First of all, I greatly appreciate the manner in which the Bill has been received by the House and the contributions which have been made by Deputies on all sides. A Leas-Cheann Comhairle, from your experience in this House you will probably agree with me that the standard of debate on this Second Stage augurs well for the future of this Dáil. I hope that the spirit in which the measure has been received and the quality and range of the arguments put forward will be a constant feature in regard to other legislation. I am very honoured by the number of new Deputies who decided to make their maiden speeches on this measure.
A number of the points raised by Deputies are not particularly relevant to the legislation. They were important and interesting points and they were valuable from the point of view of the general administration of the health services. Even though they were not perhaps relevant to this legislation and to the functions of this new council, nevertheless I want to assure the Deputies who put forward these points of view and raised these issues that I shall keep them in mind in the general context of health administration. A number of the matters which were raised about the Bill dealt with the new council which is to be established, its constitution, its membership, its functions and the committees which are to be established under it, particularly the Fitness to Practise Committee. Reference was also made to the financing of the council and to the special register for specialists which will be established under the legislation. Some criticisms were made about the council itself as to its constitution and membership, but before coming to these I would like to talk for a moment about the general and fundamental principles on which the legislation is based.
I want to emphasise that this is primarily legislation which will enable the medical profession to regulate and control itself, and in this context I want to reject most of the arguments and criticisms put forward by Deputy Noel Browne in his very interesting and stimulating contribution. It is possible for me to recognise and admit that the contribution he made was interesting and stimulating while at the same time I contradict his basic thesis. I suggest to the House that in this country we are firmly committed to the idea and concept of our professions in so far as possible regulating themselves. One of the hall-marks that distinguishes a profession is its ability to control and regulate itself as a profession in the best interests of the community. I have no hesitation whatever in entrusting to the medical profession that task and that responsibility. We have the same situation prevailing in relation to many other professions. Solicitors in particular have their own legislation which enables them to control their profession, and if anybody thinks about it for a moment and examines it in depth it will be realised that this is by far the best way to do things. If you do not have a profession controlling and regulating its own affairs and imposing its own disciplines on itself, what other way could you achieve it? Would you entrust the task to some bureaucratic agency? Would you entrust it to some general purposes body of public opinion? When you look at it in depth you realise that by far the best way of doing this thing is to devise legislation which will enable a profession to govern and discipline itself in accordance with its own best traditions.
To anybody who would criticise that concept I would like to say that I have found—and I am sure that many other Deputies in the House have found the same thing—that when it comes to professional matters and protecting standards and traditions in a profession, the profession itself and the members of that profession are far more assiduous about that aspect than anybody outside the profession is likely to be. Very often you find in this area that a profession in disciplining, controlling and regulating itself is far more severe on itself and far more exacting and demanding than any outside body or person would be. In so far as this legislation is based on the principle of the profession, subject to the overall public interest and public control of its activities, looking after its own standards, procedures, discipline and conduct, that is easily the right approach.
Having said that I want to add that I cannot agree with Deputy N. Browne in his severe criticism of his own profession. Like most other Deputies in this House I am fully aware of the activities and standards of the profession. I was fully aware of the activities, standards and approach of the medical profession long before I ever became Minister for Health. While it is fashionable these days to criticise professions as élitist groups, I think that generally the medical profession does hold its own special place in the respect and affection of the Irish people. It has served them well and if in the complicated, complex situation of a modern society the members of the medical profession have to band together in an endeavour to protect their own interests as best they can in a competitive society, then they are perfectly entitled to do that. I could not possibly accept that they protect their own interests on any occasion to the detriment of the common good.
The traditions of the profession are as respected today as they ever were and the concept of dedicated service is still cherished in the medical profession today the same as it ever was. I do not think Deputy Browne need worry too much about there being a very strong pressure group so far as my being Minister for Health is concerned. First of all, I do not regard them as an unduly abrasive pressure group at all, but even if they were excessibly active in their pressurising, I would hope that I would be prepared to resist those pressures if I thought they were going beyond the bounds of what a particular situation called for.
I have a very high respect and regard for the medical profession as it presents itself to me today and in particular for the traditions of commitment and dedication which it has built up over the years. I have had, on a number of occasions, medical people coming to me and proposing courses of action which seemed to them to be desirable in the public interest. I have said to them on such occasions: "But if I pursue this particular course of action and if it is successful, it means that your branch of the medical profession will be superfluous." Very often medical men propose courses of action which will ultimately result in the complete eradication of a particular disease or ailment, and time and again I have been met with the reply by the representatives of the profession: "So be it. Even if this course of action results in our becoming superfluous in this area and there is no longer any need for our services in this area, the common good will have been served, the welfare of the community promoted, and we will be satisfied."
As to the council itself, the first criticism has been about its size. Here a number of factors have to be kept in mind. This is a representative council primarily. It is not an expert body. If it were to be an expert body entrusted with the implementation of some medical programme, then it would be a different type of body, but basically it is a representative body which hopefully will represent all the best people in the different areas of the medical profession, who will come together to decide on the issues relating to the control, the discipline and the regulation of their profession. It has to be a certain size if it is to be as fully representative as it should be. On the other hand, it cannot be too big, because we all know that if a council is too big effective power falls into the hands of a small executive group, committee or clique. I think we would all like this governing body of the profession to be as representative as possible and that the council, what-ever size it is, would be able to operate effectively as a council and not because of its size, have to delegate its powers and functions to some small section or committee.
Because of its function in the areas of under-graduate and post-graduate education, it is essential that the council represent the various bodies involved in these areas. It is also important that the general practitioner sector of the profession be adequately and fully represented. Some Deputies expressed anxiety about that aspect. They were afraid the council might be overloaded with academics or with specialists and that the general practitioner section of the profession would not get adequate representation. I will look at that again, but as far as I can assess at this stage, I think the mix is probably about right. There are only about five people who must be from the academics, and the rest of the members can come from any sector of the profession. In the normal operation of things, because general practitioners constitute such a large body of the profession as such, I would think that the election procedure and the other procedures would ensure that they would have a high level of representation on the council.
On the question of size and membership also, a fair amount of comment was devoted to the question of consumer representation. This is important, but here again we have to be careful to preserve a balance. This is basically a council of the profession to control the profession itself and there would be a great deal to be said for having it confined exclusively to the profession. In former times such a concept would have been unchallenged. It would have been mantained that only the members of the profession would be in a position to understand all the intricacies and complexities of the profession and to know and to comprehend its traditions, and therefore only a body composed of the profession itself would be legitimately entitled to decide questions of discipline, striking off and so on. But I think today there would be fairly wide acceptance of the fact that, whereas in the main the profession should govern itself through its own mechanism, at the same time the general public should have some voice in the procedures. For that reason the Bill provides that the Minister can nominate four persons for membership.
I would not like at this stage to commit myself to the opinion that those four persons should represent the consumer interest entirely. It might be that in the normal working of the mechanisms which the Bill establishes, some section of the profession would not be represented on the general council which I would like to see, and therefore I might wish to avail of one, two or three of these four places which are reserved to me to give representation to a particular branch of the profession which had failed otherwise to have a voice. These four places will provide me with an ample opportunity to give reasonable representation to consumer interests.
That aspect of consumer interest and representation was raised in connection with the council as a whole, but also in relation to the Fitness To Practise Committee. People felt that on that committee there should be a consumer voice, and it is easy to sympathise with that point of view. Deputies will have noticed that as the Bill is framed other committees can have outside representation on them. Other committees established by the Medical Council under the Bill can have persons appointed to them who are not members of the council, but that does not apply to the Fitness To Practise Committee: it is stipulated in the Bill that that committee must be composed exclusively of members of the council. They will be a very important committee dealing with very delicate and serious issues and it is right they should be composed entirely of members of the council fully conversant with the affairs of the council. There might be something to be said for the suggestion that there should be some provision that the Fitness To Practise Committee would necessarily include one or more of the four persons appointed to the general council by the Minister. That would meet both points: it would give a consumer interest in the committee without at the same time breaching the principle that the committee should be composed exclusively of members of the general council.
I was particulary impressed by the wide range of interesting points made during the debate. I can honestly say that Deputies raised aspects of the whole matter which had not previously occurred to me. One question was that of making finance available to the council. It is intended, as is the case of other professions, that the council should be financed by the medical profession—that the profession should finance their own governing body. However, there is no reason why if I were to ask the council to perform some particular function I should not make funds available to them in the normal process of the finances available to me.
I will now come to some points made by Deputies, and I am sure other Deputies will forgive me if I first take the points made this morning because they are freshest in my mind. Deputy Fox raised a very interesting point about the profession being confined to an intellectual élite. This has attracted a great amount of attention and debate in recent times—how entry to the medical profession would be determined, what is the process of selection? This is a deep problem which does not alone apply to the medical profession but to the other professions.
The principal stumbling block that confronts one who wishes to have an element of flexibility in the arrangements is that if one departs at all from the objective criteria one raises the whole question of patronage. I am sure Deputies have come across a suggestion put forward recently that entry to the medical profession should be, if not reserved for doctor's children, at least that they should get special preference. That is a very old tradition which applies more to crafts and trades than to the professions.
There is the practice that one of the perks or privileges of a trade or craft is that the son of the tradesman or craftsman is entitled to preference.
I do not think anybody would seriously suggest that we should adhere to that traditional principle where modern medicine is concerned. I merely mention it as a factor here. I do not know what the mechanism should be; I have no great practical experience in relation to this profession. However, I know about the veterinary profession in which I have come across cases of young people, who because of their natural attributes would make ideal members of that profession, who because of their love for and knowledge of animals would make excellent veterinarians but who, because of the academic qualifications laid down have no hope of securing entry to the profession.
I am sure that in the medical profession there are boys and girls who would make excellent doctors or surgeons but who because they cannot achieve that degree of academic excellence being laid down have no hope of securing entry. That is a very real difficulty in this area but I could not possibly envisage how it can be overcome, because if you depart at all from the objective academic criteria you leave the way open to all sorts of undesirable practices. There-fore I am afraid that at the moment we have no option but to stay with the existing system, and perhaps this council may bring forward in conjunction with the medical schools and universities some more sophisticated and improved way of selecting persons for the profession, devising an entrance system that will ensure that the best people are selected. At the moment I cannot put forward any possible solution along these lines.
Deputy Fox also mentioned an interesting aspect relating to the general question of recruitment to the medical profession and the number of doctors we produce. He related this to the developing situation in so far as the Third World is concerned, and particularly the Middle East. There is no doubt there is an almost insatiable demand for medical and paramedical personnel in the Middle East, and more and more we are being involved in this situation.
It is, of course, absolutely right and proper that we should, but the contacts with these countries are increasing every day and the possibility of fruitful arrangements between ourselves and these countries are manifesting themselves. I have been giving some thought to this matter and it will be both necessary and desirable to establish some sort of formal channels through which these contacts can be pursued. At the moment there are a number of countries in touch with us looking for various facilities. The requests coming in are diffuse and the manner in which they are being received and dealt with at this end is also diffuse, so there is a case for some sort of formal arrangements for this whole area. I am very glad Deputy Fox raised the matter. It is, perhaps, not strictly relevant to this legislation but I am glad to have had an opportunity of dealing with it.
Deputy O'Toole adverted to the provisional registration situation envisaged in section 28. He asked, very validly, if there is any test at the end of the period. I want to make it clear now that this is not really a probationary period. This provisional registration is meant to cover a period of a year of supervised hospital experience. The doctor must have been awarded a certificate from an appropriate medical school in which he graduated before he goes on to the provisional register established under section 28. Section 29(2) provides that the council may extend the period provided the aggregate does not exceed five years. That is a different matter. That is intended to deal with the case of foreign doctors from countries outside the EEC who come here for post-graduate experience.
There are two different proposals enshrined in the Bill. One deals with a period of supervised hospital practice and experience and the other deals with a doctor coming in here for post-graduate experience from a country outside the EEC. Perhaps I should deal here with the EEC situation because it is important that the House and the general public should fully understand what is involved. Deputy Dr. Browne inquired as to whether or not we have the right to go over to the institutions and schools in member countries of the EEC and inspect them and whether they would have the right to come here. That will not happen. That situation will no longer prevail. Under the EEC directive which came into operation on 20th December, 1976, any doctor of a member State with a qualification of training in that state is entitled to become established and provide a service in another member State.
This brings about a very significant change in the traditional relationship we have with the United Kingdom. Up to now our doctors could establish themselves and practise in the United Kingdom and, in return for that privilege, the British Medical Council inspected our schools and institutions. That situation will no longer apply. Instead there will be a new situation under EEC competence. There will no longer be any inspection between EEC countries. Each member country will inspect the diploma and the qualification of a fellow member country but medical persons coming to establish themselves here and practise here will have to register here and they will be entitled to that registration. We will have to accept the qualifications of other member countries and they will have to accept ours. There will be no process of inspection.
The EEC has established a committee of medical training. That was established on 11th June, 1975, and its task is to help to ensure a comparable standard of medical training in the Community with regard to both basic training and further training. That committee will operate in the following way. First of all, there will be an exchange of comprehensive information as to the training methods and the content, level and structure of theoretical and practical courses provided in the member States. Secondly, there will be discussion and consultation with the object of developing common approaches to the standard to be obtained in the training of doctors and as appropriate to the structure and content of such training. Thirdly, the committee will keep under review the adaptation of medical training to developments in medical science and teaching methods. There, in very broad outline, is the new situation. Each country in the Community will respect the qualifications of the other and members within the profession will be entitled to establish themselves and practise in any other country. All they will have to do is register with the appropriate authority. There will be a central advisory committee which will, broadly speaking, endeavour to synchronise and improve standards of training, both basic and advanced.
There will, perhaps, be one little gloss on that in regard to specialists. We will still maintain in a modified form our traditional links with the United Kingdom. Those links will be maintained as far as specialists are concerned through the joint higher training committee. Irish visitors will be involved in inspecting training programmes in the United Kingdom and United Kingdom visitors will inspect programmes here and trainees will complete their training at the same stage in both countries. As I mentioned yesterday, the establishment of a specialist register in the United Kingdom was recommended by the Merrison Report but that has not happened and, until that happens, we still keep our 1927 agreement in existence.
The right way to proceed, and what the medical profession here are anxious to do, is to synchronise the introduction of a specialist register here with the introduction of a similar register in the United Kingdom. Whereas throughout the medical profession generally this new EEC situation will prevail in regard to normal basic degrees and specialist degrees we will have at the same time this particularly close link at specialist level with the United Kingdom and it is hoped they will establish their specialist register simultaneously with ours. In that context then this mutual inspection and training will continue.
Deputy MacSharry, understandably in the light of his experience as a former chairman and as a member of a health board, concerned himself with the question of the conditions of service for doctors. I want to make it quite clear that will not be a matter for this council. The council will be concerned with training, education, post-graduate training, admission, striking off, disciplining and so on. It will not be concerned at all with conditions of service. I am sure most Members are aware that the conditions of service where consultants are concerned have been unsatisfactory for some considerable time and recently I made arrangements to have a working group or committee established which will set about devising an appropriate contract for consultants to be of general application and also devise a new common procedure for the selection of consultants for appointment to our hospitals.
Deputy MacSharry also asked about this council giving advice. He is quite right in that regard. As Deputies will see, section 62 of the Bill provides for the giving of general advice to the profession by the council.
The question was also asked, again by Deputy MacSharry, as to whether there will be an onus on doctors to participate in post-graduate education and training. Deputy O'Hanlon also referred to this. In my view this is not only a very important aspect of the training of doctors, specialists and consultants but it is also very important from the point of view of the administration of our health services. Both medical bodies, the association and the union, mentioned this matter in discussions I have had with them: the absolute desirability, even to the point of calling it a necessity, of post-graduate training for the ordinary practitioner, some system whereby he or she can secure from time to time refresher or updating course and be enabled to do this while continuing to practise. It is very desirable and important that they should be able to keep in touch with the very latest developments and advances in their field and so on.
I would certainly see an important role here for the Medical Council. This is something I had not thought specifically about until Deputies raised it and I commend them for directing attention to it. Certainly it is worth thinking about and exploring, whether I should not ask this new council from time to time to undertake some particular programme in this area of providing post-graduate training for general practitioners. Whether or not that would involve provision of funds could be teased out.
Deputy O'Hanlon had some reservations about the constitution of the council. He thought it might be too academic, too few practical people on it and that it might be too Dublin oriented. There is no reason why it should be academically controlled or even why there should be any overwhelming academic presence. The only specific provision for academics is in section 9(1)(a) where it is provided that there must be five members from the academic institutions. Otherwise there is no reason why any of the others should be academies. It will be very much a matter for the profession to decide, and I again stress that the overwhelming number in the profession are in general practice and hopefully, their very numbers would ensure that they are represented. The same situation should ensure that the council will not be excessively Dublin oriented—I do not think anybody would wish that to happen. One very encouraging thing in the administration of our health services now is the way in which so many excellent centres are developing outside Dublin particularly in the regional hospitals. In some of the provincial regional hospitals standards of excellence and centres of specialisation are developing which are completely on a par with what is available in Dublin. One hopes this will reflect itself through the procedures laid down in the legislation in the composition and membership of the Medical Council.
I have already dealt with Deputy O'Hanlon's point about post-graduate education but in that connection, apart from a sort of general power and competence which the council will have in the whole area of postgraduate education, it is open to me under one of the sections to assign specific functions to the council and ask them to carry out particular assignments. I shall certainly consider the question of whether or not at some time we would ask the council to take positive steps—or even place some obligation on them, perhaps—in regard to post-graduate, refresher type education for the general medical practitioner.
I hope I have dealt with most of the points raised in the debate about the legislation, the council and the general provisions of the Bill. Some Deputies raised other matters of very great importance. For instance, Deputy R. Burke spoke of the very urgent and important question of the type of medical practice which is evolving in Dublin city and suburban areas where one gets an answering machine instead of a doctor when one telephones. While important, that is not strictly relevant to this legislation and it is not something in which the general council would be involved but it is something of which I must take cognisance in the general context of health administration.
Other points of a similar nature were raised by other Deputies and the fact that I am not specifically dealing with them or adverting to them in my reply does not mean that I shall not give particular attention to them; I will, because they are all very valuable and important. No doubt we shall hear about them again when we discuss Estimates and other Health business in the House.
I hope that in the time available I have dealt as fully as possible with the arguments put forward and the points raised by different Deputies. I congratulate the Deputies who spoke on all sides on the very useful and valuable contributions made. This is very much a Committee Stage Bill. We shall not take the Committee Stage for a couple of weeks and I hope that Deputies will put down any amendments which they feel appropriate arising out of the Second Stage discussion. I assure them that all amendments will be carefully considered and will be dealt with in the same spirit as Deputies have considered this legislation on the Second Stage.