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The Shortage Of Doctors

Volume 235: debated on Wednesday 29 November 1961

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3.1 p.m.

rose to draw the attention of Her Majesty's Government to the growing shortage of doctors, its causes, consequences and possible remedies; and to move for Papers. The noble Lord said: My Lords, the picture which I shall try to paint this afternoon reveals an alarming situation. It is painfully easy to overlook the obvious when it comes upon one gradually, and until I started a few months ago to investigate in detail the situation with regard to the shortage of doctors I had no idea that things were so bad. Moreover, it is a situation which is bound to get worse. It takes, perhaps, a year to build a house from the day that the foundations are put in, but it takes seven years to make a doctor and ten years to make a general practitioner, so that our supply of homegrown doctors for the next seven years is already determined. They are, as it were, in the pipeline of medical training and there is nothing we can do to increase the number of doctors who are coming forward for the next seven years.

Your Lordships know that the population of these Islands is increasing, and is increasing fast. The increase is due to our own people living longer and having more children. Between 1939 and

1948 our population rose by 1·3 million. Between 1949 and 1958 it rose by 2·3 million. Dr. Charles Hill, speaking earlier this month, said that for the next twenty years:

"We must plan for another four to five million people".

Are we doing this? Well, so far as doctors are concerned we certainly are not.

Look, for a moment, at the increase in the number of university students. Between 1939 and 1958, our general population rose by 10 per cent. In the arts the number of university students rose by 70 per cent., in the sciences by 183 per cent., but the increase in medical students was only 7 per cent. Population up 10 per cent.; medical students up 7 per cent. Do we need fewer doctors for our people? The answer is, "No, we need many more."

Two months ago, Dr. Godber, the Chief Medical Officer of the Ministry of Health, pointed out that we now have more consultant posts—that is, senior medical specialists in hopsitals—than ever before. Between 1948, when the National Health Service was introduced, and 1960, the number of consultants in England and Wales rose from 4,500 to 7,000-that is, an increase of 55 per cent. He went on to show that this expansion will continue, and he is quite right. Fifty-five per cent. more specialists; 7 per cent. more doctors. It is obvious that we are going short somewhere—and, indeed, we are. I have tried to find out when and where the shortage first started to show itself. It started like a small cloud no bigger than a man's hand in 1953, and it was just where one might expect. Those in charge of what might be called the less attractive hospitals in Northern and Midland industrial areas, away from the great centres of medical teaching, began to find that they were having difficulty in filling their junior medical posts. Since then the situation, year by year, has become steadily worse.

Now comes a somewhat strange episode. In February, 1956, the Government set up a Committee under Sir Henry Willink to estimate the number of doctors likely to be needed for the future and the consequent number of medical students we ought to have. Two years later, they reported. At that time, I was specially interested in general practice and I knew that we needed many more general practitioners if they were to do their work properly. I expected and hoped for an increase in the medical school intake of 10 per cent. I remember my amazement when, instead, the recommendation was a cut of 10 per cent. The Government accepted that Report and the University Grants Committee were asked to have regard to it. Thank goodness it has never been fully implemented by the medical schools! Nevertheless, between 1956 and 1960, the number of medical students starting their courses has dropped by 200 a year—that is, in effect, the Willink 10 per cent. I say that the Willink cut has not been fully implemented because most of this drop occurred before the Willink Committee had reported. Had their cut been made, the position would have been even worse.

Where did the Willink Committee go wrong? I need not trouble your Lordships with the details because, on September 3 last year, the full story was published in the Lancet by Professor Francois Lafitte and Professor J. R. Squire. Lest your Lordships doubt the credentials of these gentlemen, Professor Lafitte was for many years on the staff of The Times newspaper in charge of social affairs before he became professor of Social Policy and Administration at Birmingham, while Professor Squire has recently been chosen by the Lord President of the Council to be head of the new research hospital which the Medical Research Council is establishing.

They showed that the Willink Committee went wrong both ways. The Committee underestimated the speed of growth of the population, misled, I am sorry to say, by the Government Actuary. They underestimated the number of doctors needed, and indeed now employed, in research, in industry and in teaching. They underestimated the need for doctors in the Army, where there is now a critical situation, and they certainly underestimated the needs of the population for general practitioners. Finally, they overestimated the number of general practitioners who would stay on at work over 65, or, indeed, over 70, when once the National Health Service retirement pensions became payable.

A year ago, Professor Lafitte and Professor Squire told us that, as a matter of urgency, we ought to step up the number of medical students from 12,000 to 15,000 or more, for, they said, unless there is immediate action, something like a crisis in the supply of doctors may emerge around 1965, by which time it would be much harder to deal with it. As it turned out, even they were over-optimistic, for the crisis is here now.

I want to say a further word about the Willink Committee. We all make mistakes, and the only point in holding a post-mortem is to make sure that we do not make the same mistake again. I have a great friend who served on that Committee—namely, my noble friend Lord Cohen of Birkenhead. I am pleased to see he is here to-day and to know that he is going to speak in this debate. Just how much the nation, the sick people of this country and the National Health Service owe to my noble friend we shall never know, but I am sure it is almost more than to any other single person. I feel sure your Lordships would wish me to congratulate him on becoming President of the General Medical Council this week. It is an appointment that will give the whole medical profession great pleasure. We hold him in great esteem and trust, and I cannot imagine anybody better for the job. I hope he will be able to tell us that the Committee were wrong, and that he will be able to give us from his unrivalled experience advice as to what we must now do to put things right.

To assess the situation, I have made inquiries from medical colleagues all over the country, many of whom hold official positions and many of whom do not. I shall not reveal the names of the hospitals or the areas unless they have been published, but your Lordships may take it that the picture I shall present is as honest, fair and accurate as I can make it. Fortunately, four weeks ago there was published in the British Medical Journal an account of the situation in the area covered by the Sheffield Regional Hospital Board, and from this I can quote directly. For the benefit of your Lordships who are not particularly knowledgeable of the hospital situation, this represents just under one-twelfth of England centred on the Sheffield area. The situation there is fairsly typical of that throughout the North and West of

England and Wales—at least, half the country. In some parts of the country it is a little better, and in some parts a little worse; but it is broadly the same.

Between July, 1959, and December, 1960, 705 registrar posts were advertised in the Sheffield region: that is for middle-level hospital doctors, who take a great deal of the responsibility. Of these advertisements, 134 attracted no applicants at all, or the applicants withdrew their applications before interview, or such applicants as there were, were quite unsuitable. A further 132 advertisements attracted no applications from English, Scottish, Welsh or Irish doctors, and that includes Northern Ireland and Eire. For the whole 705 posts 188 appointments only were made; of those appointed 50 were "home-grown" doctors and 87 were Indians. Remember, my Lords, that this is typical of half of England and Wales: 705 posts and 188 appointments. How can anyone say that there is no shortage of doctors? With regard to the more junior posts—those of house physicians, house surgeons, casualty officers and resident anesthetists—the situation is just as bad, if not worse, though there has been in some areas a slight improvement, which unfortunately can be only temporary, occurring as a result of the lessening demands from National Service.

What does this mean in terms of individual hospitals, and in human terms for the patient and the treatment he gets? Here is a situation in a famous provincial non-teaching hospital: house surgeon—two posts; one at present vacant. It is usual for both to be vacant for six to seven weeks before a suitable appointment is made. House physicians—two posts; both fall vacant in two weeks' time; no applicants yet received. Senior hospital officer, pathology: vacant for the next six months. Then, another famous non-teaching hospital: anesthetic registrars—two posts advertised ten times in the past year; either there were no applicants, or candidates withdrew at the last moment because they had secured other jobs. A mental hospital: 3 out of 5 posts filled at the present time; remaining two unfilled for a year. Then, another mental hospital: hospital management committee forced to employ elderly retired doctors, one for as long as eight years. Of the four present junior medical officers two are Greek and another is an elderly Pole. In mental illness it is vitally important, and more important perhaps than in any other kind of condition, that the doctor should be able to speak the language of the patient. Yet it is very rare indeed that you will find the staff of a mental hospital now is an English or a British staff. Then, another mental hospital: of 8 posts, 3 are vacant at the present time. The quality of the applicants is "invariably poor".

Another colleague writes:

"We have been short of junior staff for eight years. The position has got steadily worse. Three years ago the shortage started to show itself in the senior grades—especially in anesthetics, radiology, ophthalmology and geriatrics. But our greatest difficulty is in casualty officers."

Remember, my Lords, that it is not in the great teaching hospitals that the shortage is showing itself. They have their own students, eager for experience, though even here it has started to appear. Recently two of the great teaching hospitals had difficulty in filling senior registrar posts in general medicine, one of the finest stepping-off posts that our profession has to offer. It is in the peripheral hospitals outside the large teaching centres where the great bulk of the people are treated that the situation is critical. I cannot recommend your Lordships to go into such hospitals as a casualty, for there is in many cases no casualty officer. A house surgeon will have to leave the theatre when he can to treat you, and his experience will be far less than that of your own general practitioner. When he comes he will probably not be a British graduate and he could well have difficulty in understanding what you say. This is at a time when speed and efficiency may be literally life saving.

The whole of our hospital service would have collapsed had it not been for the enormous influx of junior doctors from India and Pakistan. There are now working in our hospitals between 3.000 and 4,000 such doctors trained in Indian and Pakistani universities and medical schools and coming over here to get experience. There has been some influx, too, from Australia; hut, alas!

there are signs that this is drying up. Another colleague writes:

"When India and Pakistan have their own post-graduate medical training schemes it will be quite impossible to staff our peripheral hospitals."

That is in an area near London, where things are not too bad. The gap which these doctors are filling is shown by the Sheffield figures. Of 459 junior posts, mostly house officers, not registrars, 38 are vacant at the moment; 178 are filled with "home-grown" doctors; 243 are filled with doctors of overseas origin.

Now I want to choose my words very carefully. These doctors from medical schools of India and Pakistan, Egypt, Israel and Africa, Malta and Portugal, Turkey and China, Greece and Ceylon are usually less experienced than our graduates at the same stage, for their teaching is rather different. They are corning here to learn, and they are going 'to the worst places to do it, where there is less supervision. They are acting as pairs of hands, usually with very incomplete and inadequate supervision, because the consultants in these hospitals almost always have to cover several hospitals. All things considered, most of them do a very good job, but I am afraid that, through no fault of these doctors, there is a general lowering of standards of hospital care. I have asked colleagues whose opinion I trust, and this is the consensus of their views. First of all, it is very hard to assess the qualities of these doctors at interview. Practical ability does not always go along with academic qualification. Secondly, many, if not most, give valuable and conscientious service, but they are often expected to do things in which they are inexperienced. Thirdly, they often have an exceedingly legalistic attitude and are obsessed with the fear of litigation; consequently, they are often reluctant to accept responsibility, especially in casualty work and anæsthetics. I may say that the shortage of casualty officers is the most serious of all. Fourthly, there are difficulties over language and customs. They do not always understand patients or general 'practitioners on the telephone, and that is very important indeed. Nor do they always understand the relationship between the hospital and the general practitioner. But when all is said and done, we are in their debt. Without them, our hospitals would collapse, and we should be proud that they want to come to us and learn. But we are not treating them fairly.

A brief word only about the position in the senior posts and in general practice. These are the better permanent jobs in medicine, so they are the more sought after. But already the shortage is starting to show itself here. The number of applicants for each vacancy is going steadily down. Three years ago, there were thirty to fifty applicants for a good general practice in the South or Southern part of England. To-day there are often only six to eight. In a bad area, a less attractive area, where there used to be six to eight, there are now one or two, or even none. In parts of North Wales general practitioners are having to be allowed to exceed their maximum permitted list of 3,500 patients, which is a ridiculously high number anyway, simply because the doctors are not there. With regard to consultants, it is the same story—applications halved. In the less popular specialities—psychiatry, radiology, ear, nose and throat surgery, anesthetics and sometimes pathology—there are very few applicants, so that posts are having to be re-advertised.

This will get worse as the population grows in the next seven years, with no increase in the number of doctors coming forward. Moreover, there is a peak of retirements among specialists due in the next five years. These are doctors who entered the specialities and started to train as specialists just at the end of the 1914–18 war. There is a peak coming which one can see perfectly well in the curves in this excellent Report, the Medical Staffing Structure in the Hospital Service, by the Platt Committee. That is coming in the next five years and the people are just not there to fill them. So you see, my Lords, it is a pretty ghastly, awful picture.

The Ministry is trying two palliatives, both of which I fear are useless. First, they are offering an extra £100 a year to supplement the pay of posts in "black area" hospitals. Some hospitals, in dire need, have refused this extra £100, because they fear it will mark them out as of lower status. All this can do at the best is to alter the distribution; it will not increase by one the number of doctors available. Secondly, they look to the general practitioners to help them out in the hospitals. But the general practitioners are already working as hard as, or harder than, most hospital doctors. General practice has got harder all the time for a very simple reason: that patients everywhere are demanding what might be called middle-class standards of treatment, which is the kind of standard that used to be given to middle-class patients before the war, whereas the general run of the public were pushed through quickly. They are all asking for middle-class standards of treatment, and it means there is no time available for the general practitioners to do any more work. We cannot solve our hospital problem and we cannot solve our general practice problem without more doctors. If we try to do this it will simply mean that we transfer the shortage from the hospitals to general practice. But you cannot do it. General practice, which already outside the South of England is strained to breaking point, must go on.

I will tell your Lordships the remedies, but I must warn that the matter has gone so far that there is no short-term cure. First, the Willink Report must be officially repudiated. The Government must say, once and for all, that the policy of restricting intake into the medical schools to the present ridiculous figure is dead and finished. Secondly, we cannot much enlarge our existing medical schools, for that would gravely jeopardise our standards of teaching—and in Great Britain we are very proud of our standards of medical teaching, which are based on the small clinical class. If we "whack up" the number of students, we shall destroy those standards of teaching. Indeed, it is often physically impossible, for most of the buildings are already full to capacity. So we must have at least three, and preferably six, new medical schools at once—and bear in mind that that will only solve the problem seven years hence. We have the seven lean years to go through anyway.

I think it is correct to say that no new medical school has been opened in this country for over sixty years. None of our new universities has a medical school. I suggest, as a crash programme, that we open first year medical courses next October at, say, the following places: Southampton, the Central Middlesex Hospital in North London, and Nottingham. This would give us time to build up the teaching for second and subsequent years. All that is needed is hutted laboratories and the first-year teachers; and, given the proper sense of urgency, both can be produced in time. Once one has the first year going, one has one and three-quarter years to get the second year going, and so on. In the great modern conurbations in Birmingham and Manchester, there is room for second medical schools taking the local university degrees. In London, we have twelve medical schools, with the students working for London University degrees. Surely Birmingham and Manchester can each support two. I know that there are regional board hospitals with first-rate consultant staffs in both great cities who could soon rival those already established.

Thirdly, we must have at the Ministry of Health a proper statistical department, with trained statisticians in charge, to 'review continuously and intelligently the state of the Health Service of this country. If we had had such a department seven years ago, this mess would never have occurred—and, my Lords, it must never be allowed to occur again. Fourthly, we must, again as a crash operation, do somehing to fit our medical colleagues coming to us from the less developed countries for the work they have to do here. For the next seven years it is inevitable that we shall have to rely upon overseas doctors for something like half our junior hospital staff. At present, many of them are not fit for the jobs we are asking them to do and expecting them to do.

I think we should at once establish four short-course intensive training centres, which might well be in some of the excellent tuberculosis sanatoria which we are no longer using. To these centres, every doctor coming to us from overseas from an underdeveloped country should go for a period of six to eight weeks. Here they should be taught something about the work they are going to do, the service in which they are going to work, the patients they are going to care for and the role they will have to play, especially in their relations with other doctors inside and outside the hospital. The British Council could help them to brush up their English. We should teach them ordinary emergency casualty medicine and surgery, as we practise it here; how to fit up a drip or a blood transfusion; how to suture a tendon and how to do a small skin graft. We could, in these centres, help to place them properly according to their capacity and our needs. For the great majority we can find mutually advantageous jobs, but a few will be unable to make the grade and they should go back to their own countries. I know this is a new and unconventional approach, but we are facing a new and desperate situation.

My Lords, I have given you the outline only of this tragic picture. My colleagues will fill in many of the details, and I should like to thank them all in advance for giving time and effort to help to make the story plain. One we are particularly pleased to see here is my noble friend Lord Evans. We only wish he could come to us more often, but we are very pleased he is here today. What is the lesson of it all? In 1946 Parliament passed the National Health Service Act. In 1948 the Service was created. My Lords, it is no good willing the ends unless you also will the means. Because of our folly in not increasing the number of medical students at least in step with the population we should have had this crisis whether we had a National Health Service or not. But the National Health Service makes it a statutory duty of the Minister of Health and the Government to see that the health needs of all of us are properly and fully met. A succession of Ministers have failed in this simple duty, and now, for the next seven years, Britain cannot have the doctors it needs to look after us properly. My Lords, we demand action now to mitigate the folly of the past and the leanness of the seven years which lie ahead. I beg to move for papers.

3.32 p.m.

My Lords, I welcome, as think and hope most Members of this House will welcome, the putting of this Motion by the noble Lord, Lord Taylor. I have not been able to study with the excellent care and industry which he has shown in moving this Motion all the documents about our Health Service and about the condition of our doctors, but it so happened that only on Saturday of last week and Sunday of this week I was asked to attend a two-day conference of experts on health and on the Health Service from many parts of this country. Let me say that, while the experts disagreed on many points—I think we all know that it is the habit of experts to disagree with one another—there was general agreement on essential points.

The first was that the provision for doctoring people in Britain was neither as large nor as good as it should be. That is, these experts were saying in a different way exactly what the noble Lord, Lord Taylor, has said. They went on to say that this deficiency was not due to to our having a National Health Service. There were one or two experts there who seemed not to want a National Health Service, but I think I may say they were in a minority—I will not say an insignificant minority, because no expert is insignificant or should be allowed to be called so—but the majority thought it was not due to our having a National Health Service. With one or two exceptions all of us accepted such a Service, enabling people to be doctored even if they could not pay the doctor's fees. Obviously nothing will come out of Lord Taylor's Motion or out of such a conference as I attended to put an end to the Service or to alter it materially.

The third point was that this deficiency of health treatment was due to, and was increasing steadily because of, the declining number of doctors, though not through that alone. I will not go into minor details, but it is still worth mentioning. The conditions of doctors' service under the scheme as it now stands are sometimes such as to cause doctors to retire. Some of your Lordships may have seen in the newspapers of last Sunday a statement of a doctor who was giving up the Health Service because he had far too much to do. There is a friend of mine, a doctor, who found he could never do any doctoring on a Monday because he spent every Monday filling up the forms he had to fill up in order to get paid for the work he was doing. That arises out of the excess number of patients that doctors may have, and sometimes because they need the money due.

My Lords, will the noble Lord allow me to interrupt? I am quite sure he would be the last one to allow a statement to go out Ito this country of that kind, for which there is very little foundation; and I assure him, from my knowledge—and I have just been able to have one word with my noble friend Lord Taylor, to whom the doctor's field is very wide—that what he has said is completely without foundation. Never have I known any doctor anywhere who has spent Monday filling up forms before he has been able to see patients. It is a gross exaggeration from a very prejudiced person.

My Lords, I hope that the noble Lady would not mind inquiring as to the validity of this kind of statement and whether the official work which falls upon doctors can in any way be lightened, so that they can keep themselves to their essential business of helping people against illness. I do not like saying such a thing as "entirely unfounded" without its being proved to be so by inquiry; and there will be no harm in proving it to be so and there would be every encouragement to the noble Lady.

This problem of securing sufficient and good doctoring lies at the heart of our Health Service problems. Every citizen has a duty to others to keep as well as he can, because even if he does not infect any of his fellow citizens he becomes a burden on some or other of them, and the State has accepted the duty of abolishing unnecessary illness which destroys welfare. Our Health Service is a recognition of this duty by the State, and I think it is rather remarkable that the scope of some of the questions of practical method, and even the number of people to be dealt with by one doctor, seem never to have been the subject of serious study by an expert body, either before the Health Service—which, like all reasonable people, I welcome—was established in 1948, or since 1948.

As I go about the country I find myself continually being hailed as the inventor of the National Health Service. Let me emphatically deny any such claim on my part; I am not the inventor. The Health Service is not part of the Beveridge Report, as it is called, but an assumption of the Report. I was never asked to report upon health any more than I was asked to report upon children or on full employment. But when I had written that Report it seemed to me so clear that these three things, full employment, health service and children's allowances, were necessary that I put them in as assumptions.

I hoped that the Government in 1942-they had plenty of time for it—would appoint a new committee (without myself on it) on the working in detail of every practical question arising through this great change to a National Health Service. They did not do so. They had two years to do it; they did not do it. Finally, when the Labour Party came to power Mr. Aneurin Bevan introduced the Health Service Scheme, and it is enormously to his credit that it should be as excellent as it is, but I think it might have been even better. I think it would at any rate be worth finding out whether it could be made in any way better. The conclusion that all my experts came to was that it was worth having a detailed formal inquiry about the practical working of the Health Service, without delaying all the immediate action which the noble Lord, Lord Taylor, has mentioned. I am supporting all the immediate action. The detailed inquiry into the practical workings of the Health Service would show whether in any way it could be made to give more health for the same work by the doctor, whether in any way the health treatment could be improved.

Let me also say that in this country we have always believed, not in the State's doing everything but in working for welfare by co-operation between the State and the citizen; we have believed in voluntary provisions for old age; we have believed in voluntary provision for welfare, and all the rest of it. That is a tradition very deep in the people of this country. I should like that also examined to see how far it is a good thing and how far it can be carried. That was the main conclusion to which the conference of experts last Sunday agreed: that there should be an inquiry, not simply as to how much doctors and surgeons and dentists should be paid and from what sources, but into how the Health Service of the State should be organised in practice and how it should be related to voluntary provision for health made by the citizens themselves.

Many people make the suggestion that if they are not coming into the Health Service they ought to have certain payments remitted. Whether that is a good argument or not, I do not know. I only think it is an argument worth inquiring into so that we may keep welfare in this country, with all the necessary action that the State alone can take, taken by it, with room left for action by the individual for himself.

If the Motion now before the House and its discussion here lead to such an inquiry into the Health Service as we in this House achieved with a Motion concerning the problem of old age, which produced a good deal of influence on the action of the Government and others, then this Motion will undoubtedly increase the reputation of this House. I think it is worth increasing the reputation of this House equally as a helper of good government and welfare, with freedom, in regard to the Health Service as in regard to old age. Let me repeat that I hope that all the practical measures which the noble Lord, Lord Taylor, has suggested, will be taken. I hope he will allow me to enlarge his proposal of a statistical department in the Ministry of Health into a general inquiry as to the whole working in practical affairs of the Health Service. I am a statistician myself and I will not misrepresent them, but there are some things which are better dealt with by inquirers other than statisticians. I hope the noble Lord will allow me to expand his proposal into my proposal.

My Lords, I did not want to interrupt the noble Lord, Lord Beveridge, at the beginning of his speech, but in view of what he said at the beginning I must say it is inconceivable that any doctor should have to spend all Monday filling in forms in order to get his pay.