Skip to main content
Normal View

Dáil Éireann debate -
Thursday, 20 Oct 1977

Vol. 300 No. 7

Medical Practitioners Bill, 1977: Second Stage (Resumed).

Question again proposed: "That the Bill be now read a Second Time."

I would like to compliment the Minister on introducing this Bill. The Medical Registration Council have served the community and the profession very well over the last 50 years and I am sure over the next 50 years the new Medical Council will serve both the community and the profession equally well.

I would like to make a few brief comments on this Bill. First, I will comment on the membership of the council. I am glad to see the Minister has increased the number of elected members from two to ten. I have slight reservations about how the council will be made up. On paper it looks very good but in practice I have reservations. One, it may be too academically orientated and insufficient representation from the active practising profession. Two, it may be too Dublin orientated. We do not have anything against Dublin but in the past some health committees have been very overloaded towards the city, particularly Comhairle na nOspidéal with the result that rural Ireland was not well represented. It is important that in this council rural Ireland should be well represented because the council will have some responsibility for post-graduate education. In this field particularly there are problems in rural Ireland that do not exist in the city, such as the difficulties of doctors coming together and getting cover to attend courses.

In relation to the election of members to the council, I would draw attention to section 11 (3) which states:

(3) Regulations made by the Minister under subsection (1) of this section may, in particular—

(a) specify, in relation to any class of persons specified in the regulations, the qualifications to be held by candidates for election to the Council, and

(b) specify that the chief executive officer of each health board shall act as local returning officer at an election in relation to those persons who are entitled to vote at the election, and are engaged in the practice of medicine within the functional area of such health board.

The present system of drawing up an electoral roll is that when there is an election for medical officers or other allied professions to the health boards an advertisment is placed in the newspapers inviting members of the profession to apply to get on the electoral roll. This appears to be a cumbersome procedure because for one reason or another many members may not see the advertisement or they may forget to apply. It would be better if the health board kept an electoral roll and brought it up to date from time to time. There is not much movement of members of the profession in each health board within the five-year period, or what-ever length there is between the various elections that may take place, either elections to the health boards or to the General Medical Council.

In relation to education, the new Medical Council will be responsible for under-graduate education, for examinations and post-graduate education, particularly post-graduate education relating to specialty degrees. They will not have any direct interest in admission to medical schools. In my opinion the present system might be improved upon, because while it eliminates patronage it does not take account of the aptitude of the student to follow a career in medicine. This is a disadvantage.

In relation to post-graduate education, it is clearly stated in the Bill that the council will be responsible for post-graduate education relating to specialty degrees. Section 36 says:

The Minister may, by order, assign all or any of the following functions to the Council—

(a) the promotion and development of post-graduate medical education and training, and the co-ordination of such development,

I am not clear if the Minister intends that to be on-going post-graduate education for the profession rather than just post-graduate education for specialty degrees. This would be an important role for the council because at the moment there is no viable post-graduate centre for doctors to keep up to date. Doctors, like politicians, are in a learning situation all the time. It is essential both for the benefit of the public and the profession that the doctors get an opportunity to keep up to date with what is happening and to keep abreast of medical developments throughout their working careers.

In relation to fitness to practice, while suggestions have been made that cases of shortfall in the existing medical services might be referred to the Medical Council, I think this would be a mistake. As the Medical Registration Council have done in the past, this council should deal with serious cases of professional misconduct. There is ample facility within the existing health services for discipline against doctors who are in breach of their contracts. The chief executive officer of the health board has authority to suspend a doctor in certain circumstances. Therefore, in my view it would not be in the public interest if all cases of complaint against doctors were referred to the new council.

In relation to the EEC and free movement of doctors, I am not sure whether the Minister or the council will have a say in who practices where. I would like the Minister to answer this question. Will it be necessary to go on the register of another country in order that one might practise in that country? At present for those who work in Border areas here it is necessary to be on the register of the Medical Registration Council and on the General Medical Council register.

I compliment the Minister on this Bill and I congratulate him on the manner in which he is dealing with his Department and on the goodwill he is creating not alone with the medical profession but with the other professions involved in the health care of the people.

I welcome this necessary Bill but I would like to make some points as a former chairman of the South Western Health Board and as a member of the board. While the Bill has been given wide powers in relation to disciplinary measures for the profession and in relation to the registration of professional graduates, it is not going as far as it might in relation to the working conditions of the medical profession. Earlier speakers made the point that in the establishment of the Medical Council members elected to the council should be more nationally based rather than centralised in Dublin and I agree. Members should not have to work, live or practise in this city. I agree with the suggestions made about ministerial nominees to this council, that consumers should be represented. My experience with health boards and health committees is that on many occasions the profession welcome the opinions put forward by lay-people who could be called consumer representatives. The Minister should consider this when nominating members.

This council will have the power to strike somebody off the register for various reasons thereby depriving an individual of his living. The council should also involve itself in making recommendations on many aspects of the working conditions of the doctors. From my discussions with doctors I have found that they do not have sufficient protection. I know we have the medical defence organisation, but they are not involved with the Medical Council. There should be some contact between both organisations.

New drugs come on the market fairly regularly. High-powered salesmen go around selling them and quite a lot of publicity is involved in the launching of a new drug. Because a drug is new doctors will prescribe it even though it costs much more than a similar type drug which will do the job as well. Because the drug is new, and because of the publicity and sales pressure doctors are led to believe that this is the best product. The prescribing habits of doctors should be examined and recommendations should be made to the profession by this powerfully representative body. I am not a medical expert but I have been told by members of the profession that penicillin, for example, is just as good as Penbritten although Penbritten costs twice as much as the other. Because of the publicity surounding newer drugs there is a tendency for doctors to prescribe them. There have been enormous increases in the cost of drugs and an increase in the cost of general medical services. When talking about the increase in the cost of general medical services we must take into account the 50 to 60 per cent of the public who have to buy their own drugs. How is it that the cost of drugs in Ireland is much greater than that in England? All these matters should be looked into by the council. This council can do much more work than has been outlined in the Bill. The Minister should take these points into consideration when making recommendations to the council in relation to additional functions they might have dealing with working conditions of doctors.

Section 36 of the Bill was referred to by Deputy O'Hanlon dealing with on-going post-graduate education and training. Will there be an onus on the graduates to participate in post-graduate education and training? There should be an onus on somebody on the council to encourage each practising doctor to become involved with the opportunities for post-graduate education and training.

Provision has been made for the creation of a specialist registrar. I hope that as soon as the council is set up that provision will be implemented. At present in relation to specialist and consultants. there are two different methods of appointment. In the health board hospitals the local appointments commissioner is involved in the appointment of senior consultants and specialists of one kind or another and in the voluntary hospitals such appointments are made privately. The medical profession will be the first to agree that there should be some type of uniformity in this type of appointment. The Medical Council should use its influence to ensure that appointments made in any hospital and in medical practice generally will follow the same pattern.

I should like to think that the Medical Council, when formed, would make recommendations to the Minister and the health boards in relation to entry to the GMS for doctors and that some guidelines would be laid down. A body such as the Medical Council would be an appropriate one to lay down those guidelines in relation to the number of patients, type of area a doctor would serve and the kind of cover he would require. Somebody has to make these rules somewhere.

The situation in Europe at present is front page news today—the spy in the cab in relation to the employment of long-distance truck drivers who must drive for a period of eight hours only without taking some rest. If that be the case in relation to truck drivers surely a professional man's conditions of work—having to give seven days a week, 24 hours a day cover to thousands of people—and the pressures to which he is subjected must be examined. This Medical Council who will be involved in the education, regulation and control of the profession as a whole sooner or later must be the body to direct themselves to recommending to the unions on the one side, the Department and health boards on the other the kind of guidelines to be laid down in respect of their working conditions. I shall not go into the detail of how one doctor is capable of making a living in a smaller area with a smaller number of patients, or a consultant in the same position, while another may be in a position to render a similar service with three or four times as many patients. It is difficult to have something definite done in this respect. However, I repeat that this Medical Council—which I am sure will be recognised as the important medical, professional body here —will be listened to in regard to anything they may say or recommend for the profession or the public at large. I am sure such suggestions would be taken into account by the people who have to make the decisions eventually about their conditions of work and the service they must render to the public.

Since the Medical Council have the power to strike somebody off their register or deprive him of his livelihood, for various reasons, they must become involved also in ensuring that that individual has adquate remuneration for his work and is in a position to give maximum cover as a professional service to the public.

I do not think there is provision in the Bill for its scope to be widened to take account of the points I have made. As Minister for Health the Minister is involved in all aspects of this. People may say that a body such as the Medical Council, made up almost entirely of professional medical people, might not be the most appropriate organisation to lay down guidelines in respect of their working conditions lest they be interested only in safeguarding their own positions. I do not think that is the case. I believe they are a noble, hard-working group particularly those in the area I represent, the north-west, where people live in scattered areas, where doctors have huge areas to cover and where consultants and all other staffs involved in the functioning of hospitals do so under extreme pressure, perhaps not even with the most modern facilities. Those people and their representatives on this Medical Council will be concerned, as they have been. about the public interest and therefore should be entrusted with the task of making recommendations on the points I have raised.

I congratulate the Minister on introducing this legislation. I hope it will achieve the goal intended. Eventually I hope it will resolve all of the problems in relation to conditions of employment of the medical profession which are of even greater concern to the public at present than are regulations and control.

I endorse what has been said about the introduction of this Bill. Any Bill that sets out to improve matters in an area as important as health is to be welcomed. One of its most pleasing aspects is the fact that the Minister has intimated that he will repeal the 1927 Act, ending up with another comprehensive one covering all aspects of this important area of life. At a time when people's lives are becoming more and more complicated, constrained by regulations and so on at national and EEC level, it is heartening to see such an approach being adopted and the production of such a comprehensive Bill containing all the answers.

As the Minister said, in the 50 years' existence of the previous Act many changes have taken place. The main ones have been in society's own attitude to medicine, in the approach of the medical profession to medicine and in the approach of the medical profession to their patients. If society is to be informed about where it is going and what to expect from this kind of service the incorporation of all legislation in one Bill is admirable and a situation which is to be welcomed.

The Minister's predecessor established a committee with specific terms of reference. The committee reported and the Minister is now acting on that report. The need for legislation to regulate the medical profession, its activities, standards, qualifications and so on possibly is overdue. Deputy MacSharry mentioned the high cost of health services in this and in other countries. In England it is very high in relation to the cost of other services.

Here we have a system of health boards which cover regional areas. So far as health services are concerned we have adopted a decentralisation system. In one sense these regulations concern a fairly narrow field but they will have consequential effects right down the line to the patient in the doctor's surgery. Because of the massive costs involved in providing these services—costs that are escalating daily—it is essential that we get value for money. That should be the main objective of any activities pursued by the Minister in relation to this Bill.

How can we ensure that this objective will be attained, that is, if it is attainable at all? The establishment of the Medical Council to replace its predecessor is a first step forward. In common with other speakers I am disappointed about the representation on the council of people from the greatest portion of the population, namely, lay people. Section 9 states there will be representation from the colleges of medicine, from the various specialist interests such as an anaesthetics, radiology, pathology, obstetrics, gynaecology, psychiatry and two from the general practitioners area.

When we discuss this matter on Committee Stage I hope to hear that the Minister's four appointees will be lay people. That would be some redress for the imbalance that appears to exist on the council at the moment. Of course it does not follow that because of the number of specialist interests represented on the council the end result will be a misrepresentation of the facts, it does not mean it will work to the detriment of the general public. However, it would seem to the lay man that risk exists because of the composition of the council. To minimise that risk representation might be juggled around to give more to lay people. We should be seen to be equitable in our approach in this matter if that is possible.

I appreciate the Minister's difficulty in that the matters to be dealt with by the council are highly specialist matters dealing with the type of education the medical profession will obtain and with other matters concerning the profession. Many of the questions they will discuss will not be within the competence of the lay man to discuss but we must remember that at the end of all this is the lay person in the doctor's surgery. The way he will be treated by the general practitioner or by a specialist will depend ultimately on the activities of the council and the way they lay ground rules for the qualifications necessary for medical personnel.

Section 26 deals with the establishment of the register and one aspect strikes me as commendable. Up to now we have had a general register on which was included all doctors with different kinds of qualifications. Now we will have a general register of medical practitioners and also a provisional register. Has the Minister in mind a kind of probationary period? If so, is the person on the provisional register open to any kind of test or examination before he is put on the general register?

Section 29 (2) states:

The Council may extend a period determined under subsection (1) of this section for such further period or periods as the Council may determine, provided that the aggregate of such periods shall not exceed five years.

When the change-over comes does that person have to go through any kind of test? It will be a good thing to have a register specifically dealing with post-graduate training; we have not had this up to now. It always was a highly specialised area and it is becoming even more specialised. In these modern times the equipment needed to carry out work in hospitals is highly technical and specialised knowledge is needed to operate this equipment and use it to its full capacity. I presume a specialist register will look after the type of personnel involved in this activity in the profession.

The west of Ireland in the past has suffered because the population is scattered. Many sparsely populated areas have not been a great attraction to doctors. Is there any way the practical difficulties of the Western Health Board, which includes Mayo, Galway and Roscommon, can be overcome? Patients in those areas, because of their geographical location, do not get the same service as patients in Galway, Dublin and areas adjacent to the medical centres, the specialist hospitals, the general hospitals or the university medical schools. A person in some areas of the Western Health Board who needs a particular type of specialist treatment may have to travel up to 100 miles to get it. He may have to travel from the north west of Mayo to Galway where the specialist facility is available.

I appreciate the Minister's difficulty in getting over that problem but we must set out to treat all our citizens equally. I do not know how the Minister can get over this problem. Obviously, this Bill will not be concerned with that although it must have a bearing on it when one considers the qualifications of the people coming out of medical school. It is important to disperse that manpower in the most efficient way to give value for the money invested in the service. We must remember that no amount of money will buy a life and we are dealing with the lives of people. The problems facing us in the future will be even worse than those that face us now because people will demand the service they feel they are entitled to.

People are now looking for information about their rights and are not prepared to be fobbed off with highly technical data. They want to know why a person living in a backward area should not be able to get the same treatment as a person in a central area. Under the law that person is entitled to get it. We are dealing with an enlightened community whose demands are increasing all the time. We will not be able to provide the facilities demanded by that community if we do not plan ahead. We have long gone past the day when a Minister for Health can say that something cannot be done because it will cost too much. He is dealing with the health of the people.

I would like, first of all, to congratulate our very discerning Minister for Health on bringing this Bill to the House. It is one of the most important Bills which has come before the House because it deals with the life and welfare of the community. I was pleased to hear some of the Deputies saying they would like to see some lay people represented on the new council. This is very important because for too long we believed that the medical profession should always be separated from the views of the ordinary people. We have seen during the past six or seven years that this does not work. There has been great co-operation on the health boards throughout the country between the medical profession and the public representatives who represent the community.

It is very important to note that in the early days, which we may refer to as the blood-letting days of 1858, the first measure was enacted to protect the community. The preamble to that Act stated that the ailing patient must be in a position to know and distinguish between the qualified and the unqualified. This Bill seeks to clarify that. The enlargement of the Council will ensure that there will be a wide range of opinion in the deliberation of the new council. This means there will be greater protection for the ordinary people. Patients will be assured that they have the best qualified doctors to deal with them. We know that there is no more vulnerable person than the patient. He or she is totally dependent upon the skills of the doctor who is giving medical attention. In other professions error can occur which can be remedied. The architect or engineer can make an error in drawing a plan but the plan can be rectified. This does not apply where the doctor is concerned.

I am glad to see that provision is being made for the setting up of a separate register of medical specialists. This is most important. According to the Bill, this will be at a later date and the Minister will undoubtedly give deep consideration to it. Such a register is in use in all the other member States of the EEC except the United Kingdom.

The Minister has taken steps to ensure that there is no conflict between the provisions of the Bill and the Constitution. This is of paramount importance. It is right to say that the medical profession, no more than any other, is not free of human error. Errors can occur and it is of the upmost importance to ensure that those who enter the field of medicine should be very well qualified. The community must be assured that the very best that can be provided by the State will be provided. I should like to compliment the Minister on the introduction of this Bill and to wish him well. I know that he is a very discerning person and that he will do all in his power to ensure the maintenance of the highest medical standards.

I should like, first of all, to compliment the Minister on the efficient way he opened the debate in assuring the House that he is taking the best possible advice available in the planning of the hospital in north county Dublin. This is in total contrast to the suggestion from the other side of the House that the hearsay of a rather disgruntled junior Member should be given precedence over the evidence of the experts.

One of the functions of this Bill is to ensure that the standard of knowledge required at examinations held by the medical schools is adequate. It would seem that certain professions and some trades admit people according to the attainment of a competitive standard rather than an objective standard. The most important resource of any nation is the intellect of its people. The utilisation of the intellect of our people should not be confined by restrictive practices of this type. There might be a case for saying that the attainment of an objective standard is more worthy of consideration than confining a profession to a small competitive élite. Even with an amount of free education it is still a very great sacrifice for many parents to pay for the training of a doctor or a nurse. Because of the intense competition a person who may have achieved a very satisfactory standard may be ineligible for entry to a certain profession. This is to be deprecated.

The achievements of the Irish medical profession range far beyond the borders of Ireland. Its members have made a contribution throughout the free world, particularly in areas of great need. The contribution of Irish nurses and doctors in Africa, South America and the Far East is incalculable. There is tremendous wealth in the Middle East but a great scarcity of hospital facilities and trained medical personnel. I am led to believe that whole hospital towns are being established on a contractual basis in various parts of this area by international cartels. I would suggest that the intellect of our people could be used in that area. After all, medicine is a global thing; it is not national or parochial. It could be of great benefit to this country to ally the availability of talent in the fields of medicine and construction.

At this point I digress for a short time to mention the fishermen of Skerries. Being anxious to expand their trade and knowing that Skerries is the most suitable point on the east coast for the provision of a harbour, they employed a consultancy firm to confirm that it was feasible to put a fine harbour at that location. They have given an example to the medical profession, not just in the maintenance of standards but in the provision of opportunities for the people.

Africa is at the threshold of expansion. Its untold wealth must surely be used by its people but they have great educational needs in the medical sphere. There was a time when we were known as the island of saints and scholars but the Africans would recognise us as the island of doctors and nurses because we have provided a considerable number of doctors and nurses for that Continent.

I respectfully suggest that there is an opportunity for the Department to explore the feasibility of that need to the advantage both of our people and the people of the developing countries. In this context we could expand our training facilities and if possible provide a total package where necessary for the developing countries. The one thing they are not short of is money. It is true that they can pay for the provision of training facilities. I suggest to the Minister that the various facets of the medical profession should not be confined to standards for doctors and nurses but that the undoubted opportunity for the widening of the profession for the benefit of the country should be considered.

In common with the other speakers I should like to congratulate the Minister on the great work he is doing in his Department. People are more aware of the efforts being made to expand and improve the health services and this Bill represents a further step in that direction.

It is 50 years since we had major legislation on this matter. In the meantime we have had minor legislation but this Bill is fundamental and reflects the thinking of the Minister and his Department. We all believe that a change was needed and the Minister is giving us a change which will be of advantage to the medical profession. The medical profession must change in order to keep up with modern trends. One hears complaints about the lack of doctors at certain times in some areas of the city. I have often wondered whether it would be possible to have a mobile team of doctors at each health centre who would be on call to perform minor operations on patients in their own homes. Nowadays, most of our housing is of a high standard and I believe that it would be of benefit to people if minor operations were performed in their own homes. It would mean that the mother of a young family would not have to be removed from her home and family, which can be very inconvenient. I suggest that it would be a less expensive way of dealing with minor ailments. This is not a new idea as maternity hospitals have been providing a similar service for a long time. The medical profession deserves the respect which we give to it. We must fight disease and therefore cannot invest enough money in the health services.

The Minister has a difficult task ahead of him. Some time ago I read that we need to appoint 300 more consultants to the teaching hospitals and that, if they are not appointed, the service will have to close. I read that in a responsible journal and I am sure that it is true. On the other hand, we hear that the medical schools are reducing the number of entrants.

While this year's cutbacks will not influence the number of consultants, we will have a scarcity of consultants in a few years. On one hand, people are complaining about the shortage of doctors in certain areas and on the other hand the medical schools are cutting back on the number of entrants. Generally speaking, the medical profession has been drawn mainly from middle class. Many young boys and girls want to study medicine but their hopes are remote at present despite free education. Even if people have the money to attend medical school, the high grades required mean that a great number are refused entry. We may well be paying a terrible price for this system in that many young people who might become brilliant doctors are never given a chance.

The medical profession is going through a bad time in Dublin because of the proposed federation, the closing of the older hospitals, the enlarging of St. James's and the new hospital at Beaumont. I would like the Minister to assure doctors and staffs of the federated hospitals that their future will be safeguarded. I believe the older hospitals will be used for long-term patients. The Minister should consider the plan of the federation of hospitals, especially as he has sanctioned the extension of St. James's hospital. There will be a great demand for doctors, surgeons and specialists and I hope the new Medical Council will consider the problems of the doctors in the federated hospitals in order to ensure that their places will be safeguarded.

Deputy Fox mentioned a very important point—our connection with the Third World and even with the more developed countries in, for instance, the Middle East. It is only fitting that we pay tribute to all those Irish men and women who gave up so much to help the people in those other countries. In this tribute we include not only the religious but all those lay people who have been involved so actively in improving medical services in these areas. Their task in the past was very difficult because they had not available to them the drugs and various aids that we are familiar with today. In addition to the people in the medical sphere we have exported people who became involved in the political life of those countries. In a sense there is an association between a politician and a doctor to the extent that public representatives when they attend at what are popularly known as clinics are often confronted with people who merely have come along for a chat. One such person, an old man, comes to see me regularly at my clinic. On such occasions one can become impatient if there are a lot of other people waiting for a consultation but I always try to have regard to the fact that it means a lot to this man to come along to the clinic merely to talk to somebody.

However, politicians may not be the best people to cope with situations like these and this is where the doctor is very important. Deputy Brady raised a point about how difficult it is for a patient to see a specialist. Indeed it is very difficult for one to see the doctor of his choice. Although people may not be ill as such they may be disturbed emotionally in which case a chat with their doctor could be of immense help. It is said that there are not sufficient jobs for the numbers of personnel graduating from our medical schools but it is my opinion that we should be training doctors in even greater numbers so that we could concentrate more on preventive medicine. Economically, too, this would make sense since it is not as costly to prevent illness as to cure it. Because of the pressures of today's life styles, there is a much higher incidence of nervous disorders especially in so far as young people are concerned. We hear tragic stories from time to time of students finding the strain of examinations too much and, consequently, having to be hospitalised. This can happen to students at any level of education and it is an aspect of this whole sphere of medicine to which the new council might give close attention.

This Bill signals a very good beginning to the tenure of office of the new Minister but we must not let the occasion pass without recording our acknowledgment of the very good work that has been done by the present Medical Council. Discipline in the medical profession has always been high here. However, one hears from time to time of apparent breaches of this discipline. I am referring to allegations of over prescribing of drugs but perhaps one can sympathise to some extent with a doctor who, under much pressure, takes the easy way out and prescribes drugs which may not be totally necessary. On one occasion I asked a well-known doctor whether he had any view in this regard. He said that in his opinion there was over prescribing in some instances. On many occasions people coming to see me, women in particular, produce bottles of tablets that have been prescribed for them and say that without these drugs they could not survive. I wonder often whether all these drugs are necessary. A politician, although he may be under a great deal of pressure in trying to cope with a heavy work-load cannot take the easy way out when people come to him with their problems. He must do everything possible to help.

It would be a wonderful contribution to the Third World if we could find it possible to provide places in our medical schools for personnel from these areas, especially people wishing to be trained as nurses. It will be a long time before that part of the world has a sufficiency of doctors but if our teaching hospitals, for instance, could accommodate trainee nurses from the Third World, these nurses, on the completion of their course, could return to work with their own people. I am sure that this would be of tremendous benefit until such time as there are enough doctors in these areas.

We need have no fears regarding the standards of doctors in the EEC countries but our membership of the Community brings changes in this sphere of medicine. It presents a challenge which the medical profession must face. We have always had a good relationship with the medical profession in the UK and it is accepted that our medical schools are of a very high standard but the demand on them will be much greater in the future.

Up to now it has been the situation here that we have drawn on a fairly narrow sector of society for our doctors but with this new legislation at our disposal we should look at this whole situation and endeavour to recruit people into the profession from all sections of society in order to ensure that the people who are best suited to this profession will be recruited. We can aim at the expansion and benefit of the profession and, therefore, at an improvement in general health. This Bill will play a tremendously important part in the change which must be brought about. Again I congratulate the Minister on the Bill.

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.

Question put and agreed to.
Committee Stage ordered for Wednesday, November 2nd, 1977.
Top
Share