ORDUITHE AN LAE. - ORDERS OF THE DAY. MEDICAL PRACTITIONERS BILL, 1927—SECOND STAGE.

In moving the Second Reading of this Bill, I would like to refer briefly to what I said about three years ago when I introduced a Bill to extend the rights which the General Medical Council at that time were believed to have with regard to this country to make arrangements and carry on those arrangements to a further date until such time as a new scheme for this country could be thought out. On the Second Reading of that temporary Bill I indicated my own point of view that a change would have to take place and some time later on, after this matter had been subjected to a certain amount of discussion and consideration, a statement was made indicating the point of view which the Executive Council had with regard to the control of medical practitioners qualified and resident in this country. That indication of policy raised a certain controversy to which I need not refer now to any great extent, but at that time it was stated that the policy of the Executive Council was to secure that nationals of this country who obtained their medical qualifications in this country should, during their professional life in this country, be subject to the control of a body composed entirely of Irish nationals, and that the conditions for their obtaining qualifying diplomas and all the conditions under which they studied should be entirely in the hands of that body composed entirely of Irish nationals. This Bill does, in fact, carry out that policy.

On the domestic side—there is an international side which is referred to in the schedules—it is made quite clear that under this Bill there is to be established in the Free State a separate medical register under a Free State Medical Council, and that consequently nobody will be allowed to practise medicine in the Saorstát unless registered in the Free State register established under this Bill. It is further provided that no person can be struck off the Free State register except by the Medical Council of Saorstát Eireann, and as far as qualifications and degrees are concerned, it is established that the curricula of studies, leading to medical diplomas, will be supervised by a Council of Irish nationals. On the other side, it is further laid down, by agreement, that the General Medical Council will continue to register on the General Register whatever persons have been trained and qualified in the Free State, and for the purpose of the keeping of that register will continue to exercise supervision over the curricula bodies which give diplomas entitling to registration on the General Register.

The representation on the General Council is continued as heretofore with one exception. Previously there was a representative appointed by the Crown for Ireland. That situation ended on the setting up of the Free State, and the legal position was under the Adaptation of Enactments Act in England that the right to nominate by the Crown previously for Ireland became the right to nominate for Northern Ireland. That is stereotyped in the agreement, and the representative for the future will be the representative for Northern Ireland, appointed by the Governor-General of Northern Ireland. The reciprocal arrangement is that we here continue to admit persons who are registered in the General Register to registration on the Free State Register on the payment of whatever fees are demanded from our own students.

I need not go through the sections of the Bill. The Bill proposes to set up here a separate council with complete control of the medical curriculum of the bodies giving qualifying diplomas. That Council will have the completest control in regard to the admission to the register of Irish nationals, and to the striking off from that register for felony, misdemeanour, crime, or what is called unprofessional conduct. There is one section as far as the domestic side is concerned, to which attention has already been drawn, and there is another section to which I would like to direct attention myself.

Under Section 28 of this Bill an arrangement is set out to put an end to what has been described as an objectionable feature of the Medical Acts as they have up to this existed. There is laid down here special provision giving the right of appeal in the case of people who are struck off for what is described as infamous conduct in the professional sense. That is a complete change, and a complete break away from the Medical Acts so far as they operated here previously. This is regarded as a very necessary provision.

The other point to which attention has been drawn is the composition of the Free State Council, which is referred to in Section 3. That Council is to be abody of nine, one of whom is to be nominated by the Executive Council, one is to be the joint nomination of the Colleges of Surgeons and Physicians; two are to be elected by the registered medical practitioners resident in the Free State, and the remainder are nominees respectively of the three Colleges of the National University, one representative from Trinity College, Dublin, and one representative from the Apothecaries Hall.

Attention has been called to this section specially because it is alleged to contain an injustice. The injustice is said to be that the Royal Colleges of Surgeons and Physicians are only given a joint nomination, whereas all the other bodies mentioned are given a representative each. The position with regard to this is easily explained. All the bodies who are mentioned in paragraph (b), sub-section (3) of Section 3 do, in fact, give, each and every one of them, a diploma which qualifies a person to practise medicine in this country. University College, Dublin, gives a qualifying diploma in medicine and surgery, which is essential to practising medicine in this country. The Apothecaries Hall gives a diploma which entitles a person to practise medicine and surgery in the country. Trinity College, Dublin, does the same, and the other two colleges of the National University do the same. The College of Surgeons does not give any diploma which entitles the recipient of it to practise medicine in the country. The College of Physicians does not give a diploma which entitles the recipient to practise medicine in the country. The diploma must be a conjoint diploma given after an examination held by the joint bodies. Nobody can be licensed to practise medicine in this country having received merely a diploma from the College of Surgeons. Neither can a person practise medicine in this country having received a diploma merely from the College of Physicians. There has to be a conjoint examination, and there has to be a qualifying diploma given by the joint bodies—the College of Surgeons and the College of Physicians. So that there is definitely given, under this proposal, a nomination to each body which can give a qualifying diploma. It happens in the case of the College of Surgeons and the College of Physicians that these two bodies must join before a diploma which entitles to practise can be given. That is the foundation for the proposal here.

That is one way of looking at the position of this Council. There are, possibly, other ways by which the Council might be built up. The one that was taken was the institutions which held examinations, the result of which entitled to practise medicine and surgery in the country. There may be other ways of looking at it. One way has been rather suggested already, and that is, that one should take the institutions and see the number of students that were qualified by those bodies. Unfortunately those who have adopted that line of argument have failed to make a distinction between the students who enter for medicine and the students who ultimately emerge as qualified men. To take the entrants to medicine in any year in any of those colleges and to found any argument upon that makes no allowance for the large number who disappear at various stages of the medical course. If that, or anything like that, is to be the foundation upon which this Council is to be raised, it should be the graduates who have qualified in medicine in those institutions.

I have here a series of figures which shows the graduates who qualified in medicine in the five years 1921 to 1925. I have not the figures, as yet, for 1926, but I can get them quite soon. They may be interesting to use for purposes of debate afterwards. In the University of Dublin in the five years 1921-1925, there were qualified respectively, 51, 72, 98, 75 and 95, or a total of 391. In the Royal Colleges of Physicians and Surgeons—the conjoint examination—in these same five years, the graduates who qualified numbered 65, 53, 64, 55, 58, or a total of 295. In the three Colleges of the National University—I have not those divided, but I can get them segregated later—in the same five years there were qualified: 149, 163, 132, 185, and 190, or a total of 819. Those qualified from the Apothecaries Hall in the same period were 6, 6, 2, 6, and 2, or a total of 22. So that as far as graduates qualified in those places in the five-year period are concerned, the totals were:—From Trinity College, Dublin, 391; from the National University of Ireland, 819; from the joint Colleges of Physicians and Surgeons, 295, and from the Apothecaries Hall, 22. Leaving the Apothecaries Hall out of consideration for a moment, if one was to take it as between Trinity College, Dublin, the National University of Ireland, as a group, and the Colleges of Surgeons and Physicians together, the comparison is very nearly what the allocation of nomination would be—very nearly what is, in fact, set out in the Bill: one to Trinity College, Dublin; one to the joint Colleges of Physicians and Surgeons; something more than two, but less than three, on the proportion, to the National University.

There may be other ways, perhaps, of forming this Council, but the procedure that was adopted was, more or less, what was found to hand: that the qualifying institutions should be allowed to nominate, but when one came to look at those qualifying institutions, one segregated those which of themselves can give a diploma which entitled to practise. When that was done the College of Surgeons had to be joined to the College of Physicians, as only by that junction can a qualifying diploma entitling to practise be given. There should be in addition to those a member nominated by the Executive Council and some number of members —two it is stated here—to be elected by the practitioners of the country. It is obvious that the qualifying bodies should be given representation as separate entities, and that the whole representation should not be given to the vote of those practising in the country, because a great part of the duty of the Council will be to supervise the educational system, the courses of training, that the medical student has to get, and it is necessary that those who are in control of the authorities that do give diplomas should have a fairly substantial representation on that body.

But there is a further point that has to be borne in mind, if one is to go on numbers—that this Council is to take charge of the professional lives of those doctors who elect to remain in this country for the period of professional practice, and that a mere allocation of seats on the Council determined by means of an enumeration of the students who qualitfy would not be fair. This Council is to be the body dealing with those who elect to remain at home, and there would have to be some appreciation of the percentage of students who qualify in any of the qualifying institutions mentioned, and who, in fact, do remain at home for their professional lives. If that percentage be taken, I think it would be roughly accurate to say that a great deal more than fifty per cent. of the students of the National University of Ireland do intend, and do, in fact, make their practice at home; that much more than fifty per cent. of the students who qualify in Trinity College, Dublin, do, in fact, go abroad, and that about fifty per cent. of those who qualify from the Colleges of Surgeons and Physicians do go abroad. So that on the percentage of those who, in fact, are being trained to look after the nationals of this country, those figures would have to be subjected to still further division. An argument may be used afterwards founded upon those figures and I leave the matter for the time being.

Has the Minister got the figures available for the entrants for 1921, 1922, 1923?

No, but I could get them.

I think they would be important as the Minister has given the leaving figures.

I think the Branch Council could quite easily supply the figures that the Deputy requires, and I can make an effort to get them. In anticipation of what may be said, I just urge that no proper consideration can be based upon the entrance figures—it should be rather upon those who qualify.

There is just this consideration: that if you take the number of entrants in a year you cannot expect the number leaving in a year five years later to be greater, and the total number of entrants for the three years that we know of would give a very different set of figures from the number given for those qualifying.

On the international side, while, as I say, the Executive Council had the policy that students of this country who attended a training course in the country, who got a qualifying diploma here, and who intended to practise here, should be entirely under the supervision of a Council composed completely of Irish nationals, there had to be some attention paid to the other side—that in fact a very large number of those who get qualifying diplomas in this country leave and live their professional lives outside the country. An attempt had to be made to discover if it was possible to get an arrangement which would safeguard the nationals who intended to practise here, and, at the same time, would continue the rights which qualified men in the country up to this possess of going abroad, and of getting their entrance to the General Medical Register, and in that way secure qualifications which entitle them to positions in Great Britain, Northern Ireland and the Dominions. The agreement which is the First Schedule to the Bill is the result of the attempts that have been made. The net result of this First Schedule is that it entitles those who do get qualifying diplomas in this country to have their names entered upon the General Register, and to get whatever rights which entrance upon that register brings with it; while at the same time there is no over-riding power given to entrance on the General Register so as to, in fact, negative anything done by the Free State Council with regard to the expulsion of members from the Free State Register.

The point at which it seemed there was likely to be conflict was in this matter of expulsion. A case might easily be imagined of a doctor being accused of what is described as infamous conduct in the professional sense, and on being subject to an investigation and trial there might be a decision against him by the Irish Council, and in his favour by the General Council. One had to ensure that in such a case the doctor expelled from the Irish Register by the Irish Council could not assert his rights on the General Register, and come back again to this country, despite the fact that the home Council had decided that his conduct merited expulsion. That can no longer happen. A doctor who has qualifications entitling him to registration on both registers, who commits an offence of the sort described, who is adjudged guilty by the Free State Council, and struck off the register, and is, at the same time, adjudged not guilty by the General Council, and allowed to remain on the General Register, cannot assert his General Register right so as to ensure his registration again in this country after previous expulsion.

That was the main point that had to be met in the agreement and that point has been very definitely asserted and has been met in Section 4, subsections (c) and (d) of the First Schedule. Sub-section (3) of the agreement indicates that for the purpose of keeping the General Register, and only for that purpose, the Medical Acts continue as heretofore, save where amended by this Schedule, and that the powers of the General Medical Council and of the Branch Council shall continue as heretofore, for the purpose only of the keeping of the General Register. There were two subsidiary points which had to be attended to. They are set out in subsections (5) and (6). Sub-section (5) was to meet the case, which at one time seemed likely, of a body which is now entitled to give a diploma qualifying for entrance on the General Register ceasing to be merely a college and becoming a separate university. That seemed likely to happen at one time in the case of Cork College, that it might break away and become Cork University instead. In that case it looked as if a new agreement would have to be entered into in regard to the right of that new university to hold an examination leading to a diploma, but which right might have disappeared under the new conditions, and that point is attended to in sub-section (5) of the Schedule. Sub-section (6) deals more with machinery than anything else. It sets out to avoid the inconvenience and embarrassment of having a doctor here who committed an offence, say of the unprofessional conduct type, who had his name on both registers being subjected to investigation by two bodies for the same offence, and the arrangement in this sub-section provides machinery to avoid the embarrassment that might otherwise occur.

The net effect, then, is what I have described, that what the Executive Council laid down in 1924 as the best policy has been achieved, that the control of those who carry through their course of education and get their diplomas for qualification purposes in this country, during their professional lives here are subject only to the control of the Irish body, and in addition there has been achieved that those students who wish to have their old rights, if and when they went abroad, are now entitled to the same rights as they previously held.

It has been said of this Bill that it leaves the position very much as before. That phrase can only be used by one who has entirely misread the Bill. The position is not as heretofore. The jurisdiction of the General Medical Council with regard to removal from the Register of any Irish practitioner is very definitely limited. The jurisdiction of the General Medical Council with regard to the supervision of the courses leading to a diploma entitling to practise in this country disappears. The jurisdiction of the General Medical Council over those students who, qualifying here, elect to practise in England, still remains, as it is only right that it should remain, and the right of the General Medical Council, through the Branch Council, or in any other way which seems suitable, to supervise the courses entitling to registration on the General Register, still remains, as it is only right that it should remain. But there have been the very big changes that I have spoken of, that in the matter of supervising the courses leading to examination, and in the matter of regulating the examinations which come at the end of these courses of study, in the matter of controlling the professional lives of those who continue to practise in the country, and, finally putting an end to the professional life of any man practising in this country, the General Medical Council has in fact lost whatever power it once had in this country. Whatever of their powers are continued now relate entirely to the purpose of the keeping of the General Register.

It may be said, and it has been said, that inasmuch as the students who are exported are the majority at the moment, obviously the Free State Council will have to pay more attention to the wishes of the General Medical Council than to what they think beneficial to the students of this country, because they will have to cater for a greater number of students, and these in fact are the exported ones as things are. That may be the case at the moment. It is not necessarily the case. It is not incumbent on that Council to pay attention to the wishes of the General Medical Council with regard to courses of studies. I understand that there has been before the General Medical Council a plea put up by the Irish representatives for many years that a certain portion of the examination should be increased in difficulty. If that point of view still holds with the Irish representatives, then they can ensure, as far as Irish qualified men are concerned, that a stiffened examination test will be held. If, on the other hand, which I hope would be a most unlikely event, they decided that the courses here were too difficult and that there should be some relaxation as far as practice in this country is concerned the Council may do what it pleases with regard to the qualifying diploma.

It is meant that there will be a general relation between the General Council and the Free State Council, inasmuch as so many of our students go abroad at the moment, and if that state of things continues that will always have to exist. But it is not necessary that it should continue. In fact to a great many people it seems undesirable and a great waste that it should, and if the Council sees that there is a tendency for the number of students to diminish, for them to get into other occupations, if other professions become more important in relation to the country's needs, then the Council has power to do all that is necessary to aid a change to other professions. While the present state of things continues there is bound to be a very definite relation between the two Councils. It may be said that there is not the completest and the most absolute form of reciprocity as between the two countries on this. There are, possibly, two small points on which reciprocity could not be said to have been achieved. But neither can a demand for that be reasonably put up unless one can accept the corollary to that demand, which would necessarily be that representation of Irish qualifying bodies on the General Council should cease.

For the future we will have a separate Free State Council controlling the professional lives from beginning to end of medical men practising in this country, and we will have in addition a certain number of Irish representatives attending the meetings of the General Medical Council, supervising not merely Irish education, but the education of those Irishmen who left the country to practise abroad, and also helping to supervise the educational courses and examinations of those students who pass examinations in England, Scotland, or Wales. For many years to come there undoubtedly will be a very close liaison as between those two bodies. In fact, it would seem desirable that there should be the closest possible liaison between those bodies. But if the Council here, if the practitioners, if the qualifying bodies think that that particular liaison should be broken, it will be in their power to cut clean away. The Bill is midway between simply continuing the old state of affairs, in which the establishment of the Free State would be neglected for the purpose of medical education and the old powers of the General Medical Council with regard to education and examinations would still continue as before, and particularly the power with regard to the control of medicals in their career afterwards, and it stands midway between that situation and what was put up at one time as the alternative, that there should be a complete break with the old system, and that without paying any attention or giving any heed to the fact that a very big number of medicals do, in fact, leave this country to practise elsewhere, that we should have proceeded to set up a Council here simply having regard to Irish medicals who are going to qualify here and live their professional lives here. This, I hold, has achieved the best points of both. It gives the Free State Council the completest control that one could imagine over the students qualifying and living here in their professional capacity, and at the same time it has made arrangements which will allow those students who want, or are driven to go abroad in their professional capacity, to get all the rights that were previously secured to them under the control of the General Medical Council.

Home Rule within the Empire!

Debate adjourned; to be resumed later in the day.