The main purposes of this Bill are to bring up to date the legislation dealing with the requirements for the registration and control of persons engaged in the practice of medicine, including the standards of education and training needed for such registration, and to provide for the better promotion and co-ordination of post-graduate medical and dental education and training.
In aiming to achieve these purposes, the Bill provides for the establishment of two new bodies. The first of these is the Medical Council, the establishment of which is provided for in Part II of the Bill. The second body is the Post-graduate Medical and Dental Board the establishment of which is provided for in Chapter 2 of Part IV of the Bill. I shall have more to say about the constitution, membership and functions generally of these two bodies later but first I would like to make some general comments about the new legislation.
This Bill does not aim at preventing anybody from practising medicine in the widest sense. Most of us do this, to some extent, regularly, either by way of self-medication or by advising our families, our friends or our colleagues. What the Bill proposes to do, in this respect, is: first, to make certain provisions related to the requirements for the education and training of persons seeking entry of their names in the statutory registers of medical practitioners; secondly, to reserve certain rights and privileges to persons so registered; thirdly, to provide for the mechanism whereby the name of a person can be erased or suspended from any register or have conditions attached to continuing registration and, fourthly, to make it an offence for any person falsely to represent himself to be a registered medical practitioner when he is not so registered.
The present legislation regulating the registration and control of persons practising the profession of medicine is contained in the Medical Practitioners Act, 1927. Some changes to this Act were made in amending Acts passed in 1951, 1955 and 1961 but the main provisions are those which are contained in the 1927 Act. While this existing legislation and the Medical Registration Council which was set up under the 1927 Act, have served the country well, it is considered that the time is ripe for a review and overhaul of the present legislation. There is considered to be need for change to take account of developments which, inevitably, have come about with the passage of time and to up-date the position generally having regard to modern thinking and knowledge.
Because of the nature and extent of the changes which proved to be necessary, I considered it better to approach this matter, not by way of amending legislation, but by introducing this comprehensive measure. I trust that this approach will meet with the approval of this House. It should certainly facilitate consideration of the Bill and should also facilitate those who will be concerned with its operation once it has been enacted.
The provisions of the Bill are based largely on the recommendations of a committee which my predecessor set up to go into this whole matter. The committee was representative of the Medical Registration Council, the Irish Medical Association, the Medical Union, the medicine schools, the Royal College of Physicians, the Royal College of Surgeons, Comhairle na nOspidéal, the Council for Post-graduate Medical and Dental Education and my Department. The terms of reference of the committee were as follows:
To examine and report to the Minister on the changes necessary in the existing legislation for the regulation of the medical profession, taking account of the directives in relation to medical practitioners adopted by the Council of the European Community, the recommendations of the Report of the Committee of Inquiry into the Regulation of the Medical Profession in the United Kingdom—the Merrison Report—in so far as they affect this country and other related matters,
This committee produced a unanimous report and recommendations and these, as I have said, form the basis of the proposals now before the House. It gives me pleasure to acknowledge the contribution made in this matter by the members of the committee and, through them, by the organisations which they represented. It was an example of what can be achieved by the exercise of goodwill and co-operation which, I hope, will augur well for the future working of the various provisions included in the legislation.
As with any profession, the medical profession properly demands the right to regulate its own affairs and rightly takes pride in the very high standards which it sets for its members and in the strict observance of those standards at all times.
Turning to the specific provisions in the Bill, Part I deals with preliminary matters such as the short title, interpretations, commencement of the Act, the establishment day for the new Medical Council and repeals. These are all standard provisions in a Bill of this kind. The First Schedule includes the enactments which are to be repealed. They consist of all the existing Medical Practitioners Acts. To the extent that some of the provisions contained in these Acts will still be required, they are to be reenacted in the new consolidated measure which is now before this House.
Part II provides for the setting up of the new Medical Council which will replace the present Medical Registration Council and for the dissolution of the latter and for the transfer of its assets and liabilities to the new council. This Part also contains whatever consequential provisions are necessary arising from the setting up of the new council. These are matters such as the appointment of staff, the keeping of accounts, the setting up of committees and matters incidental thereto. It also enables the Council to charge fees for services given, including fees for the retention of a doctor's name on a register which is a new provision. Retention fees of this kind are already in existence for other health professions in this country such as dentists and opticians and the practice is commonplace abroad.
In relation to the composition of the new council, I would like to say a few words. The present Medical Registration Council consists of 11 members made up of a representative of each of the medical schools together with two members elected by the practising profession and two members appointed by the Government. The Medical Registration Council maintains the general register of medical practitioners and it has a regulatory role in relation to the standards of medical education and training at undergraduate level and in relation to what is known as the "intern" year which a newly qualified doctor must undergo before he can become a fully registered medical practitioner. The new Medical Council proposed in this Bill will differ considerably in its size, constitution and powers by comparison with the present council.
Over the years there has been a steady development of specialisation in medicine and post-graduate education and training leading to specialisation now forms a large and important section of medical education and training. To take account of the new situation, the new Medical Council is being given duties and responsibilities in relation to standards of post-graduate medical education and training as well as undergraduate education and training. Membership of the council is being extended to give representation to bodies with functions in the post-graduate field.
The organisations representing doctors have, for many years, been unhappy about the extent of representation on the existing Medical Registration Council. It is accepted that the practising profession has a valid case for better representation on the new controlling body and, for that reason, it is being proposed to extend the number of elected members of the new council from two members to ten members.
The committee to which I referred earlier favoured a Medical Council of 21 members. It is a difficult problem to give representation to all the organisations and bodies that would like to be represented and at the same time ensure that the council will not be too unwieldy in size, that it will not be so large a body as to militate against its own efficiency and lead to its having to delegate too much of its work either to an executive committee or to its own staff. In the light of representations received, I decided to increase the membership to 25 to allow for the addition to the following: one member to represent post-graduate interests in psychiatry; one member to represent post-graduate interests in general medical practice; an additional member to be appointed by me to increase representation of the interests of the general public; and, one additional elected member to restore the balance between elected and non-elected members.
On the whole, I think that the constitution now proposed for the new Medical Council represents a reasonable balance in regard to membership. I should point out that there is provision under section 13 enabling the council to set up committees to assist it in carrying out its functions.
The council will be obliged to establish two committees, namely, a Fitness to Practise Committee in relation to Part V of the Bill and an Education and Training Committee in relation to Part IV of the Bill. Apart from the Fitness to Practice Committee, the council will be empowered to appoint persons to any of its committees who are not members of the parent council. In the case of the Fitness to Practise Committee, membership is restricted to members of the council including at least one non-medical member appointed by the Minister to represent the interests of the general public.
In relation to the Education and Training Committee, the council will be obliged to appoint to that committee the representative on the council of each of the medical schools.
In general, the aim—which I think will be achieved by this measure—is to establish a Medical Council the functions, constitution and membership of which will reflect the requirements of the profession of medicine in this day and age. The powers of this new body, as is the case of any similar body charged with the regulation of any other profession, will derive essentially from its role as the custodian of the statutory register or registers the keeping of which is provided for in the Bill.
Part III of the Bill deals with registration and obliges the council to keep what can be called a basic register of medical practitioners. It also enables the council, with my consent, to establish and maintain a Register of Medical Specialists. The main provisions in relation to the basic register are the same as obtain at present, namely, provisional registration of doctors who have qualified but who have yet to do their "intern" year; temporary registration for doctors coming from abroad, mainly for further training, who are not otherwise entitled to be registered and want to come here for a limited period to engage in the practice of medicine, and then full registration. Here, might I say, a new procedure has been introduced in so far as a doctor will be obliged to display in his consulting rooms the certificate of his registration with the council. This is one of the measures introduced in the Dáil aimed at protecting the public in that it will help to identify registered medical practitioners.
It will be noted in section 27 that nationals of other member states of the European Community who have recognised medical qualifications will be entitled to be registered here. The mutual recognition of medical qualifications and freedom of movement for doctors with the EEC were the subject of the first directives adopted by the Council of the European Community in respect of any professional group in the member states. In at least one of the member states it is not permitted that any doctor registered in that country should at the same time be on the register of any other country. This applies to its own nationals as well as nationals of other member states so that it is not a discriminatory practice. Arising from this situation, and for other reasons, I have introduced a new provision in section 33 which enables a doctor to apply to have his name removed from the register. Otherwise a doctor's name could only come off the register through erasure of his name which could have undesirable connotations.
Another feature in Part III is the provision in section 30 whereby the council may set up a separate register of medical specialists. This would be a register which would indicate the doctors who are trained to a level entitling them to be regarded as specialist physicians or surgeons or anaesthetists or psychiatrists or any of the other recognised specialties. Registration of specialists is a common feature in many continental European countries but has not as yet been introduced in this country or in the United Kingdom. Its introduction in the United Kingdom has been recommended in the Merrison Report, to which I have referred earlier.
There are very close ties between this country and the United Kingdom in the field of post-graduate medical education and training and what we are really proposing here is to give the new council the necessary enabling powers to go ahead, with my consent, with the introduction of a register of medical specialists at the appropriate time. The timing of its introduction may be important so it is considered that is a matter best left to the council to make up its mind on. Before I leave this area might I explain that if a specialist register should be introduced it will not legally restrict the practice of a specialty to persons entered in the division of the register relevant to that specialty. It would be completely impractical if not impossible to restrict, say, the practice of surgery to persons registered as specialist surgeons. All doctors presumably from time to time carry out some forms of at least minor surgery. The purpose of the register will be to indicate to the public who are recognised and accepted by the authoritative body as specialists in surgery and so on.
Part IV deals with education and training. The first chapter of this Part provides the new Medical Council with the necessary regulatory powers to enable it to ensure that medical education and training programmes provided in this country are of a standard that will produce persons with the requisite skills and knowledge that will make them suitable for registration. The present council's powers only extend to undergraduate training and the "intern year" which is required for full registration in the existing register of medical practitioners. Under the Bill, in addition to the powers which the present council already has, the new council is being given similar powers in the post-graduate field. This is particularly necessary because of the enabling powers that are provided in Part III for the new council to introduce a register of medical specialists.
Chapter 2 of Part IV provides for the setting up of a new statutory board which would have the function of promoting and co-ordinating the development of post-graduate medical and dental education and training. This was not the original intention. The provisions of the Bill as introduced in Dáil Éireann would have enabled me to assign to the new Medical Council the functions of promoting, co-ordinating and organising post-graduate medical education and training.
The Bill had already passed through its Committee Stage in the Dáil when a joint deputation from the Medical Registration Council and the Council for Postgraduate Medical and Dental Education—anad hoc body established some four years ago—came to see me. This deputation stated that in their view it would be inconsistent with the primary regulatory powers of the new Medical Council if functions relating to the promotion, co-ordination and organisation of post-graduate education and training were also to be assigned to it. They recommended that what was needed was a new statutory body to replace the ad hoc Council for Postgraduate Medical and Dental Education. I was convinced by the case made by these bodies representing important sectors of medical and dental opinion and I sponsored the necessary amendment and put it before the Dáil where it was agreed to.
There has been a considerable amount of criticism and, I think, misunderstanding, in relation to the functions of the new Post-graduate Medical and Dental Board and, in particular, in relation to my powers to appoint the 25 members of the board.
It is of the utmost importance not to lose sight of the fact that the functions of the new board will not in any way detract from the powers of the new Medical Council. The council will be the body with sole responsibility for the setting and maintenance of standards of medical education and training, both at undergraduate and post-graduate levels and for standards of professional conduct and discipline within the medical profession. There will, of course, have to be the closest working co-operation between the council and the board, with unquestioning acceptance of the primacy of the council in matters relating to standards of medical education and training and the formal recognition of medical qualifications at all levels.
With regard to the appointment of the 25 members of the new board, I can honestly say that I see no alternative to my having the power to appoint them.
In assuming these powers to myself I am not relying on any questions related to funding or public accountability. There are many bodies with legitimate interests and aspirations for representation on this new board. They would include the new Medical Council, the Dental Board, Comhairle na nOspidéal, the Higher Education Authority, the medical schools, the dental schools, the Royal College of Physicians and the Royal College of Surgeons and their Faculties, the health boards and public voluntary hospitals involved in medical teaching and training, the Department of Health and the Department of Education, the Irish Dental Association, the Irish Medical Association, the Medical Union, along with many bodies, including the post-graduate training committees, representing the major specialties and sub-specialities of which there are no fewer than 37 alone listed in the EEC Doctors Directives as being disciplines of specialised medicine applying in this country.
I am satisfied that apart from questions of geographical representation, the new board must reflect a fair and reasonable spread of all these interests and that, if the body is not to be unwieldy in size, several members will have to represent more than one interest as is the case in the constitution of the presentad hoc Postgraduate Council. I can see no way in which this can be ensured if a system of direct nomination is to operate. On the other hand, recognising as I do the strength of feeling within the medical and dental professions on this matter, I am prepared to give every reasonable assurances that, in making appointments of members of the new board, my aim will be to create a body which will not only be expert and representative but will be accepted as such by the professions. It is my intention to see to it that all the major interests concerned, especially the medical and dental schools, the Royal College of Physicians and the Royal College of Surgeons, the post-graduate training committees, the employing authorities, the Medical Council, the Irish Dental Association, the Irish Medical Association and the Medical Union are clearly seen to be represented on the new board. In turn, I would ask for the full co-operation of all these bodies in my efforts to create a board which, as I have stated, will be an expert and representative body in the field of post-graduate medical and dental education.
In a further effort to allay the fears and apprehensions of the professions I am examining the possibility of sponsoring, on Committee Stage, some amendments to sections 40, 41 and 42. I have had discussions and correspondence with the bodies concerned and I have every hope that, because of the assurance which I have now given in this House and of the amendments which I would propose to sponsor on Committee Stage, all the interested parties will be satisfied with the provisions, as amended.
The remaining provisions of Chapter 2 of Part IV provide for the necessary financing and staffing of the board.
We now come to Part V which deals with the important matter of the fitness of doctors to continue to engage in the practice of medicine as registered medical practitioners.
At present there is provision for the Medical Registration Council to erase a doctor's name from the register if he is convicted of crime or if he is found by the council to be guilty of professional misconduct. In both cases it is the council that makes the erasure and in the case of professional misconduct there is an appeal to the High Court against the council's decision. In order to ensure that the powers of the new council will not run the risk of being in conflict with the Constitution, it is now being provided that any decisions of the council under Part V of the Bill involving the erasure or suspension of a doctor's name from any register cannot be put into effect until confirmed by the High Court.
A number of new features have been provided for in Part V. At present the Medical Registration Council has only the power to erase a doctor's name because of conviction of crime or professional misconduct. The new council will, in addition to erasure, have the power to suspend registration, to attach conditions to continued registration and power to advise, admonish or censure a doctor in relation to his professional conduct. It is now being provided that the council can take action against a doctor if he is considered unfit to engage in the practice of medicine because of physical or mental disability. There is also provision for action against a doctor for failure to pay a retention fee, which itself is a new feature.
Apart from erasure because of court conviction of an offence triable on indictment, decisions of the council to use any of its disciplinary powers are taken following an inquiry and report by the Fitness to Practise Committee. Fortunately it is very rare that steps of this kind need to be taken but I am sure the House will agree that such powers are necessary and every precaution has to be taken to protect, on the one hand, the interests of the doctor who may come under notice and, on the other, to safeguard the legitimate interests of the public at large.
Part VI largely re-enacts provisions in the existing legislation which are being maintained. I would like to draw attention to a few of the provisions. In subsection (2) of section 57 a new feature is being introduced whereby the council will be obliged to make the registers maintained by it available for inspection by the public and they will also be available for inspection throughout the country at the headquarters of health boards.
In section 61 the penalties for making misrepresentations for the purpose of getting on the register or for misrepresenting oneself to be a registered medical practitioner have been considerably increased. There have been problems over the years with bogus doctors and under existing legislation a person who wilfully and falsely represents himself to be a registered medical practitioner is liable to a fine not exceeding £25. This has not been an adequate deterrent and, in addition, it has been difficult to prove that a person wilfully represented himself to be a registered medical practitioner. In the new provision the need to prove wilful knowledge has been dropped and the new penalty of £500 or imprisonment for a term not exceeding 12 months or both will, we feel, help to eliminate this particular problem.
Section 68 provides for the continuance for the time being of a reciprocal arrangement between this country and the United Kingdom which is set out in the First Schedule to the Medical Practitioners Act, 1927, despite the repeal of that Act. Statutory registration of medical practitioners was first introduced here and across the channel by the Medical Act, 1858, and following the establishment of the State, the Medical Practitioners Act, 1927, set up our own Medical Registration Council and conferred on it all the duties and responsibilities which the General Medical Council of the United Kingdom had exercised in relation to Ireland. At the same time a mutual agreement was entered into between the two countries under which doctors qualifying in either country would be entitled to be registered in the other country as well. Under the agreement four representatives of the medical schools in this country are entitled to sit on the General Medical Council in the United Kingdom; that council, in turn, has power to inspect Irish medical schools. The two councils have had very harmonious relations over the past 50 years and have co-operated with one another to ensure proper standards of training and professional conduct in these islands.
With the advent of the EEC directives regarding doctors bringing with them mutual recognition of medical qualifications and freedom of movement for doctors throughout the member states, it will be seen that quite apart from any questions of national sovereignty, the special relationship which has hitherto existed between this country and the United Kingdom no longer has the same relevance. My Department, in consultation with the Medical Registration Council, have been in contact with the Department of Health and Social Security in London. There is wide acceptance that the present agreement is no longer necessary. The British Merrison Report has recommended that the Irish medical schools should no longer send representatives to the General Medical Council. At the same time, they did make it clear that it was their hope that the fruitful co-operation between the two councils that had existed hitherto would continue.
A Bill providing for the reconstitution of the General Medical Council and for the termination, by agreement with this country, of the 1927 Agreement was introduced to the House of Lords in the United Kingdom on 10 November 1977. Pending the actual terminations of the agreement, section 68 provides for its continuance; when the time comes for its termination it will be possible to do so by ministerial order. It is hoped to maintain the present close ties between this country and the United Kingdom in the field of medical education and training, particularly at post-graduate level, on some non-statutory basis. With this in view it is proposed in section 13 of the Bill that the Education and Training Committee of the new Medical Council can have persons co-opted to it who are not members of the council. A similar provision is included in the new United Kingdom Bill.
In relation to section 69, might I say that the new council is being given a new statutory function to give guidance to the medical profession in regard to matters of ethical conduct and behaviour. It is also being given the function of keeping the public informed on matters of general interest. I look forward to the new council playing an active part in advising the medical profession and keeping the public informed on matters of importance.
We are indebted to the Medical Registration Council and to the medical profession for the high standards of medicine and ethics that obtain in this country. I hope that the House will accept the measures which I now bring before it are aimed at ensuring that these high standards are maintained, that improvements are made where possible and that the legitimate interests of the general public are adequately safeguarded.
I look forward to getting the views of the Members of this House to whom I commend this Bill.