Dáil Éireann debate -
Tuesday, 18 Oct 1977

Vol. 300 No. 5

Medical Practitioners Bill, 1977: Second Stage.

Minister for Health (Mr. Haughey)

I move: "That the Bill be now read a Second Time."

The legislation regulating the registration and control of persons practicing the profession of medicine in this country and the maintenance of standards of medical education and training is contained in the Medical Practitioners Act, 1927. Some changes were made in amending Acts passed in 1951, 1955 and 1961 but the basic provisions are still those which are to be found in the 1927 Act. This legislation has stood the test of time to quite a remarkable degree.

The Medical Registration Council, established under the 1927 Act, has served the needs of this country and of the medical profession down the years. We are indebted to all those who, from time to time, have served as members of the council, as well as to the staff of the council, for their valuable services in maintaining the high standards in the medical profession which exist in this country and of which we can be justly proud.

I am satisfied that there is now need for change; need for fundamental change to reflect developments which have taken place especially during recent years, and to incorporate the very best of modern thinking into the law governing the profession. That is what this Bill attempts to do. Because of the nature and the extent of the changes which are proposed and because of the need to project a modern legislative image for the profession, it is proposed, rather than attempt to make these changes by way of amending legislation, to put forward the Bill as a comprehensive measure, repealing all existing legislation and proposing the re-enactment, where necessary, of any existing provisions. I am sure that this approach will be welcomed by the House.

It is essential in preparing a Bill of this nature to seek out and to consider the views of all the parties dedicated to promoting the profession of medicine, to maintaining and improving the standards of education, training and behaviour and then to incorporate those views in the new measure. This has, in fact, been done. My predecessor established a committee which was widely representative of the medical profession and he asked it to examine and report to him on the changes considered necessary in the legislation for the regulation of the profession.

The exact terms of reference given to the committee were as follows:

To examine and report to the Minister on the changes necessary in the existing legislation for the regulation of the medical profession, taking account of the directives in relation to medical practitioners adopted by the Council of the European Communities, the recommendations of the Report of the Committee of Inquiry into the Regulation of the Medical Profession in the United Kingdom (the Merrison Report), insofar as they affect this country, and other related matters.

The committee had among its members persons representing the Medical Registration Council, the Irish Medical Association, the Medical Union, the medical schools, the Royal College of Surgeons, the Royal College of Physicians, Comhairle na nOspidéal, the Council for Postgraduate Medical Education and Training and my Department. The unanimous report of that committee forms the basis for the measure which is now before the House. I think it is only right that I should pay tribute to the members of the committee; a spirit of reasonableness and compromise must have existed among them to a rare degree in order to enable them to agree on the terms of their report and recommendations.

Before commenting on the principal provisions of the Bill itself, I would like to make a few comments on this question of the purpose of regulation in regard to the medical profession. Why should there be regulation, by legislation, of the profession? What should be the nature of such regulation? The basic characteristic of any profession is, firstly, that its members claim to have specialised knowledge and skills which will be used by the public and, secondly, that it will be self-regulating, usually under statute.

To enable the public to recognise a member of a profession, the practice has been to provide a statutory register of those members of the profession who are qualified by their education and training to be entered in it. Control of the profession is then achieved by the body which is given the custody of the register with the functions of setting and maintaining standards for entry to and removal from the register.

This was first put into practice in relation to the profession of medicine in this country, as part of the United Kingdom, by the Medical Act, 1858. In those leisurly days, the legislators had the happy habit of putting informative preambles to Acts which the science of legal drafting has now, perhaps, unfortunately, cut out of modern Acts of Parliament. The preamble to the Medical Act, 1858 stated that it was "expedient that persons requiring medical aid should be able to distinguish qualified from unqualified practitioners".

The benefits of statutory registration are two-fold. It protects the public from the unqualified practitioner. To the advantage of the profession is the fact that the register gives statutory recognition to the qualified competent practitioner which in turn confers practical advantages to him in the form of public recognition and protection of his status.

Registration, as part of regulation, can, therefore, be likened to a contract between the profession and the public to the benefit and advantage of each.

The Medical Practitioners Act, 1927 set up our own Medical Registration Council in this country and conferred on it all the duties and responsibilities which the General Medical Council of the United Kingdom had hiterto exercised in relation to Ireland. Furthermore, because of the mutual benefits it conferred on Ireland and on the United Kingdom, a special relationship was created at the time between the two countries. This took the form of an agreement signed before the 1927 Act was enacted providing for the mutual recognition, on the two sides of the Irish Sea, of the medical qualifications awarded in these islands. The provisions of the agreement were confirmed by and were incorporated into the 1927 Act as the First Schedule to that Act. This special relationship was to the advantage of each country and in a way could be said to have foreshadowed the doctors directives adopted by the Council of the European Communities in June, 1975. I shall have more to say later about the agreement with the United Kingdom and the EEC Directives.

The Bill itself is in six main parts and I propose to deal with each part seriatim.

Part I contains the normal provisions for the interpretation of the words and phrases used in the Bill, for the commencement of the different provisions and for the repeal of the existing Medical Practitioners Acts.

Part II provides for the establishment of the new Medical Council to replace the Medical Registration Council. Here we come to the first of the major changes being proposed. The existing Medical Registration Council has eleven members; seven nominated by the undergraduate medical schools, two elected by the practising profession and two nominated by the Government.

The new Medical Council, proposed in the Bill, will differ greatly in its size, powers and constitution from the old council. Firstly, its powers and constitution will recognise the growing importance which post-graduate medical education and training now play in "the making of a doctor" by giving representation to the major post-graduate educational interests. The proposals will also greatly increase the representation on the council of the practising profession who are to be elected to membership by colleagues; the numbers of those will go up from two to ten. Furthermore, provision is being made in the electoral and nominating procedures to ensure that all the major areas of medical practice will be represented on the council. The remaining four members of the council will be appointed by the Minister. These may include non-medical members to represent what might be called "consumer" interests.

The committee which I referred to earlier recommended a council of 21 members. In the light of representations made to me following the report of the committee, I decided to increase the membership by four as follows:

—one member to represent psychiatry

—one member to represent general practice

—one additional member to represent the practising profession and

—one additional member to be nominated by me.

I realise that the committee was keen that the size of the council should be kept as small as possible consistent with its being able properly to discharge its functions without having to delegate too much to a secretariat. I sympathise with the committee's views in this regard but I regarded it as essential to give the extra representation as indicated. I do not think that the increase in membership will be detrimental to the efficient functioning of the council along the lines envisaged by the committee.

Before leaving this question of the membership of the new Medical Council, I would like to mention that it is not proposed to give representation to the Apothecaries Hall of Ireland. The licentiate of the Apothecaries Hall was listed as one of the recognised qualifying diplomas in the Second Schedule to the Medical Practitioners Act, 1927. The Hall has ceased to function as a qualifying body since the end of 1971 and it is not considered necessary that it should be recognised in the future for the granting of basic qualifications in medicine in this country. In this respect, the proposal accords with the recommendations of the committee to which I have referred earlier.

The remaining sections of Part II deal with procedural matters related to the establishment and the staffing of the new council, to the dissolution of the Medical Registration Council and to various specific powers of the new council including the borrowing of money, the acceptance of gifts, the establishment of committees and the charging of fees.

Part III deals with the registration of doctors, including the establishment and maintenance of the basic register of medical practitioners. Provision is made for the establishment, at a later date, of a separate register of medical specialists should this be considered necessary.

The provisions relating to the establishment of the basic register contained in sections 26, 27, 28, and 29 follow the pattern of the existing legislation except that provision is made specifically in section 27 for meeting the obligations of the State pursuant to any directives in relation to doctors which may be adopted by the Council of the European Communities. Obligations in relation to the directives adopted by the Council of the European Communities in June, 1975, were discharged by means of regulations made in December, 1976—Statutory Instrument No. 288 of 1976—under the provisions of the European Communities Act, 1972.

Two directives were adopted by the Council of the European Communities in June, 1975, and they came into effect in all the member States on 19th December, 1976. In brief, they made provision for the following matters:

(1) the recognition by each of the member States of the medical qualifications, at both general and specialist levels, awarded to nationals of member states by the member states;

(2) the giving effect to the right, contained in the Treaty of Rome, of the freedom of movement for workers and their right to establish themselves in their work or profession within the Community, and

(3) the setting and maintaining of specified minimum standards of medical education and training within the Community.

The meaning of the provisions is that doctors from other member states are entitled to practice their profession here on the same basis as our own nationals and our nationals have similar privileges in the other member States.

With regard to the register of medical specialists provided for in section 30, the position is that while statutory registration of medical specialists is common practice in the continental member states of the EEC, the practice has not been introduced in this country or in the United Kingdom. It is thus considered desirable that the new council should have the power, with my consent, to introduce statutory registration for specialist doctors should it decide to do so at some future date. I should mention that the British Merrison Report recommended that specialist statutory registration should be introduced in the United Kingdom.

Part IV of the Bill dealing with education and training again marks a significant expansion in the powers of the new Medical Council as compared with these of the Medical Registration Council. The Medical Registration Council's functions relate only to undergraduate medical training, or, to be more precise, medical education and training up to the stage where a doctor has completed what is known as the "interim" year which entitles him to full, as distinct from provisional, registration in the register. Under the provisions of Part IV, it is proposed to give recognition to the significance which post-graduate education and training has assumed in recent years, by giving the Medical Council statutory powers in relation to such education and training. It is important to stress that these powers will fall to be exercised by the new council irrespective of whether there will be statutory registration for specialist doctors or not.

When statutory registration was first introduced in the 19th century, and for a long time afterwards, it was accepted that all the skill and knowledge needed by a doctor could be imparted to him during the education and training leading to his graduation. It has long since been recognised that there is now much more to the "making of a doctor" than that. It is fully accepted that the education of a doctor is a process which should never end whether the doctor is a top-level consultant or a country general practitioner. Post-graduate education and training is a complex and lengthy business and it is all an integral part of the education and training needed by all members of the profession. Hence the necessity to give statutory responsibility for the continuum of medical education and training, on all levels, to a single statutory body, the new Medical Council. The council will, of course, work in the closest co-operation and harmony with the many bodies engaged in practical aspects of this work.

In section 35, provision is made for giving legislative effect to requirements imposed on the State by directives adopted by the Council of the European Communities both in relation to basic medical education and in relation to education and training in specialised medicine. The new Medical Council will, therefore, be the body competent and responsible in this country for seeing to it that standards of medical education and training at undergraduate and post-graduate levels will, at the very least, meet the minimum requirements for such education and training laid down by the EEC. Need I say that I hope that the objectives will be to establish and maintain standards which will be higher than the minimum standards required by the EEC? Our standards in medical training and education are already very high and our doctors are well regarded abroad.

Part V of the Bill makes provision for dealing with cases of discipline, of professional misconduct and of general fitness to practise. While, fortunately, it is only very rarely that it is necessary to have recourse to disciplinary action in regard to any member of the medical profession, it is essential to have adequate and suitable machinery available whenever it is necessary to have recourse to such action. The statutory powers of the Medical Registration Council provide only for the erasure of a doctor's name from the register. Recognising the fact that circumstances may arise where some disciplinary action may be called for but that the penalty of erasure would not be warranted, provision is made in the Bill for lesser penalties.

Section 40 empowers the council to suspend a doctor's registration; section 41 gives the council power to attach conditions to a doctor's continuing registration and section 42 contains provisions enabling the council to admonish, to advise or to censure a doctor in relation to his professional conduct.

In relation to Part V as a whole, it was necessary to ensure that its provisions would not be in conflict with the Constitution. It is no secret that difficulties have arisen over the years in relation to the constitutionality of the powers of registration councils and other bodies dealing with the regulation of certain professions and that there have been some instances where these powers have been found to be in conflict with the Constitution. The provisions in Part V of the Bill have been very carefully drafted and I am satisfied that there can be no conflict with the provisions of the Constitution. What is proposed requires every disciplinary decision of the council to be subject to the approval of the High Court either on appeal by the doctor concerned or by way of application to the court by the council in the event of no appeal being made.

There is a new provision which enables the council to take action against a doctor because of his unfitness to practise by reason of physical or mental disability. Again the judicial safe-guards have been built in.

As regards Part VI the proposals, in the main, relate to the re-enactment of existing provisions but there are one or two matters of particular importance to which I would like to refer. First, there is the question of penalties for offences. Under existing legislation a person who wilfully and falsely represents himself to be a registered medical practitioner, when he is not so registered, is liable to a fine not exceeding £25. This has not, of course, proved a sufficient deterrent and the Medical Registration Council has expressed concern about instances of persons purporting to be registered medical practitioners when they were not in fact so registered; these instances have been of great concern to the council who have felt themselves frustrated by the situation and have been extremely conscious of the likelihood of danger to the public by the activities of these persons.

Under the provisions of section 55 of the Bill it will be sufficient in future for the purposes of obtaining a conviction, that a person should falsely represent himself to be a registered medical practitioner when he is not so registered. The penalty is being increased to a maximum fine of £500 or to imprisonment for a term not exceeding 12 months or to both such fine and imprisonment. It is to be hoped that the changes proposed in this section will be sufficient to deter, in future, any person from falsely holding himself out to be registered medical practitioner.

Secondly, I would like to say something about section 61. When all Ireland was part of the United Kingdom, the General Medical Council had power in this country, as in Britain, to recognise medical schools and to register medical practitioners. Even after the establishment of the Medical Registration Council in this country under the Medical Practitioners Act, 1927, the British General Medical Council continued, under an agreement which is incorporated as a schedule to the 1927 Act to register graduates of Irish medical schools direct and provided, and still provides, an office in Dublin for this purpose. The General Medical Council also has power to inspect Irish medical schools. The constitution of the General Medical Council provides for four representatives of the Irish medical schools.

The British General Medical Council and the Medical Registration Council here have worked very closely together in policies and practices as regards both the standards of training and the discipline of doctors. However, the arrangement is not one of real reciprocity and, in any event, its continuation would not be appropriate in the light of our membership of the EEC and the provisions of the EEC directives in relation to doctors. There is a wide measure of agreement that the arrangement has outlived its usefulness and that it should be terminated. Discussions regarding transitional provisions which may be necessary are to be held between the two countries. In the meantime, it is proposed that the agreement should continue in force notwithstanding the repeal of the 1927 Act. The proposal is that when—hopefully in the near future— it will be possible to terminate the agreement, this can be confirmed by way of an order under section 61 of the Bill.

The continuing close co-operation between the medical profession in this country and in the United Kingdom, which is desired by the medical profession of the two countries, can be structured by co-opting to the respective education committees of the councils in each country of persons from the other country.

Before concluding I would like to place on the records of the House my appreciation of the vital and leading role which the medical profession have played and continue to play in our society. The medical profession have given long and dedicated service to the people of this country and I know that that dedication and selflessness will be preserved and continued in the future.

So far as the functioning of the health services and the work of my Department are concerned I would particularly like to thank the profession for the unstinted help given voluntarily and without reward by so many of their members acting on various boards and commissions, committees and working party, councils and so on.

I have already mentioned the members of the Medical Registration Council and the members of the special committee which examined the law regulating the medical profession. In addition, doctors have contributed and continue to contribute to the deliberations and the decisions of practically all the bodies in the health field. To name but some, doctors are involved as members of all the health boards, the National Health Council, Comhairle na nOspidéal, the Council for Postgraduate Medical and Dental Education, the many specialist national bodies like the National Drugs Advisory Board, the National Rehabilitation Board, the National Blood Transfusion Board, the Health Education Bureau and so forth. It is quite impossible to contemplate the existence of these bodies without the specialist input of the medical profession to them.

I have given the House the general background to this Bill and I have drawn attention to its main provisions. I hope that the House will accept that the changes proposed are aimed at the advancement of the practice of medicine and at safeguarding the general public. On the occasion of my recent discussions with them, the representatives of the medical profession expressed their desire to have this new legislation enacted and brought into operation at the earliest possible date. I hope that the House will co-operate with me in making this possible.

Mr. Boland

As the Minister said, this is a worthwhile and non-controversial Bill which updates the law in regard to the registration of medical practitioners as well as improving disciplinary procedures and extending the powers of the Medical Council regarding standards of education and training, especially in the post-graduate field. The Bill is to be welcomed in all of those respects. It replaces the 1927 Act, which was the Principal Act in this field, which, as the Minister said, has stood up to the passage of time remarkably well, together with the 1951, 1955 and 1961 Acts, which were merely minor amending Acts regarding temporary registration of doctors coming here from abroad.

The worthwhile work done by the advisory committee set up by the Minister's predecessor to examine the areas in which the law could be improved and brought up to date in this field is evident in the Bill. They are to be thanked for the contribution they have made. It is in the best interests of the medical profession that there should be a proper register setting out the qualifications and expertise of all those engaged in the practice of medicine in every sphere in the country. It is in the interests of the general public that that register should be kept as assiduously as possible. I feel there is one weakness in the Bill in that respect, to which I shall refer later. I believe this might be tackled at this stage when the law regarding the registration of doctors is being brought up to date.

This side of the House welcomes the extension of the Medical Council and the new areas of representation. The council are being increased from a total membership of 11 to 25 and will now encompass representatives from various specialised fields of medicine so that there can be a greater overall knowledge at meetings of the Medical Council. A very important aspect of the Bill is that the Medical Council will in the future be responsible for overseeing the further education of doctors after they have received their primary education. The Medical Council will be involved in post-graduate training and in seeing that adequate standards are brought in and maintained in the post-graduate training of doctors. The education of a doctor, as in so many other professions nowdays, does not cease when a doctor obtains his primary qualification. It is an on-going thing and as new experiments and discoveries take place in medicine every day it is important that this information be made available to all medical practitioners and that they are encouraged to take on additional post-graduate qualifications. It is a good thing that the Medical Council should be asked to become involved in that sphere of responsibility.

It is important that registration matters should be improved. Up to this, if a complaint was made against a member of the profession the Medical Council were only given a very simple option. If the case was proved they could either have that person's name taken from the register or they could decide to leave it on. We now have a very sensible suggestion that the council should be given the power to suspend the doctor for a limited period of time, to attach certain conditions to his continuing registration or to censure him on his operations as a doctor without actually removing him from the register. That is a much better way of dealing with problems than the rather restricted way in which the matter was dealt with up to this. Obviously any complaint made against a member of the medical profession is a very serious matter for the doctor and for his patients. It is well that the Medical Council should have a wider area in which they can advise a member of the profession rather than be left with the option of total removal or taking no action whatsoever. Those aspects of the Bill are very welcome.

There is one aspect of registration which I believe could have been dealt with more efficiently in the Bill. This relates to registration in the first instance and also to the methods of checking and verification which are carried out by employers in the health field at the time a doctor first applies for a position. I appreciate, as has been pointed out, that the penalties for false representation of qualifications have been radically improved and are now of quite a punitive nature and involve a possible jail sentence as well. There is still an area which I do not believe has been properly dealt with. When a doctor applies for appointment on a health board or a hospital board is the onus on him to provide proof of his qualifications or does it fall on the employer such as the health board?

I do not see that there is contained anywhere in existing legislation or in this proposed legislation anything to stop a person from setting up as a general practitioner in some remote part of the country and claiming that he is qualified. While a person to be registered must apply to the registration council, there does not appear to be any method whereby someone who does not so apply has to produce proof of qualification before setting up as a general practitioner or going to an employer and representing himself as being qualified.

If most Members of this House had not been engaged in other activity during the month of June they might have heard more about a particular case which arose in one of the health board areas. We are given to understand that in that instance a person was employed as a junior house officer by the Mid-Western Health Board in late 1976. Subsequent to his appointment—which the health board say was made because he appeared to have the relevant experience—he was asked to forward details of his qualifications to the registration council. This he did and, somewhat to my concern. I understand that the registration council accepted the details and registered the doctor. We seem to have a situation in which a big employer in the health field was prepared to accept somebody without checking his registration or claim. When he was asked to apply for registration he sent sufficient details to allow himself to be registered as a foreign doctor practising in this country. It was only when he had been employed for a considerable number of months as a junior house officer in an orthopaedic hospital that the suspicion of some of the staff was brought to the attention of the executive of the health board, who decided to ask for further details from the doctor. When those details were not forthcoming the gentleman decided to take extended leave of absence. There, apparently, the case rests.

It concerns me that this man should have been employed without producing a certificate of registration and that having been employed he was able to supply sufficient information to the registration council apparently to mislead them into registering him, however temporarily. There should be contained in the Bill an onus on some body or other to ensure that someone representing himself as a qualified medical practitioner has, in fact, the relevant qualifications. Perhaps this onus should be placed on the area health boards so that they could check on the qualifications of all persons applying for positions in the general medical services, the hospital service or in voluntary hospitals. They could also check on the qualifications of all persons setting up as general practitioners within the area. If this onus is not placed on the health boards, perhaps the onus should be on the Garda to ensure that a person has the necessary qualifications and has been registered with the registration council. These powers are not included in this Bill and are not given to the Registration Council. The 1927 Act has stood the test of time well, but if we are to bring the law up to date and into line with some of the EEC Directives we ought to include specifically not only the power but the direction to the registration council to ensure that all persons within the country are made to apply to them and are checked in advance of their being allowed to practise. In that respect the Bill falls down and needs to be examined on Committee Stage.

There is also an unclear aspect in relation to the agreement with Britain as to whether doctors who qualify in Britain are obliged to register with the registration council here or if their registration in Britain alone is sufficient for them to practise here. That may have been part of the difficulty in the Limerick case to which I have just referred.

I welcome the aspect of the Bill which brings in recognition for our medical qualifications in other EEC member-States and allows persons who have properly qualified within the Community to practise freely here. This is an aspect which we will see more and more in various legislation as the mobility of qualified persons becomes more widespread.

The Bill also provides for the possible creation of a separate register of medical specialists but it does not provide that this register should be set up at present. I understand that in most of the member-States of the European Community and in quite a number of other countries there is a separate register of medical specialists as well as a register of medical practitioners. That is not the case in Britain. This Bill is now allowing for the creation at some time in the future of a separate register of specialists but not suggesting that the register should be set up at the time of the formation of the new Medical Council. Now that the law is being updated and revised in relation to the registration of doctors, I would suggest to the Minister and to the House that serious consideration should be given to placing an obligation on the Medical Council to create a register of medical specialists. I understand from a number of health and hospital board sources that they would welcome such a register and would find it very helpful in the recruitment and employment of specialists. I believe the House should give consideration to the possible amending of that section.

The Minister has referred to the constitutional difficulties, of which we are all aware, in relation to part 5 of this Act and difficulties which exist in relation to the terms of reference of many bodies who register and try to control the professions and various other fields. The Bill as now drafted appears to meet any constitutional difficulty which might have arisen and I accept that the need to check on the constitutionality of sections of the Bill may have resulted in delay in its appearance. The House will agree that it was well worth while that the matter should have been thoroughly investigated before the Bill appeared.

I have a small criticism of the drafting of the Bill. There is reference to a committee known as the Fitness to Practise Committee which appears at section 39 but does not appear prior to that except for a reference to a committee which should be set up under Part V of the Act. However, the committee is not given a title until this Fitness to Practise Committee suddenly appears in section 39. This will be the most important committee in dealing with complaints and disciplinary matters. There is need for re-drafting here.

I believe that we can be proud of our medical profession. They have served us well over the years and the standard of the medical schools is remarkably high. Students from all over the world come to study medicine in several of the medical schools here. I believe we can be proud of those schools and the graduates they produce. The Irish doctor has served Ireland well abroad and enhanced our reputation. At home he has served the people well.

I welcome this Bill. Because of its non-controversial nature it is not the type of Bill on which one would choose to deliver a maiden speech. However, it represents a very important aspect of health legislation and an up-dating of the law in regard to the registration of doctors. For that reason it is to be welcomed. I believe it should be improved by tightening the procedure for checking the qualifications of those who purport to be doctors. The suggestion that an obligation be placed on the Medical Council to create a register of medical specialists ought to be examined. With these reservations I welcome the Bill.

Dr. O'Connell

In extending a general welcome to the Bill I must say that I have waged a campaign to bring about changes in what I consider to be an outmoded Medical Registration Council. It is a body which has isolated itself in many ways from the public it was meant to serve. Any Bill that promises a revitalised Medical Council can only be viewed as a long overdue measure.

The new Medical Council does have the same basic framework of reference as its predecessor—it will regulate medical education and register those engaged in the practice of medicine. There are some small changes due to EEC directives on the mutual recognition of medical qualifications, on the free movement of doctors, on the co-ordination of training standards and so on. There are also major innovations in the Bill. The major innovations involve the expanded membership of the Medical Council from 11 to 25 persons, the provision for a second registrar of medical specialists and the adoption of a more flexible range of disciplinary measures in regulating professional conduct.

All these innovations are to be welcomed. The introduction of more flexible disciplinary measures is long overdue. Someone said that these measures only provided for the erasure of a doctor's name from the register. In fact, they provide for the following: no action, the putting of a doctor on probation, the immediate erasing of his name. These measures constitute an unsatisfactory and inadequate disciplinary procedure. They are unsatisfactory because the erasure of a doctor's name from the register is a severe penalty and can only be justifiably imposed in cases of gross misconduct. They are also inadequate in that having one single harsh penalty will inevitably prevent many cases from being heard. It would be advisable for all those who are studying this Bill to look at the Medical Registration Council's functions, procedure and disciplinary jurisdiction on professional misconduct which relates to advertising, canvassing for patients, the abuse of a doctor's knowledge, illegal abortion, adultery with a patient, improperly disclosing information obtained in confidence from a patient, the disregard of personal responsibility to patients, gross neglect in diagnosing their treatment, the public medical practice by unregistered persons, convictions arising out of the misuse of alcohol or drugs and issuing untrue or misleading medical certificates.

This Bill provides for the suspension of registrations as well as the erasing of names and the setting of conditions to registration. It also provides for admonishing, advising or censuring of doctors in relation to professional conduct. This new element of flexibility should be welcomed because it shields a doctor from harsh and excessive penalties and provides the public with more protection. The introduction of a second register was another bonus for the public. I hope the Medical Council will exercise its options under this Bill. It is right to grant the new Medical Council an option because there is disagreement at present among the countries in the EEC as to what constitutes a specialist. Until this has been harmonised, the provision of a medical registrar for specialists will have to be delayed. The public has a right to guarantees that those claiming specialties have certain minimum qualifications. One important aspect of this Bill is the provision for an expanded membership.

The composition of the new Medical Council deserves closer scrutiny. It seems anomalous and unrepresentative that in a list of 25 members family doctors should be outnumbered in representation. An indication of this imbalance is that there will only be three family doctors with seven consultants and one junior hospital doctor. At present there are more than 1,600 family doctors in the country and they will be represented by only three family doctors. There are only 800 consultants and they will be represented by seven members. The one junior hospital doctor will adequately represent the junior doctors. Having regard to the number of family doctors in the country, I hope the Minister will consider my amendment which relates to representation.

It is essential that the voice of the consumer be represented on the new Medical Council, that is, the person who is provided with health care by the medical profession. As it stands the Bill does not guarantee such representation. The old council had two nominees of the Government and both were doctors. This Bill gives the Minister the right to appoint four nominees. If he follows the example of his predecessors he will be appointing doctors. I consider it his obligation to appoint consumer representatives to the council. It is important that these four people be genuine representatives of consumer interest. I have tabled an amendment to the effect that these four people should be appointed by the Minister in consultation with such bodies as in his opinion represent consumer interests. The Minister may intend to do this but within the terms of the Bill he does not have to make such appointments. It is important that consumer interests are represented on the council, that they are mentioned in the Bill and given legislative status. The Minister could appoint four persons to represent consumer interests without changing the Bill but there is merit in changing the Bill to acknowledge in statutory form the role of consumer interests on the new Medical Council.

I am also tabling an amendment seeking the appointment of a public information officer to the council. Consumer interests demand that the structure, composition and complaints procedure of the council be given the widest public exposure so that people will know that their interests are being recognised. Regrettably the present Medical Registration Council have not a proper information officer at their disposal to enable them to answer queries from the media on many matters relating to discipline, forms of registration of the council and so on. It is a deplorable situation that an officer of the Medical Registration Council must wait for decisions from a formal meeting of the council since a formal meeting may be held only twice each year. We need a properly informed information officer who will be available to answer queries for the public. People with genuine grievances in regard to the medical profession do not know to whom they may refer their complaints. These people write to the newspapers or to the Medical Union and if finally they become aware of the Medical Registration Council there is still no help for them in regard to the processing of their complaints. That is why I ask the Minister earnestly to have regard to the consumer interest. The appointment of a proper information office would restore public confidence in the council.

In addition, the access of the general public to the complaints machinery of the new council must be assured. This brings in the services of a public information officer who would have the responsibility of making available full information in regard to the council's existence, their work, their complaints procedure and their responsibility in regard to answering queries from the media or from the public. It should be the function of this Bill not only to recognise consumer interest by ensuring consumer representation on the council but also, by listing among the duties of the council, the actual promotion of consumer interest. This could be done in two ways. First, the Bill should list among the duties of the council in relation to medical school curricula, the duty to promote an understanding of consumer rights and interests in medical education and training. Secondly, the Bill should list among its general advisory functions the responsibility for giving guidance to the public on all matters relating to ethical conduct and behaviour. As the Bill stands, the council have general advisory duties only to the Minister and to the medical profession. We must realise that the triangular relationship in regard to health matters is constituted by the State together with the medical profession and the general public. It is my intention to table amendments both in the area of the council's duties in the field of medical education and of their general advisory functions in order to ensure that the consumer interest is given its rightful place.

So far I have been referring to the legitimate interest of consumers in the primary function of this council, without establishing or defending these interests. Perhaps this is due to my assumption that everybody recognises the fact that we are living in an era of consumer rights. In all spheres of society people are insisting that the supplier-consumer relationship entails responsibility on the part of the supplier and rights on the part of the consumer. There is the right to clear and comprehensive information, the right to genuine quality and the right to proper service. These rights and many others constitute the Magna Carta of the consumer today. This movement has spread to medicine and health and rightly so. The three major functions of this council are to regulate medical education, to register and control those engaged in medical practice and to advise generally on matters relating to professional ethics. To speak of consumer interest in the context of medical education may seem odd but we must remember that medical education is concerned with the provision of health care to the consumer. It is regrettable that not enough emphasis has been placed on the issues of society's needs in regard to medical education. In other words, the viewpoints of the recipients of medical health care have not been recognised as they should have been recognised.

We must realise, too, that the funds used to subsidise medical students are provided by the public through the Government and that the public, provide also the bulk of payments to doctors. In short, the consumer is footing the bill to a very large extent in respect of medical education and practice. Consequently, he has a right to a say in the medical education of our doctors. The formation of an appropriate attitude is a key aspect of medical education from the consumer point of view. To illustrate this point I shall quote from a recent report of a one-day conference that was held to determine the community's views on goals for medical education. The conference was organised by the medical faculty of Trinity College and included members of community-based organisations. Medical professionals were in the minority at the conference. To give an idea of what the public think of doctors I quote from the Journal of the Irish Medical Association, 2nd September, 1977 issue:

The group did not accept the doctor as a professional whose skills are limited solely to the application of medical science; he must have a broader capacity to deal with human problems as they relate to health and disease.

Another observation was that:

Doctors generally come from middle-class backgrounds and belong to a profession that expresses middle-class values and attitudes. In consequence, they often do not appreciate the beliefs and values held by other sectors of society and as a result, fail to communicate easily and effectively with them.

The group contended that doctors should be concerned with the social and environmental aspects of the patients' medical problem and be able to provide guidance and initiative in dealing with these problems. Another observation from the report was that:

Increased attention must be given to the question of patient-doctor communication in the hospital setting; the patient is often unfamiliar with the consultant to whom he has been referred.

These are but few of the many observations made and they indicate that the public are not happy with the training of doctors and are anxious to have a say in this regard.

The representatives of the consumer interest on the council should have a say in regulating the curricula and the standards of education and they should be represented on the education and training committee. They should be represented, too, on the Fitness to Practise Committee. Such representation would be to the benefit both of the public and of the profession. It is a sign of strength and credibility for any profession to have its members subjected to genuine scrutiny relating to ethical conduct and fitness to practise. Consumer representation on the Fitness to Practise Committee should end once and for all the disparaging notion that there is a professional conspiracy among doctors to protect their own members.

The time has come for us to bridge the gap of suspicion that seems to have grown between the medical profession and the general public and what better way can this be achieved than by having both interests working together on the Medical Council? So far as the general advisory functions of the council are concerned it is apparent that in addition to advising the Minister and the medical profession on ethical matters, the council should undertake also to educate the public in this regard. The consumer should know what sort of treatment and conduct he has a right to expect.

I am in full agreement with the general intent and purpose of the Bill but the changes I would propose are those I consider necessary to ensure the protection of the consumer interest. I shall be recommending, by way of amendment, that the consumer interest be given statutory recognition on the council and that those whom the Minister considers representative of consumer interest should sit both on the Fitness to Practise Committee and on the education and training committee. The medical profession in general would approve representation also for general practitioners in proportion to numerical strength within the profession. With these additions the Bill would meet present day needs.

One other very important aspect I would like to mention is the question of finance for the present Medical Council. The council will meet their administrative and other costs from the fees paid by doctors under registration. At present the Medical Registration Council receive no grant from public funds and it is not proposed to change this situation with the new Council. I believe the council should receive State subvention for two reasons. First, the council in regulating medical education and registering medical practice is providing a public service. The Medical Council with general consumer participation is protecting the public interest by making sure they have recourse to complaints machinery and by making sure their interests are taken into account in the whole structure of medical education and medical practice. If the medical consumer is given a real voice on the Medical Council then I see the Medical Council as a body providing public service and therefore deserving of a substantial State subvention. We should also ensure that there be more accountability to the Legislature than there is at present.

It is necessary that the Fitness To Practise Committee should operate in private. Everyone here and the public in general will agree that if an irresponsible complaint is made against a doctor and the disciplinary proceedings are not held in private that doctor's practice may be destroyed forever even though the complaint could be without foundation. Even if the doctor is cleared his practice could be destroyed. It is only right therefore to ask that such proceedings be conducted in private. If as a result of the proceedings there is a conviction this should be made public. It is not necessary or desirable that privacy be maintained after that.

There should be a set of guidelines, not only for the protection of the doctor, which should indicate what constitutes ethical conduct on the part of the doctor and should be published not merely for the medical profession, medical students and new doctors, or even for the Members of this House, but for the benefit of the public also. I hope that the Medical Council when established will examine the present disciplinary function procedure and jurisdiction, a lot of which is out-dated. For instance, a doctor found guilty of manslaughter could find his name erased from the register. He might go to a party and become drunk and then be found drunk in charge of a car, and he could find his name erased from the register on account of something that had no more connection with his practice than it would have with that of a judge or a member of any other profession. There-fore I hope that the guidelines when established by the new Fitness to Practise Committee will be published.

Mr. G. Brady

First, I would like to congratulate, if rather belatedly, Deputy Haughey in his new Ministeries of Health and Social Welfare and I wish him well in these. We all realise the enormity of the task that lies ahead in the question of health. I welcome this Bill which has been carefully constructed after lengthy discussion and negotiation between the Government, medical opinion and all others interested in this field. The legislation updates guidelines set nearly 50 years ago, and as a past chairman of the Dublin City Local Health Committee I became very aware over the past two years of the pressing need to co-ordinate various factes of medical activity in Dublin city. The establishment of the proposed Medical Council with clearly defined objectives is the direct result of an urgent need that has been developing over the past number of years and will serve to benefit the public and medical practitioners alike. With approximately 1,300 doctors and perhaps 700 or 800 specialists engaged in medical activity in Dublin, it is patently obvious that it is necessary to co-ordinate and regularise their activities in a modern manner.

Modern medicine has brought in its wake immense problems. Our annual budget now is in the order of £400 million and yet we are spending less than two per cent of this figure on preventive medicine, the entire emphasis being on the curative side of medicine. Health is wealth of course, but ill-health means colossal expenditure. If the Medical Council can direct their attention to educating doctors in the field of preventive medicine very large savings in the health budget will accrue. A personalised approach to medicine must be maintained. This is of paramount importance and there is no reason why it should not be maintained. An efficient national health service can work hand in hand with a private sector. It is very important that we have a voluntary health organisation functioning and serving the public as well as an efficient national health service.

The major killer drugs ethyl-alcohol and nicotine are sold liberally almost in a glamorised manner to a confused society. There are lots of modern pressures about us and we will have to address ourselves to these. I would like to see the Minister in some way, in the short term certainly, encouraging doctors who have been in practice for a number of years to update themselves by taking necessary post-graduate education. We read of blanket accusations of the over-prescription of drugs. In this morning's papers this became quite an issue. These accusations can be made without fully realising the implications of the pressures that doctors are under from pharmaceutical manufacturing firms pressuring them, perhaps insidiously, into prescribing products—I will not say unnecessarily but in many cases without doctors in very busy practices having a chance to sit back and take a second look at their prescribing habits.

One of the great problems in modern medicine is that the public have become acclimatised to going into surgeries and coming out with prescriptions for drugs or medicines. They are not conditioned to the necessity of being able to take no medicine as being an effective cure. People have to be educated on this level. The Medical Council can go a very long way in this respect. We have read the statistics for the over-prescribing of tranquillisers, all due to the fact that the public have become used to these habits and are going to their doctors and almost demanding treatment rather than taking a more long-term attitude towards their problem. There is emphasis on the rapid cure in advertising—"fast action gives quick relief" and so on. This is totally contrary to the way proper medicine should work. Rehabilitation takes time and should not be advertised in such a bland manner as in some of these unethical techniques that are used by some pharmaceutical firms to push their products.

People are living longer nowadays and this in itself is imposing immense burdens on care for the aged through modern medicine. If one is to study the statistics available and the projections, this will present immense problems over the next ten or 15 years.

A doctor in practice for a number of years is certainly in need of updating his knowledge. A recent figure I read indicated that something of the order of 10 per cent of patients in hospitals are there primarily due to the over-administration of drugs. That is an alarming statistic, the cost of keeping 10 per cent of patients in hospital on account of I will not say the over-prescription but the over-administration of drugs and medical cure.

The role of the general practitioner can vary from area to area. In suburban estates newly-married couples have particular problems—children and so on—and the demands on a GP in such an area are far greater, with night calls, for instance, than in a more settled area where perhaps people are living closer to hospitals and can avail of night treatment more readily. We are living in an age when a patient dialling his doctor has to be content with an automatic answering device which will tell him to ring another number and consult with another practitioner. This can cause a lot of distress and dissatisfaction to patients. New problems require new solutions. The lack of doctors in rural areas is a huge problem as well.

An Leas-Cheann Comhairle

I do not like interrupting you, Deputy, when you are making your maiden speech, but you are widening the debate.

Mr. G. Brady

I was just coming to the question of rural doctors. I do not want to be constantly referring to the Bill, but I studied it through and it does make reference to the distribution of doctors in the country. Perhaps the Medical Council could take a look at medical orderlies in certain areas where there is a great shortage of doctors.

Another question which is causing some disquiet is the very high standard of entrance to the faculty of medicine. Twenty-six points does not necessarily make a good medical practitioner. Many doctors in practice today would not have a chance of coming up to the accepted standard. The Bill refers to the guidelines of educational standards, and the Minister will have to take a very close look at this question of entering the profession. We do not want to have a nation of brilliant Dr. Whos who are content with exterminating the patients if they do not respond to the prescribed treatment. What we do need are doctors with compassion and understanding. Perhaps such entry standards would also come within the parameters of the Department of Education, but they do have an immense bearing on this Bill, and I believe the Minister should take cognisance of this and work very closely with the Department of Education.

The free movement of doctors and specialists, which is also referred to in the Bill is a very important issue. It is not desirable to have a sudden inflow of doctors from the EEC into Ireland when many of our graduates are forced to emigrate. Reference has been made to the establishment of a specialist register. This is also most desirable because the prevailing situation in many hospitals in Dublin is that there is an understaffing from the specialists' point of view. Take, for example, the speciality, facial maxillary surgery, where a graduate can spend 16 to 18 years practising and studying abroad and at home, and at the end of all that time there is no position for him in any hospital because this has not been properly researched. Reading through the Bill I find that a strong effort is being made to put that right.

Again I welcome the Bill and congratulate the Minister and his Department on its formulation. I urge him to set about his task as quickly as possible, even if I might say to remove the ill-health that prevails in many areas of the administration of the health services.

Mr. W. O'Brien

I welcome the Minister for Health and wish him luck in his new role. Legislation of this kind is important because not alone do we deal with the health of people who are ill at the moment but with the health of those who are now walking around in good form. I did not intend to speak but in view of the fact that the Mid-Western Health Board, of which I was a member, was mentioned, I would like to say I agree with Deputy Boland in his reference to the lack of information concerning the qualification of a candidate for a very important position such as that of medical doctor. The members of the board were left in an embarrassing position in regard to the appointment mentioned by Deputy Boland. However, in fairness to the Mid-Western CEO and personnel, I would point out that they had been in touch with the registration board and finally were led to believe that the qualifications which were given by the person were in order and, through a misunderstanding on both sides an unfortunate position arose where an unqualified man was appointed to a very important position in the hospital in Croom.

It is true that the man did not perform any surgical work, but it could have happened. Were it not for the fact that the existing surgeon was available during that period of three months and the unqualified person was not called upon to carry out any operations a patient could have been deprived of the use of his hands or his back or even have died as a consequence, of making this appointment. I am not suggesting that this Medical Council should be a glorified interview board, but that before a person who has been selected is appointed the council should have some responsibility for ascertaining the credentials of the candidate. It is not right to leave the responsibility to the health board. They have not the necessary information available to them. There should be an amendment transferring the obligation in this respect to the council. It should be broader as regards functions. I may be going wide of the terms of the Bill but it seems important that many more doctors should be recruited to the health service. I welcome the Bill and sincerely hope that it will achieve the purposes for which it has been introduced.

Mr. Horgan

I welcome the broad terms of the Bill and I will confine my remarks to the effects of Part IV which, as the Minister has pointed out, refers largely to medical education. I will put my remarks in the context of the important social dimension which medical education assumes here as in every other country.

It is obvious that in so far as medical education is concerned we are now in a rapidly evolving situation. For some time past it can be argued that we have consistently produced rather more doctors than the country has needed.

This has had all sorts of implications. It has had implications for the subsidisation of the higher education system as a whole, given the enormous expense of the education of medical practitioners. It has also had serious implications within the higher education institutions where some of the less expensive faculties, such as Arts, traditionally have acted as an internal subsidy to the expensive medical faculty.

The problem has been that while we have been arguably producing too many doctors, that is not the same thing as saying we have been employing them at home. Indeed a substantial proportion of our output of medical practitioners has been going abroad. One could argue that there is good sense in this when they go for service in developing countries, but not all of our qualified doctors by any means went to developing countries. A high proportion of them traditionally have gone to economies which are substantially more developed than ours. Accordingly our difficult, struggling under-subsidised educational system has been further subsidising the educational systems of countries such as Britain and the US.

The situation that has been created by this continuous outflow of talent, and indirectly of money, has left us with a situation in which, despite the vast amount of money we have put into medical education, we are still in a very poor position in the international league table of doctors per 10,000 of the population. The latest figures I have made available to me by the Department of Health come from the Department's statistical information relevant to the health services published in 1976. They give a rather stark picture of our position in the European league. When you read the position of doctors per 10,000 of the population, the European table reads like this: Italy, 18.4; West Germany, 17.8; Belgium, 15.9; Scotland, 15.6; Norway, 14.5; Sweden, 13.9; France, 13.9; The Netherlands, 13.2; England and Wales, 12.7; Northern Ireland, 12.4; Ireland, 12; and Finland 10.9.

We are second from the bottom despite the money we have poured into medical education in the past decade. This is a very serious situation, one which the new council will have to get their teeth into if we are to make any real impact on the growth and development of health services here. The irony is that the situation is changing very rapidly. Whereas in the past we could produce and export almost as many doctors as a political system would bear, the job market for doctors is now rapidly changing. The "house full" notices are going up not just in Ireland but in Britain and the US and in almost any other country to which our newly qualified practitioners have been traditionally going. We may yet find a situation in which there will be a queue of applicants for the position of summer locum on the Aran Islands. This is a situation which in my capacity as spokesman for the Gaeltacht I would, of course, welcome, but it is one which in wider terms has a major importance for the medical profession and for policies about the number of doctors we will allow and encourage to graduate.

As I see it, the real danger here is that, given the shrinking employment opportunities for people who leave the medical profession, some of the more conservative members of the medical profession, particularly those in positions of power and influence, may seize the opportunity to limit sharply the numbers of those leaving the medical schools not because there is any necessary correlation between the numbers leaving the medical schools and the actual medical needs of the country but simply to maintain and improve the earning power of this very small and highly qualified and subsidised élite.

Therefore the new council must watch severely this tendency in the medical profession. They must insist, in so far as they will have control over the entry policies to our medical schools, that the medical needs of the country will predominate over the desire of any profession to increase or maintain its own earning power. The problem can be fairly simply stated. To put up our position on the league table I have referred to by one percentage point, and that would only jump us above England, Wales and Northern Ireland, would still leave us only fourth from the bottom and would need an immediate injection of 300 new doctors. We must be careful that the jobs crisis now affecting the medical profession will not be used by the profession as an excuse further to restrict artificially the supply of doctors for our health services.

The other main area to which the new council will have to pay considerable attention is the social dimension of medical education as it concerns entrance to the medical profession and the curriculum of the medical schools. It is true that the entrance system for medical schools in Ireland today is a great deal fairer than it was. It is also unfortunately true that it still relies very heavily on outmoded highly academic criteria. There is absolutely no guarantee that X number of points in the leaving certificate will produce a good doctor—there never has been and never will be. The medical schools, under the guidance of the registration council, will have to look to their entry policies and procedures to ensure a closer correlation between the real attitude of people who want to become doctors and their academic performance, if any.

It is tragic that there is so little, if any, provision made for entry to medical schools on a second chance basis. Second chance education has become almost a cliché almost overnight and it is generally taken as something that can apply only to the safe faculties, the faculties which are not exclusive. You are letting eventually a handful of people without matriculation into Arts. You will steer them firmly away from architecture and the law and the other areas. If we are to be serious about second chance education for everybody we must include the medical profession as an appropriate avenue for people whose basic educational requirements may have been neglected or omitted.

The other main area I referred to is that of the curricula. This will be a major job for the new Medical Council. I hope the council will take their responsibilities seriously in this area because the responsibilities are very substantial. There is a great deal of updating taking place at the moment in the curricula of medical schools generally and a measure of that updating can be seen from the recent report published by the Nuffield Provincial Hospitals Trust for the General Medical Council in Britain. This report, which deals with research, took three years to complete at a cost of £50,000. The research carried out for the General Medical Council in Britain covers all the medical schools in Britain and Ireland. It gives a tantalising glimpse of the medical profession as it stands now and of the profession as it might be in the future. It shows very clearly that the medical profession of the future will be one which is much more integrated in a world concern than the medical profession, I dare say, of the immediate past.

Originally I believe medicine and, to a large extent, medical education were more integrated than the way in which specialisation has forced them to be over the last couple of decades. The wheel is now turning again and we are coming back to the situation of not only the patient but of the doctor in a social context. If I may quote from a recent number of The Times Higher Education Supplement for the 30th September, 1977, it states:

The survey detected a fairly general movement to extend students' experience beyond the traditional, hospital-based clinical disciplines into the community outside. The time and resources for teaching community medicine are expanding, and by next year all United Kingdom schools will include general practice in their curricula.

In the 17 medical schools, teachers of social and community medicine "are concerned to do more than impart information: they hope to influence students to adopt and retain new attitudes. They wish them to become permanently conscious of the wider context in which disease develops and medicine is practised, and to respond appropriately by being more ‘rounded', competent doctors. Their care of individual patients will benefit from their understanding of the wider social picture".

These are the standards to which the Irish schools will have to measure up in the future not just in order that our medical graduates will be as employable elsewhere as they have been up to now but so that the quality of medical care they will give to the community which has nurtured them and, by and large, paid for their education will be an adequate and appropriate one.

Dr. Browne

I would like to congratulate the Minister and wish him well in his very laudable ambition to be the finest Minister for Health we have ever had. I hope he succeeds because health is a particularly rewarding ministry in any Cabinet.

This is a welcome Bill because it is an attempt to adapt to modern needs a sphere of activity which is clearly quite unable to function in the way in which it was intended to function when originally instituted. The practice of medicine in our society falls short of what it should be. It would repay the Minister to think back carefully over the history of successive predecessors. Health as a Ministry has had a very uneven record. All Ministers, I believe bona fide, attempted to do what they felt was right, with a couple of exceptions, as far as the medical profession is concerned and ended up at loggerheads with the profession. The late Mr. Childers was one of the few who succeeded in getting away unscathed, and to a certain extent possibly Deputy Tom O'Higgins. It is notable that with both there were considerable concessions to the medical profession—in one case the Voluntary Health Insurance, a very important aspect of our service, and in the other the very lucrative fee-for-service principle. I disagreed with that particular approach because I believed the money could be better spent. The advice, and this is where this council is so important, from the medical profession would have been a fee-for-service type of approach rather than, quite obviously, the other extreme, a salary from some kind of panel, so much for each patient and the rate fixed each year.

Some people may think that the fact the Minister is a lay man constitutes a difficulty but he is obviously well advised in his Department. I belong to the profession and the profession here as in all western European countries is a notoriously politically powerful profession and has used that power mostly for the preservation of a very high status in various societies. With very few exceptions that has been the evolution. In a society such as ours where the dynamic is the profit motive, presumably that is perfectly in order. I do not agree with it but in terms of the cultural attitudes of our society it is perfectly reasonable for doctors to adhere to a principle adopted by others.

It is worth remembering when setting up a body such as this that that will be a very important, predominating determining factor in the approach of the profession to the different problems the Minister will put before them in the future and is putting before them in this legislation.

Now I want to make it perfectly clear I am not seeking to be in any way offensive about the medical profession at all. We are all of us greatly indebted to many of the profession and people with records like mine are particularly indebted to the profession. For that reason, I believe as far as most of us expect, if we have not been in debt we will be at some stage; this tends to temper our approach to the consideration of this important problem of the quality of medical service which we will get from the medical profession. Essentially, this is a selfish consideration which we must put aside. We must think of what is in the public interest when we are dealing with these people. As politicians, we have tended to be rather frightened of them and they are very frightening because they are particularly powerful. So, while the Minister is in the honeymoon period with the profession and has not come up against them so far, it is worth bearing that in mind when he brings in a Bill of this kind.

He should also bear in mind that this is a Bill which will probably be reviewed in the year 2000 and something; it is here for a very long time. Many of his successors in office will be operating within the terms, the implications and limitations of this Bill. Therefore, whatever his social attitude and ideological position is on all these things I suspect there will be Ministers who will succeed him who will have different views, probably more advanced. It is possible that in these proposals he is cutting a stick with which to beat himself later on should the relationship change between himself and the profession. Because of the composition of this body I suspect that he is cutting a stick of considerable proportions to beat some of his more radical minded successors in office.

The Bill is old fashioned in its general orientation, in its attitude of a special position for the medical profession. It is out of date. As Deputy Horgan said, considerable changes have taken place. The profession that I came into and the profession that exists now are poles apart. The profession is infinitely improved in the quality of the individual in practice. There are still diehards of my generation within the profession but the new intake is not only extremely highly qualified but is better qualified because you cannot get into a consultant situation and then into a position as a consultant in a hospital unless you are extremely well qualified now because of the appointments system. It is no longer confined, as it was in the old days, to the Knights of Columbanus on the Catholic side and the Freemason Order on the other side. There are higher competitive standards largely established by the Local Appointments Commission for public appointments. You are dealing with more forward looking people in the profession now, many of whom have had practice outside the country, many of whom have served their apprenticeship in the British National Health Service and to that extent they have been weaned away from the simple preoccupation with how much they can make out of the profession which was the old attitude of a number—not all—of the members of the profession.

The medical profession attempts to adopt another feature of the Catholic Church, this mantle of infallibility about positions they take up at any time. The interesting thing about the profession is that if you go back into their history I suspect there are very few professions with such a depressing record of total human fallibility on so many of the—at the time—sacrosanct immutable positions they took up. Obvious ones are their complete conviction that bloodletting was a wonderful thing for various diseases, apoplexy, liver diseases, kidney and stomach diseases and any other diseases you wish to mention: much of the time the bloodletting had the effect of killing the patient: the application of leeches—obviously quite unthinkable now. Again, there was this pretentious, pompous assumption of infallibility and its assertion on the patient at God knows what cost in unnecessary suffering and pain and obviously ending with the death of the victim.

I recollect in my own time in the years in which we did not understand what one should do to try to get tuberculosis right, there was a succession of papers month after month containing assertions by various physicians that this was how you cured this disease. And they were wrong continuously over 150 years.

I am trying to say to the Minister that when he is approached by these people, if they assume too much arrogance and assert their infallibility and his ignorance because he is a layman, he should think back on their record and it might give him a little assurance. They have been wrong on many occasions. In fact, we have just moved from the witch doctor phase of medicine in which the doctor's main function should have been to leave the patient alone and he would have improved anyway—but that would not have been something for which he could have charged a fee—into a phase in which we now have this marvellous new development of the research chemist, of advances in chemotherapy which we simply apply but which people like Fleming and the great scientists discovered. They provided wonderful drugs, from penicillin on and that changed medicine. We are no longer at the witch doctor stage and we should have more self assurance. We had to be arrogant, pompous and assertive of our infallibility in the old days because we did not know what we were talking about and we had to reassure the patient that we did know. Now, most of the time a doctor can be sure of what he is talking about and, therefore, should be less insecure than he had been in the past.

The Minister has continued to accept that this must be a self-governing profession. Why should he do that? Why should these people be privileged in this way? As Deputy Dr. O'Connell said, times are greatly changed. The person on the receiving end is the consumer. There are an enormous number of very valuable consumer organisations. Some are concerned with children in hospital and what happens to them in hospital. These are greatly under-represented, in my submission, on the board established under this section.

I have said that as a profession we are very much more sure of ourselves now than we were. Lest the Minister might feel he could have complete faith in the judgment of doctors even in this situation, I just have to mention the one dreadful word "thalidomide". Here we found doctors doing something which had appalling repercussions for the unfortunate patients even in this more enlightened age. In relation to my own profession, psychiatry, we read last night the perfectly legitimate criticism of the presumption by psychiatrists that they can change people's personal relationships or social conditions by giving them large doses of different kinds of pills, the libriums, the valliums, the largactils, and all the rest, when they know this cannot be true. All they do is stupefy the individual and reduce his consciousness, and possibly make life less intolerable for the lady living in a high-rise flat.

I would ask the Minister to give very serious consideration to this section. This is the section I am interested in, the medical politics of this Bill. I do not think anybody will now doubt but that we as politicians must concern ourselves with medical politics. We cannot doubt but that the record of doctors in politics has been consistently and universally reactionary and opposed to any serious, real advance in medical practice as it affects the consumer, the individual in society. As far back as the Truman era, they opposed medical schemes in the United States, and up to the establishment of the British National Health Service. There is no doubt that, while many of these services including the British National Health Service, have big defects—one of the defects is due to the lack of spending—broadly the principle adopted in the face of the opposition of the medical profession was quite obviously legitimate, valid and well worth while and has given the British, with all its faults the finest health service in the world. That was done against the opposition of the medical profession.

The Minister should look at this section again and try to strike a much more even balance in favour of the consumer. Four persons are appointed by the Minister against 21 from the various colleges and universities, the College of Surgeons, the College of Physicians and the College of Psychiatry, and various people like that. Those four unfortunate people will simply have to rubberstamp the decisions of the medical profession about their future in our society. Would the Minister not consider increasing the representation of lay people, men and women, in order that somebody will look after his interests? The Minister is a layman and, as our Minister for Health, he is representing our interests.

This Bill is not simply a straight replacement of the old Medical Registration Council who were relatively unimportant because they simply kept a list of the number of people who qualified. This is a very far-reaching Bill in its implications about the establishment of standards for consultants, the assessment of colleges which award degrees and the whole orientation of the medical profession in these very important years ahead. As he said the other day, we have only a limited amount of money and this dictates his attitude to a free, no means test health service. I believe, for instance, that in the distribution of money, where there was a limited amount of money, it was very misguided of the then Minister to opt for the fee-for-service principally, but he did this and, of course, pleased the medical profession because a number of them make enormous amounts of money out of it.

One can get popularity in that way but, because he is paying so much for that service, the Minister is now left with the difficulty of finding money to extend the service to cover everybody, as I propose, in a free no means health service. I do not blame the doctors for making that representation about the fee-for-service scheme. It is their business to look after their interests in this kind of society. I did not expect them to make any other kind of representation. The Minister for Health is a lay person attempting to arbitrate between his employees the doctors and the consumer, the sick person. This is where he must try to keep his head and try to spend whatever limited funds are available to us to the best advantage of the consumer without doing any disservice to the members of the profession.

One wonders why there is no representation from the members of the nursing profession on this body. They work closely with the doctors in all aspects of their professional lives but on most occasions that we legislate for nurses, a doctor, or more than one, finds his way on to the boards which order the affairs of the nursing profession. Why could not the position be reversed?

The other important matter for which this body will be responsible is the question of the consultants, the courses and the curriculum. Is it not misguided, to put it at its mildest, in the context of the great changes that are taking place in all our societies, even a backward one like our own, to hand over to a predominently medical body, which the medical profession so greatly predominates in its authority, the control of this body? This body will have the determination of the curricula for degrees, courses and the establishment of standards. Has the Minister considered the full implication of section 31 which is concerned with the people who shall be registered in the medical register, particularly in relation to the EEC? Does the establishing of the position of reciprocity between ourselves and the countries of the EEC become operative? This is a far-reaching proposal, particularly for the Minister in setting up this kind of body. Can he tell us what he envisages is likely to be the inevitable proliferation of personnel in a body of this kind if it is going to carry out this work? Are we going to give blanket approval to diplomas and degrees awarded to people in other EEC countries or by what mechanism do we propose to establish that we should, in the interests of the consumer—the sick people and our hospitals—accept these diplomas and the principle of reciprocity?

Will we have any right of access to the awarding colleges, medical schools or their hospitals? How far does the Minister propose to pursue this aspect of establishing that there should be reciprocity? Are we simply accepting something because it is being imposed upon us by the EEC? To what extent —in this I am being a little pretentious—are we going to try to insist that the quality of medical care which in my view is reasonably high here will be the kind of service we will get from anybody who comes here inevitably as a result of this reciprocity principle from some of the other EEC countries? Unless it is simply a nominal provision which has no serious power, no implications, if the Minister concedes the right to reciprocity how is he going to be certain that an Italian doctor or doctors from France, or Germany have the kind of attitude to medical practice that is wanted here? This brings us up to some very interesting questions, including things like euthanasia, contraception and therapeutic legal abortion. Is the Minister going to limit their right to this kind of thing, to be taught this kind of thing, to practice it? If he is, how is he going to do it? This is a wide, far-reaching decision on the part of the Minister. In order that our medical practitioners going to those countries with whom we have established reciprocity in the development of their education and in the education curriculum are we going to equip them with these skills, specifically in regard to things like contraception and therapeutic legal abortion where it is needed?

Can we disapprove of a graduate who comes here because we do not agree with his moral attitude on these different very contentious issues in our society? What happens if these people come here in order to establish our right of reciprocity in Europe and find that they do not like what they see? As the Minister may recall, this happened once before when a group of Americans came here and looked at our hospitals. I am proud to say that the only hospital they approved of completely was the local authority hospital in Galway, the regional hospital, because it had links with the university. Recently we had a visit from a group representing the Royal College of Psychiatrists of London. They visited our psychiatric hospitals and had a very depressing tale to tell not only about the general standards. On the question of whether they could recognise those hospitals as training centres for the degree of the Royal College of Psychiatry they were doubtful about a number of our hospitals for many reasons.

There is another interesting aspect to that. I may sound very self-satisfied when I say that the hospital I happen to work in was considered to be the best equipped hospital for these services at the time. The important point is that shortly after that there were severe cuts in the allocation of money to the various hospitals by the last Government.

If the same visiting committee returned to our hospital a few months ago, they would find that as a result of those severe cuts it had plummeted down to much the same standard as all the other sub-standard hospitals.

I am not scoring a political point. I am simply making this point: if the Minister is faced with the various investigating bodies which come here to establish the right of our country to have reciprocity with European countries, what is he going to do if they say "Yes, you can have reciprocity in three years time after you have rebuilt this place, added to that place, re-equipped this place, added so many staff to that place and generally up-graded the quality and level of the services in your various hospitals, clinics and institutions"? Where will he find all the money to do that? Has the Minister studied the implications of the principle of reciprocity with these other countries, some of which are very wealthy and can afford a very high standard of service, or is this simply window dressing? Is there any reality?

Obviously, the medical profession are not the Minister's best guide. Without a doubt he must have consultations with them and get advice from them, but their record is particularly poor in relation to enlightened attitudes to health legislation. This has happened all through the years, and it does not matter which Minister is in power or even in which country they are operating. Shaw was not far from it in his Doctor's Dilemma with the doctor "stimulating the phagocytes" and Molière in Tartuffe and so on. It is worth bearing all these things in mind; these were studies from life. The Minister appears to have been over borne in the gross imbalance of the number of professional people and the handful of unfortunate laymen who have very little chance of putting the layman's point of view in this extremely interesting and very important part of the life of our community.

There is the misuse of hospitals, the virtual absence of policlinics in our society, the lazy-minded approach to the use of beds: a bed is a very expensive commodity which should be used with the most rigid economy in consideration of its optimum use. Instead, people go into hospital on Friday night and are not seen by a doctor until Monday—two-and-a-half days wasted. Most of these services should be carried out in policlinics and a bed should only be used practically as an intensive care unit. Their advice to the Minister over the years has not been good. Unfortunately, there is a vested interest in keeping a bed occupied because of the general principle of the VHI where one gets paid for a person in hospital and not for a domiciliary care service. These aspects of the general principle of the expansion of a service determine the quality of the service a consumer will get. I accept that the Minister has not unlimited money but I do not think doctors are the best people for the Minister to go to to find out how he should spend the money he has available. They should be given every consideration in consultation——

Mr. Haughey

The council will not be advising on the spending of money.

Dr. Browne

This is my case, indirectly they will be because they will be determining the orientation of the medical profession leaving the medical schools and the general principles they will adopt. I gave the illustration of the fee-for-service. That was a bad principle—very good for the doctors but from the community's point of view it was unwise of the then Minister to accept it. It is all over now and there is nothing we can do about it. The old Chinese principle was much better where the doctor would stop charging——

Mr. Haughey

You paid him when you were well.

Dr. Browne

That is right, and when you were ill you stopped paying him. That is an important principle and underlines all these things——

Mr. Haughey

For most of us would it not cost us a lot more?

An Leas-Cheann Comhairle

Doctors' fees and charges do not enter into this Bill. We are broadening the debate.

Dr. Browne

I accept your ruling but the principle I am trying to establish is that they are a dangerous guide to a Minister for Health in attempting to establish the broad pattern of his health services and they will be advising him in so far as they will be determining the kind of graduate who will be running his health service in the years ahead.

In relation to the attempt by this council to determine curricula and then to see that they are carried through, could the Minister expand on that aspect of his proposals because this seemed to mean a very notable increase in the personnel needed by this body if they are going to carry out this function conscientiously?

Section 38 (4) reads:

The Council may, with the consent of the Minister, withdraw recognition from any body recognised by it pursuant to subsection (3) of this section.

This presupposes that the council will be in a position to go into the whole training procedure of any or all of these bodies at their discretion and then they will be in a position from the professioinal point of view to assess the merits of any particular course. Surely this is a very great widening of the powers of this council? Section 38 (2) says:

The Council may, from time to time, specify in relation to each speciality recognised by it, the titles and designations of qualifications in specialised medicine granted in the State which may be required to enable a person to secure registration in the Register of Medical Specialists.

This presupposes—and this is probably what the Minister has in mind—an increase in the staff of this council which will be able to monitor all the bodies which will award degrees and continuously assess standards and then feel they are in a position to say the standard is correct or is too low and because it is too low you may not continue to award this degree. This again is like the reciprocity principle; it is a further considerable extension of the powers of the old council.

There are other points we will deal with on Committee Stage which I hope will help make this as good a Bill as possible. I very much regret the predominant doctor-orientation in the Bill. Doctors in the past have always taken a very consistent class attitude to the whole question of medical practice. This probably will permeate their whole attitude to the continued training of doctors and the kind of doctors they will be turning out of our medical schools will resist the more community orientated type of doctor now being turned out in Britain in the British National Health Service where doctors are orientated towards preventive medicine rather than towards sitting around waiting for an individual to come into a hospital for treatment. The only notable advances in preventive medicine have been made by the State and there has not been the same concern by private medicine about the preventive side of medical practice. This kind of orientation will go on with this kind of council in the kind of young person being turned out of the medical schools. This will affect us as politicians because they will resist perfectly legitimate claims by us for changes which would lead to improved services. Therefore, we have a very important vested interest in deciding whether the consumer is properly represented here or not.

I recall when I was Minister being asked about something that happened in one of the voluntary hospitals. I replied to the person that I would inquire as to what went wrong. I wrote to the voluntary hospital and asked what had happened and they replied, quite correctly, that as a matter of principle I had no right to any information but they answered the query. The unfortunate person could not have found out the reply himself. Deputy Dr. O'Connell is right that the lay people must have a much bigger say in what goes on in our hospitals and clinics and in the education of our undergraduates in our hospitals. We are all paying for them as taxpayers. The Minister is going overboard, most regrettably, in giving this enormous power to the medical profession on this council. In all aspects no matter which way we look at it from the question of education to the question of general practice, to general attitudes and social attitudes of these people and of this council with its greatly extended powers, we will spend a considerable amount of money in establishing proper liaison with the European hospitals if we are to monitor them efficiently and effectively and in establishing a monitoring service for the various institutions, hospitals, colleges, universities and medical schools which will be concerned with the educational process. The taxpayer has a very big interest in this matter whether he is a consumer of medical practice, hospital services or whatever. Even if the Minister is determined that he will not have trouble with the medical profession and will run the service the way they want it run, I beg the Minister to have some consideration for those who will come after him who will probably be prepared to take a very much more enlightened approach to the organisation of medical care in a society so that nobody in that society can say that because of the lack of money they suffered any hardship. This Bill could indirectly lead to the production of a completely different type of medical profession which was not simply chosen on the old class basis of father to son but on the guidance of vocational advisers so that the person going to be a doctor is the best fitted to be a doctor. In China this is how it is decided. The local commune decides who should be the medical person in the area. That is the correct way to decide who should be a doctor. This is a definitive Bill which will determine this process over the years ahead. I very much regret the general orientation of it but I welcome the Bill otherwise.

Mr. Flynn

I congratulate the Minister on his appointment as Minister for Health and Social Welfare. The Minister has proved himself a most efficient and effective Minister for Health and has recognised the fact that much needs to be done and much is expected of him as Minister. Already the Minister has proved himself a man ready to listen, a man who understands and has the courage to take the initiative. These traits were displayed in every Ministry he ever held.

The obvious importance of this substantial legislation is readily agreed by Opposition and Government alike. In promoting this comprehensive legislation, Deputy Haughey has shown that he appreciates its significance in gearing our health services in this modern technological age. The Minister is to be complimented on tackling our health problems by starting with the fundamental issues of registration, education and training of our medical practitioners. The all important section dealing with the disciplining of doctors who act in breach of their professional rules will probably concern laymen most of all, but it is no more important to health than the other provisions of this Bill. The new medical council will differ substantially from the Medical Registration Council in that it has 25 members.

The establishment of this new, broadly-based medical council with its chief officer and appropriate staff is a welcome and long-awaited development in health matters. Of course, a function of the new council, above the traditional register, will be the set of registers of specialists with different specialist qualifications. Now we can be assured that only those suitably qualified and trained will be registered and allowed practise here in future. This development is in line with the practice obtaining at present in other EEC countries. I understand it is not yet the practice in the United Kingdom. Therefore, in that regard the Minister is to be complimented on taking the lead in bringing our services into line with other practices in the Community. An indication of the Minister's universally known attribute, that of consultation before action, is evidenced in this Bill by the wide spread of representation on this council. To help it in its deliberations it will have the representatives of the practising profession together with those of the different specialities and interests in medicine.

The four nominees of the Minister will play a significant part in the running of this council. They will represent the State and the public at large. It is hoped the Minister will use his powers to include among those four persons people other than medical practitioners. If the amount of correspondence to newspapers, magazines and periodicals of all kinds and, indeed, communication with reporters at all levels is anything to go on, those four nominees will be fully employed. We might well impress on the Minister that those four people would best serve our situation were they not medical practitioners in their own right. Indeed, I would be so bold as to suggest that what the Minister has in mind in initiating this legislation is the harmonisation and improvement of the public health facilities here. There should be co-operation with and co-ordination between public health services, social security and private health insurance. In future it will be necessary to carry out a statistical analysis to assess the health needs of the population and meet them in a rational manner. Indeed, preventive medicine should be concerted with curative medicine; hospitals in a particular health board area should pool their highly specialised techniques and therapy with corresponding improvement in the health facilities available to the population at large. We have the modern management techniques set up by a former Fianna Fáil Minister for Health. This Bill will couple them with a uniform, concerted medical standard.

It has often been suggested that some of the health boards are overweighted with administrative staff. My opinion is that the management structures we have now are capable of administering any development service the Minister might ask of them. What is necessary is an increase in their workload in conjunction with the extra development of catering for the needs of the community. We can expect that kind of performance from a caring Minister for Health.

I welcome also the Minister's proposal of ensuring the freedom of establishment for doctors and medical practitioners, that is, the freedom to carry on business in different areas of the Community of which we are now part. There is need for mutual recognition of professional qualification and the harmonisation of medical education and training. As far as Community nationals are concerned I envisage the end of the present national restrictions on practice by our doctors in other EEC countries and the mutual recognition of degrees and other qualification in the co-ordination of the conditions governing the practice of medicine. The new council will have to concern itself with reconciling our training and educational facilities with the best available in Europe. I believe that the standards of our medical schools will equal, if not surpass, the best to be had throughout Europe. The points system in the leaving certificate may not be the best for selecting those desirous of entering medicine. However, it would be fair to say that it has served us well in the past in that the Irish medical practitioner at home and abroad, has earned the respect of the world at large.

I might refer to one point so far as educational training is concerned. It reflects a situation in which I was involved in the recent past and it has some bearing on the Bill. It has been recognised always that school children should receive a minimum of three hours physical education per week—that is according to the specialists—and that the emphasis be placed primarily on the physical and mental health of the pupil rather than on performance in competitive sports. This new council should support the medical organisations designated to carry out the functional tests necessary for the healthy practice of sport. Our new medical practitioners should be trained adequately in this field. The council should encourage and advocate exchanges between sports medical specialists here and in other countries so that the minimum standard of our EEC partners will apply to our health services. I suggest also that more medical fellowships be made available to our medical practitioners to enable doctors and specialists familiarise themselves with techniques in other countries.

The proposals in regard to the control of fitness to practice are welcome also. Our present arrangement allows of one single action, erasure from the register. The new, alternative, procedures of disciplinary powers of temporary suspension are sensible especially in cases of ill-health, be they physical or mental. They allow for temporary suspension for set periods to censure doctors who, after investigation, are deemed to be in breach of professional discipline. The powers the new council has to establish a special fitness to practise committee are very welcome. They afford aggrieved persons an opportunity of complaining without fear of reprisal; alleged misdemeanours or professional misconduct can be investigated now in a frank and determined manner. Also the Minister will be fully informed on all matters relating to medical misconduct and behaviour. I hope it will be possible to convey this message to the lay person about whom we hear so much. When interviewing a lady complaining about the level of service being rendered to her or a member of her family it is very difficult to ask her to supply details to anybody for investigation let alone to the medical council.

I sincerly hope there will be built into the regulations of this new council the proviso that anybody who has reason for complaint or a genuine grievance to bring before it will be guaranteed freedom from reprisal. That has always been the main fear of the lay person as far as the medical practitioner is concerned; indeed, the lack of that function was a great disability of the present body.

I hope the Minister will indicate the number and the type of members who will sit on the committee dealing with fitness to practise and that he will reassure the public that they can always be assured of a fair and impartial hearing in respect of any grievance they may wish to bring before the council. The right of an aggrieved person or a medical practitioner to bring his case to the council is incorporated in the Bill and this is very welcome. It shows the Minister's concern to ensure that justice is done and is seen to be done and that is extremely important so far as medical matters are concerned.

I should like to congratulate the Minister on taking the initiative in these matters and on bringing this worth-while legislation before the House and I should also like to compliment him on attaining office as Minister for Health.

Mr. R. Burke

I should like to join with the previous Deputy in congratulating the Minister for Health on taking on this very important and difficult office. He has an onerous task ahead of him in view of the many demands made by the public and by medical practitioners generally with regard to medical services.

There have been many worth-while contributions during the debate. I should like to restrict myself to one particular practice of the medical profession which is not covered satisfactorily in the Bill and which needs general and serious consideration. I am referring to the practice that has developed in the past number of years, particularly in the area I represent and in the greater Dublin area, of the locum or “contract” system whereby a patient who may wish to secure medical attention for himself or his family and who seeks aid after 9 p.m. or 10 p.m. finds he is unable to contact his own doctor. He is merely referred to a locum for attention.

The explanatory memorandum to this Bill states:

1. The objects of the Medical Practitioners Bill, 1977 are—

(a) to provide for the establishment of a new body, to be called The Medical Council, whose main tasks will be—

....

(e) to repeal existing legislation dealing with the regulation of the profession of medicine.

The profession of medicine carries with it the right to practise in a particular area but it also has obligations. In my view if a number of doctors are practising in a town or village they have an obligation to provide a service on a 24-hour basis. If it involves a group practice so be it, but if it does not involve such a practice——

An Leas-Cheann Comhairle

That has nothing to do with the Bill. There is nothing about the locum system or whatever the Deputy calls it in the Bill.

Mr. R. Burke

Far be it from me to argue with the Chair. It was not my practice in the past and I do not intend to make it my practice in the future. The explanatory memorandum to which I have referred sets out the objects of this Bill and it states:

(e) to repeal existing legislation dealing with the regulation of the profession of medicine.

In my view the profession of medicine involves a 24-hour service to the general public and we are not getting that at the moment in the city and county of Dublin. I want the Minister on Committee Stage to bring in amendments to this legislation that will rectify a glaring anomaly in the practice of medicine as described in this Bill. I am referring in particular to instances where members of the general public who phone for medical aid after a certain hour at night are transferred by way of an answering service to a locum. That person will not get his own doctor or a local doctor but he ends up with somebody from a central service who has no idea of his circumstances——

An Leas-Cheann Comhairle

That has nothing to do with the Bill before the House. The practices of doctors in Dublin city are not relevant here.

Mr. R. Burke

Then I will deal with it on a national level.

An Leas-Cheann Comhairle

The Deputy will get an opportunity on the Estimates debate or on some other occasion to deal with the matter. We are dealing here with the establishment of a registration council.

Mr. R. Burke

I will deal with it under Part V of the explanatory memorandum which has the heading "Fitness to Practice". I hate disagreeing with the Chair.

An Leas-Cheann Comhairle

I accept that but I must point out that the Deputy is doing that. Rather, he is disagreeing with what the Bill is about, not with me.

Mr. R. Burke

Part V of the explanatory memorandum states:

The aim of Part V of the Bill is to up-date and extend the disciplinary powers of the Medical Council in relation to the practice of medicine and to ensure that these powers accord with the provisions of the Constitution of the State.

One of the disciplinary powers of the Medical Council should be in relation to the matter of rights and obligations in performance of the practice of medicine in certain areas. If a doctor puts up a plate outside his door announcing that he proposes to practise medicine he has rights but he also has obligations to the people in the area. In my view this is covered by Part V of the explanatory memorandum which deals with fitness to practise. One of his obligations is to provide a service to people, not just when it suits him but also when it suits his patients and their families.

An Leas-Cheann Comhairle

That has nothing to do with the fitness of a doctor to practise medicine. We are entering the whole area of medical services and we cannot discuss them on this Bill. It is not relevant to this debate.

Mr. R. Burke

I am sorry you are being so difficult on that because we have a very difficult situation in regard to the medical profession in this city and county.

An Leas-Cheann Comhairle

We will have to deal with it on some other Bill, an Estimate, a motion or some other way. We cannot deal with it on this Bill.

Mr. R. Burke

We can deal with it on this.

An Leas-Cheann Comhairle

Sorry Deputy, you cannot.

Mr. R. Burke

I welcome the Bill we are discussing and also the Minister's initiative in bringing it into the House.

Mr. Harte

Which Bill? Is it the Deputy's or the Minister's?

Mr. R. Burke

I am sorry that the Minister's predecessor failed during the four years he was in control of the Department of Health to take the initiative which the Minister has in the three months he has been in office. I congratulate him on doing that. Medical ethics and medical practice since the foundation of the State has been a very difficult matter for all Ministers for Health. I am glad the new Minister has grasped the nettle and has now decided to deal with this matter. Our doctors have been doing an excellent job.

An Leas-Cheann Comhairle

The Deputy cannot deal with that on this Bill. He cannot say whether or not the doctors are doing an excellent job. It has nothing at all to do with the Bill. It deals simply with the training of doctors.

Mr. R. Burke

I want to refer to the explanatory memorandum which states:

The objects of the Medical Practitioners Bill 1977 are—

(a) to provide for the establishment of a new body, to be called the Medical Council, whose main tasks will be—

(i) to register and control those engaged in the practice of medicine.

I believe that those engaged in the practice of medicine are doing an excellent job with certain reservations. The explanatory memorandum goes on to say:

(ii) to regulate medical education and training, at undergraduate and postgraduate levels.

I am glad to see that the Minister is doing this. It then states:

(b) to provide for the membership of the Council,

(c) to up-date and to extend the disciplinary provisions in relation to the professional conduct of doctors,

You and I fell out a few minutes ago about the professional conduct of doctors. I would like to see, in regard to the 24-hour service, group practices rather than the single practices we have and the contractual service. I would like to see the Minister under paragraph (c) encouraging group practices in all the towns of the country. The explanatory memorandum continues:

(d) to make consequential provisions arising from the accession of the State as a member of the European Economic Community, and

(e) to repeal existing legislation dealing with the regulation of the profession of medicine.

Surely we want to see a break with the link with England? I applaud the Minister for paragraph (d). Paragraph (e) is very simple. I am sorry the Leas-Cheann Comhairle and I had to fall out on his first joust with me across the House.

An Leas-Cheann Comhairle

The Leas-Cheann Comhairle will not fall out with anybody.

Mr. R. Burke

I bow to your ruling at all times. I hope the Minister takes into account the points I was making which were ruled out of order, that we should have something done about group practices in Dublin city and county.

An Leas-Cheann Comhairle

The Minister cannot take them into account on this Bill, He would not be in order in doing it.

Mr. Briscoe

I will try to stay within the confines of the Bill. I recognise that this is a debate on the work of the council and not on the work of the medical profession. I have a few comments to make about the Bill. I am very happy to see it and I am also very happy to see that the Minister has decided to add more people to the Medical Council and also that he will appoint a person or persons—this indicates that he may have more than one in mind—whose role on the council will be to act as watchdog for consumer interests, that is the public. That is a very welcome step because one of the problems with the existing register of practitioners is to feel that justice is being done when certain complaints are made to the board.

It would be impossible, with 11 people, to cover all the various aspects laid out in the Bill. The council should be able to do this now that the membership is being increased to 25. I appreciate that the council will have a great deal of work to do. The Minister referred to the many hours of work put in by the various advisers to the committee which was originally set up in 1975 to report to the Minister for Health on the setting up of a Medical Council. The Minister also stated that Part III of the Bill, which deals with registration, contains an important provision which will enable the new council, should they so decide, and should the Minister consent to establish and maintain a statutory register of specialists. It is very important that the Medical Council should have a list of the specialists in the various fields of medicine. This is a little indefinite. I hope the Minister will give the reasons why it is not more positive. I am sure if they decide to do this the Minister will give his consent. The Minister also stated that one of the advantages of such registration would be the information it would convey to the public at large with regard to the qualification and training of doctors engaged in specialised medicine.

This is a very important Bill. When a Bill like this comes before the House it is often too technical for the general public. This Bill will effect every man, woman and child in the country. I urge the Minister, through the Health Education Bureau or some other way, to make available to the public easily understandable information of what this council will mean to them. This Medical Council is something more than a body to control the medical profession. It is a charter of rights for the people the medical profession serve. We should not underestimate the importance of this Bill with regard to what it spells out for the practice of medicine in Ireland.

The Minister stated that because of the amount of work which will confront the members of the new council from the time they take up office it will probably be some time before they will get down to deciding whether or not to make proposals to the Minister for the establishment of the register of specialists. I feel I have dealt with that point.

I should like to refer to the Apothecaries Hall which went out of business in 1971. There is an old expression in Ireland, known throughout the world, "Gone to pot". That really referred to the Apothecaries Hall. People who failed to get degrees in medicine went to the Apothecaries Hall and got a lesser degree there, and many of them became excellent medical practitioners. As Deputy Horgan said, the task of deciding the educational qualifications of someone who is to become a doctor is very important. It would be a crime to prevent someone who has a vocation to the medical profession from becoming a doctor because his academic education is not sufficient. Years ago in the Royal College of Surgeons there was a professor who, when addressing students who had completed their final examinations, said: "There are those of you who have obtained first-class honours and have been brilliant students and there are those of you who have been the last, but I predict that those somewhere in the middle will be the really great doctors". This is frequently the case. As the Minister once said, academics should stay in their academies.

Mr. Haughey

Hear, hear. We sent a few of them back there.

Mr. Briscoe

I should hate to think that this body of 25 very important people might decide to limit the number of doctors. If a person wishes to study medicine, then he should be permitted to do so. Am I walking the tightrope of order?

An Ceann Comhairle

Slightly.

Mr. Briscoe

I hope the council will ensure that people whose fathers, perhaps, are members of the medical profession but who may not have achieved the high marks necessary for entry to a school of medicine will have the opportunity to study medicine, based on an assessment of their desire to enter this field. The Minister has a big role here and I know he will be sympathetic towards this aspect.

I should like to pay tribute to the fact that the Apothecaries Hall enabled people to practice medicine very successfully. I am sorry it is no longer there because it served a good purpose.

I am very happy with the composition of the board. It is proposed that ten fully registered medical practitioners engaged in the practice of medicine in the State shall be elected. That aspect pleases me. One, at least shall be engaged in community medicine. I am a great believer in staying in touch with the people. Two of these doctors are to be general medical practitioners. Again, these are the people who are very much in touch with what is happening. There is a tendency in the medical profession for an élitist group to emerge but this Bill recognises the general practitioner, the ordinary Joe Soap. He will have a say in how this board will conduct its business. At least one of these ten doctors shall be engaged in hospital practice.

I should like the Minister to say what the relationship will be between the Medical Council and hospitals, as opposed to doctors. I am particularly concerned with the situation that arises when a general practitioner recommends that a person should go to a specialist. In a case I mentioned in this House a couple of years ago such a person got an appointment to see a specialist after three or four months but was actually seen by a houseman who knew less than the general practitioner. The houseman was given the responsibility of deciding whether that patient should be sent on to the registrar. I should like to know what power the council will have to deal with such situations.

Because of its many functions, I do not know how the council will be able to operate on a part-time basis. I understand that they will not be paid full-time. It seems they will need some full time officials.

Mr. Haughey

They will have them.

Mr. Briscoe

This is very important because it will enable the members of the council to carry out their work conscientiously. At the same time we do not want them looking down the neck of every doctor. The medical profession has been very responsible and we are very fortunate.

I should like to know whether the Department of Health will have a relationship with the Medical Council especially in regard to a doctor who may have too many patients under the health service. Many years ago a doctor was called in by the Department because he had so many patients that he must have been seeing one per minute. Will the council be able to send for such a doctor and decide whether he has too many patients?

I welcome the provision in Part V of the Bill in relation to disciplinary action. It means that the disciplined person will be able to appeal to the High Court and that his constitutional rights will be protected. It means that the council will not be a kangaroo court and that the people coming before it will have an opportunity to appeal their cases.

In conclusion, I should like to refer to a point made by Deputy Brady, that is, the prescribing of drugs. Most doctors will agree that every tablet a person takes can produce side effects, even something as simple as an aspirin. Many drugs are prescribed indiscriminately. The Health Education Bureau can help to do away with the expectation of a prescription for tablets or for a bottle. Unless they leave a doctor's surgery with a prescription for drugs or a bottle, most people think they are not being treated properly.

I congratulate the Minister. I am aware of the enormous workload which he has taken upon himself and of the work he has put into the Bill since it was presented to him.

Mr. Taylor

Any legislation dealing with the improvement of the health services is important. It is rarely necessary to enforce disciplinary measures but it is wiser to have safeguards in the Bill. There have been instances of misconduct; indeed, there was a recent case of a medical practitioner who succeeded in playing a role over a long period. This Bill will ensure that such abuses are not repeated. We have had the benefit of excellent contributions, particularly from Deputies Browne and O'Connell.

Dr. Byrne

A Ceann Comhairle, is it in order that we speak to empty Government benches?

An Ceann Comhairle

It is not unusual for the benches to be temporarily vacant.

Mr. Haughey

As I explained, I was consulting the Chair about the procedure at 7 o'clock. I feel I am entitled to do that. I did not leave the House. I merely consulted with the Ceann Comhairle about the transaction of business at 7 o'clock. I recognise the Deputy's continuing anxiety about decorum in this House.

Dr. Byrne

On a previous occasion a particular Deputy, now Minister for Health, drew attention to the fact that I was sitting temporarily in the Minister's seat. He drew attention to the fact that while the seat was occupied it was occupied by a person of subservient office and was not fit to be addressed.

An Ceann Comhairle

Deputy Taylor has only ten minutes left.

Mr. Taylor

The intelligent contributions made by Deputies Browne and O'Connell were refreshing. It is fitting to reflect on the achievements of Deputy Dr. Browne during his period in office. I hope that the Minister will continue to introduce legislation for the benefit of the health boards, the medical profession and their patients. There has been a dramatic revolution in medicine since the days of the witch doctors. Part I of the Bill deals with the repeal of existing legislation but I am hopeful that it will embody the effective parts of the different Acts. Part II of the Bill deals with the establishment of a new Medical Council and provides for 25 members. I hope that the Minister will give some thought to the appointment of representatives of the nursing organisations to the council.

Part III of the Bill deals with the registration of doctors and specialists. I am assuming that the directives which were adopted by the European Council have been considered in relation to this part of the Bill. Our doctors are entitled to practise in other EEC countries and their nationals are entitled to practise here. Part IV of the Bill ensures that medical training and education meet with the minimum EEC standards. We all appreciate the quality and the dedication both of our general practitioners and of our specialists. In this regard the council need have no anxiety. However, it is wise to endeavour to improve standards wherever possible and that will be the aim of the council.

Part V of the Bill deals with the question of general fitness to practise medicine but one cannot anticipate the council being overworked in this area either.

The final part of the Bill deals with the question of the re-enacting of existing provisions in this new legislation. On the face of it the legislation before us may appear quite ordinary but it is very important since it affects every one of us. Consequently, the Bill is to be welcomed as should any Bill be welcomed which aims to improve the quality of life and of the health of our people.

Dr. Byrne

I have listened with much interest to the previous speakers, including the Minister for Health. This legislation reminds me of the old story that is told about a parliamentary deputation some of whom, on visiting a country abroad, had unfortunately indulged themselves in certain diverse activities. On their return they visited doctors at Harley Street who advised them that they should subject themselves immediately to amputation. This course of action, they were told, was the only course of treatment open to them. Later, while strolling through that section of London known as Soho they saw a name-plate which carried the name of a Chinese doctor whose charge per consultation was five shillings. They consulted this doctor and asked what treatment would curb immediately this illness they had and he replied: "You have consulted the doctors in Harley Street who have told you that amputation is the only remedy. Gentlemen, wait three more days and everything that you have, that you complain of, will amputate itself". It is with this that the legislation before us should be concerned.

In bringing forward legislation our aim is to equal the corresponding legislation in Europe but to date the situation is that any person who presents himself here as having qualified in medicine outside the country is allowed to practice here. The result of this is that doctors from abroad, be they black, white or yellow, can come here and practise although by our standards they may not be qualified medical practitioners.

We should insist that the qualifications of doctors wishing to practice here are in keeping with the qualifications of our medical schools. At present the situation is that decisions as to the employment of these people are left to individual authorities or persons in various parts of the country. Consequently anyone presenting himself as a doctor—he may be a doctor of economics or of philosophy for instance—can set up in practice and begin writing prescriptions.

Debate adjourned.