock and the Debate having continued for half an hour, Mr. DEPUTY-SPEAKER adjourned the House without Question put, pursuant to the Standing Order.

Adjourned at Half-past Ten o'Clock.