I move: "That the Bill be now read a Second Time."
The legislation regulating the registration and control of persons practicing the profession of medicine in this country and the maintenance of standards of medical education and training is contained in the Medical Practitioners Act, 1927. Some changes were made in amending Acts passed in 1951, 1955 and 1961 but the basic provisions are still those which are to be found in the 1927 Act. This legislation has stood the test of time to quite a remarkable degree.
The Medical Registration Council, established under the 1927 Act, has served the needs of this country and of the medical profession down the years. We are indebted to all those who, from time to time, have served as members of the council, as well as to the staff of the council, for their valuable services in maintaining the high standards in the medical profession which exist in this country and of which we can be justly proud.
I am satisfied that there is now need for change; need for fundamental change to reflect developments which have taken place especially during recent years, and to incorporate the very best of modern thinking into the law governing the profession. That is what this Bill attempts to do. Because of the nature and the extent of the changes which are proposed and because of the need to project a modern legislative image for the profession, it is proposed, rather than attempt to make these changes by way of amending legislation, to put forward the Bill as a comprehensive measure, repealing all existing legislation and proposing the re-enactment, where necessary, of any existing provisions. I am sure that this approach will be welcomed by the House.
It is essential in preparing a Bill of this nature to seek out and to consider the views of all the parties dedicated to promoting the profession of medicine, to maintaining and improving the standards of education, training and behaviour and then to incorporate those views in the new measure. This has, in fact, been done. My predecessor established a committee which was widely representative of the medical profession and he asked it to examine and report to him on the changes considered necessary in the legislation for the regulation of the profession.
The exact terms of reference given to the committee were as follows:
To examine and report to the Minister on the changes necessary in the existing legislation for the regulation of the medical profession, taking account of the directives in relation to medical practitioners adopted by the Council of the European Communities, the recommendations of the Report of the Committee of Inquiry into the Regulation of the Medical Profession in the United Kingdom (the Merrison Report), insofar as they affect this country, and other related matters.
The committee had among its members persons representing the Medical Registration Council, the Irish Medical Association, the Medical Union, the medical schools, the Royal College of Surgeons, the Royal College of Physicians, Comhairle na nOspidéal, the Council for Postgraduate Medical Education and Training and my Department. The unanimous report of that committee forms the basis for the measure which is now before the House. I think it is only right that I should pay tribute to the members of the committee; a spirit of reasonableness and compromise must have existed among them to a rare degree in order to enable them to agree on the terms of their report and recommendations.
Before commenting on the principal provisions of the Bill itself, I would like to make a few comments on this question of the purpose of regulation in regard to the medical profession. Why should there be regulation, by legislation, of the profession? What should be the nature of such regulation? The basic characteristic of any profession is, firstly, that its members claim to have specialised knowledge and skills which will be used by the public and, secondly, that it will be self-regulating, usually under statute.
To enable the public to recognise a member of a profession, the practice has been to provide a statutory register of those members of the profession who are qualified by their education and training to be entered in it. Control of the profession is then achieved by the body which is given the custody of the register with the functions of setting and maintaining standards for entry to and removal from the register.
This was first put into practice in relation to the profession of medicine in this country, as part of the United Kingdom, by the Medical Act, 1858. In those leisurly days, the legislators had the happy habit of putting informative preambles to Acts which the science of legal drafting has now, perhaps, unfortunately, cut out of modern Acts of Parliament. The preamble to the Medical Act, 1858 stated that it was "expedient that persons requiring medical aid should be able to distinguish qualified from unqualified practitioners".
The benefits of statutory registration are two-fold. It protects the public from the unqualified practitioner. To the advantage of the profession is the fact that the register gives statutory recognition to the qualified competent practitioner which in turn confers practical advantages to him in the form of public recognition and protection of his status.
Registration, as part of regulation, can, therefore, be likened to a contract between the profession and the public to the benefit and advantage of each.
The Medical Practitioners Act, 1927 set up our own Medical Registration Council in this country and conferred on it all the duties and responsibilities which the General Medical Council of the United Kingdom had hiterto exercised in relation to Ireland. Furthermore, because of the mutual benefits it conferred on Ireland and on the United Kingdom, a special relationship was created at the time between the two countries. This took the form of an agreement signed before the 1927 Act was enacted providing for the mutual recognition, on the two sides of the Irish Sea, of the medical qualifications awarded in these islands. The provisions of the agreement were confirmed by and were incorporated into the 1927 Act as the First Schedule to that Act. This special relationship was to the advantage of each country and in a way could be said to have foreshadowed the doctors directives adopted by the Council of the European Communities in June, 1975. I shall have more to say later about the agreement with the United Kingdom and the EEC Directives.
The Bill itself is in six main parts and I propose to deal with each part seriatim.
Part I contains the normal provisions for the interpretation of the words and phrases used in the Bill, for the commencement of the different provisions and for the repeal of the existing Medical Practitioners Acts.
Part II provides for the establishment of the new Medical Council to replace the Medical Registration Council. Here we come to the first of the major changes being proposed. The existing Medical Registration Council has eleven members; seven nominated by the undergraduate medical schools, two elected by the practising profession and two nominated by the Government.
The new Medical Council, proposed in the Bill, will differ greatly in its size, powers and constitution from the old council. Firstly, its powers and constitution will recognise the growing importance which post-graduate medical education and training now play in "the making of a doctor" by giving representation to the major post-graduate educational interests. The proposals will also greatly increase the representation on the council of the practising profession who are to be elected to membership by colleagues; the numbers of those will go up from two to ten. Furthermore, provision is being made in the electoral and nominating procedures to ensure that all the major areas of medical practice will be represented on the council. The remaining four members of the council will be appointed by the Minister. These may include non-medical members to represent what might be called "consumer" interests.
The committee which I referred to earlier recommended a council of 21 members. In the light of representations made to me following the report of the committee, I decided to increase the membership by four as follows:
—one member to represent psychiatry
—one member to represent general practice
—one additional member to represent the practising profession and
—one additional member to be nominated by me.
I realise that the committee was keen that the size of the council should be kept as small as possible consistent with its being able properly to discharge its functions without having to delegate too much to a secretariat. I sympathise with the committee's views in this regard but I regarded it as essential to give the extra representation as indicated. I do not think that the increase in membership will be detrimental to the efficient functioning of the council along the lines envisaged by the committee.
Before leaving this question of the membership of the new Medical Council, I would like to mention that it is not proposed to give representation to the Apothecaries Hall of Ireland. The licentiate of the Apothecaries Hall was listed as one of the recognised qualifying diplomas in the Second Schedule to the Medical Practitioners Act, 1927. The Hall has ceased to function as a qualifying body since the end of 1971 and it is not considered necessary that it should be recognised in the future for the granting of basic qualifications in medicine in this country. In this respect, the proposal accords with the recommendations of the committee to which I have referred earlier.
The remaining sections of Part II deal with procedural matters related to the establishment and the staffing of the new council, to the dissolution of the Medical Registration Council and to various specific powers of the new council including the borrowing of money, the acceptance of gifts, the establishment of committees and the charging of fees.
Part III deals with the registration of doctors, including the establishment and maintenance of the basic register of medical practitioners. Provision is made for the establishment, at a later date, of a separate register of medical specialists should this be considered necessary.
The provisions relating to the establishment of the basic register contained in sections 26, 27, 28, and 29 follow the pattern of the existing legislation except that provision is made specifically in section 27 for meeting the obligations of the State pursuant to any directives in relation to doctors which may be adopted by the Council of the European Communities. Obligations in relation to the directives adopted by the Council of the European Communities in June, 1975, were discharged by means of regulations made in December, 1976—Statutory Instrument No. 288 of 1976—under the provisions of the European Communities Act, 1972.
Two directives were adopted by the Council of the European Communities in June, 1975, and they came into effect in all the member States on 19th December, 1976. In brief, they made provision for the following matters:
(1) the recognition by each of the member States of the medical qualifications, at both general and specialist levels, awarded to nationals of member states by the member states;
(2) the giving effect to the right, contained in the Treaty of Rome, of the freedom of movement for workers and their right to establish themselves in their work or profession within the Community, and
(3) the setting and maintaining of specified minimum standards of medical education and training within the Community.
The meaning of the provisions is that doctors from other member states are entitled to practice their profession here on the same basis as our own nationals and our nationals have similar privileges in the other member States.
With regard to the register of medical specialists provided for in section 30, the position is that while statutory registration of medical specialists is common practice in the continental member states of the EEC, the practice has not been introduced in this country or in the United Kingdom. It is thus considered desirable that the new council should have the power, with my consent, to introduce statutory registration for specialist doctors should it decide to do so at some future date. I should mention that the British Merrison Report recommended that specialist statutory registration should be introduced in the United Kingdom.
Part IV of the Bill dealing with education and training again marks a significant expansion in the powers of the new Medical Council as compared with these of the Medical Registration Council. The Medical Registration Council's functions relate only to undergraduate medical training, or, to be more precise, medical education and training up to the stage where a doctor has completed what is known as the "interim" year which entitles him to full, as distinct from provisional, registration in the register. Under the provisions of Part IV, it is proposed to give recognition to the significance which post-graduate education and training has assumed in recent years, by giving the Medical Council statutory powers in relation to such education and training. It is important to stress that these powers will fall to be exercised by the new council irrespective of whether there will be statutory registration for specialist doctors or not.
When statutory registration was first introduced in the 19th century, and for a long time afterwards, it was accepted that all the skill and knowledge needed by a doctor could be imparted to him during the education and training leading to his graduation. It has long since been recognised that there is now much more to the "making of a doctor" than that. It is fully accepted that the education of a doctor is a process which should never end whether the doctor is a top-level consultant or a country general practitioner. Post-graduate education and training is a complex and lengthy business and it is all an integral part of the education and training needed by all members of the profession. Hence the necessity to give statutory responsibility for the continuum of medical education and training, on all levels, to a single statutory body, the new Medical Council. The council will, of course, work in the closest co-operation and harmony with the many bodies engaged in practical aspects of this work.
In section 35, provision is made for giving legislative effect to requirements imposed on the State by directives adopted by the Council of the European Communities both in relation to basic medical education and in relation to education and training in specialised medicine. The new Medical Council will, therefore, be the body competent and responsible in this country for seeing to it that standards of medical education and training at undergraduate and post-graduate levels will, at the very least, meet the minimum requirements for such education and training laid down by the EEC. Need I say that I hope that the objectives will be to establish and maintain standards which will be higher than the minimum standards required by the EEC? Our standards in medical training and education are already very high and our doctors are well regarded abroad.
Part V of the Bill makes provision for dealing with cases of discipline, of professional misconduct and of general fitness to practise. While, fortunately, it is only very rarely that it is necessary to have recourse to disciplinary action in regard to any member of the medical profession, it is essential to have adequate and suitable machinery available whenever it is necessary to have recourse to such action. The statutory powers of the Medical Registration Council provide only for the erasure of a doctor's name from the register. Recognising the fact that circumstances may arise where some disciplinary action may be called for but that the penalty of erasure would not be warranted, provision is made in the Bill for lesser penalties.
Section 40 empowers the council to suspend a doctor's registration; section 41 gives the council power to attach conditions to a doctor's continuing registration and section 42 contains provisions enabling the council to admonish, to advise or to censure a doctor in relation to his professional conduct.
In relation to Part V as a whole, it was necessary to ensure that its provisions would not be in conflict with the Constitution. It is no secret that difficulties have arisen over the years in relation to the constitutionality of the powers of registration councils and other bodies dealing with the regulation of certain professions and that there have been some instances where these powers have been found to be in conflict with the Constitution. The provisions in Part V of the Bill have been very carefully drafted and I am satisfied that there can be no conflict with the provisions of the Constitution. What is proposed requires every disciplinary decision of the council to be subject to the approval of the High Court either on appeal by the doctor concerned or by way of application to the court by the council in the event of no appeal being made.
There is a new provision which enables the council to take action against a doctor because of his unfitness to practise by reason of physical or mental disability. Again the judicial safe-guards have been built in.
As regards Part VI the proposals, in the main, relate to the re-enactment of existing provisions but there are one or two matters of particular importance to which I would like to refer. First, there is the question of penalties for offences. Under existing legislation a person who wilfully and falsely represents himself to be a registered medical practitioner, when he is not so registered, is liable to a fine not exceeding £25. This has not, of course, proved a sufficient deterrent and the Medical Registration Council has expressed concern about instances of persons purporting to be registered medical practitioners when they were not in fact so registered; these instances have been of great concern to the council who have felt themselves frustrated by the situation and have been extremely conscious of the likelihood of danger to the public by the activities of these persons.
Under the provisions of section 55 of the Bill it will be sufficient in future for the purposes of obtaining a conviction, that a person should falsely represent himself to be a registered medical practitioner when he is not so registered. The penalty is being increased to a maximum fine of £500 or to imprisonment for a term not exceeding 12 months or to both such fine and imprisonment. It is to be hoped that the changes proposed in this section will be sufficient to deter, in future, any person from falsely holding himself out to be registered medical practitioner.
Secondly, I would like to say something about section 61. When all Ireland was part of the United Kingdom, the General Medical Council had power in this country, as in Britain, to recognise medical schools and to register medical practitioners. Even after the establishment of the Medical Registration Council in this country under the Medical Practitioners Act, 1927, the British General Medical Council continued, under an agreement which is incorporated as a schedule to the 1927 Act to register graduates of Irish medical schools direct and provided, and still provides, an office in Dublin for this purpose. The General Medical Council also has power to inspect Irish medical schools. The constitution of the General Medical Council provides for four representatives of the Irish medical schools.
The British General Medical Council and the Medical Registration Council here have worked very closely together in policies and practices as regards both the standards of training and the discipline of doctors. However, the arrangement is not one of real reciprocity and, in any event, its continuation would not be appropriate in the light of our membership of the EEC and the provisions of the EEC directives in relation to doctors. There is a wide measure of agreement that the arrangement has outlived its usefulness and that it should be terminated. Discussions regarding transitional provisions which may be necessary are to be held between the two countries. In the meantime, it is proposed that the agreement should continue in force notwithstanding the repeal of the 1927 Act. The proposal is that when—hopefully in the near future— it will be possible to terminate the agreement, this can be confirmed by way of an order under section 61 of the Bill.
The continuing close co-operation between the medical profession in this country and in the United Kingdom, which is desired by the medical profession of the two countries, can be structured by co-opting to the respective education committees of the councils in each country of persons from the other country.
Before concluding I would like to place on the records of the House my appreciation of the vital and leading role which the medical profession have played and continue to play in our society. The medical profession have given long and dedicated service to the people of this country and I know that that dedication and selflessness will be preserved and continued in the future.
So far as the functioning of the health services and the work of my Department are concerned I would particularly like to thank the profession for the unstinted help given voluntarily and without reward by so many of their members acting on various boards and commissions, committees and working party, councils and so on.
I have already mentioned the members of the Medical Registration Council and the members of the special committee which examined the law regulating the medical profession. In addition, doctors have contributed and continue to contribute to the deliberations and the decisions of practically all the bodies in the health field. To name but some, doctors are involved as members of all the health boards, the National Health Council, Comhairle na nOspidéal, the Council for Postgraduate Medical and Dental Education, the many specialist national bodies like the National Drugs Advisory Board, the National Rehabilitation Board, the National Blood Transfusion Board, the Health Education Bureau and so forth. It is quite impossible to contemplate the existence of these bodies without the specialist input of the medical profession to them.
I have given the House the general background to this Bill and I have drawn attention to its main provisions. I hope that the House will accept that the changes proposed are aimed at the advancement of the practice of medicine and at safeguarding the general public. On the occasion of my recent discussions with them, the representatives of the medical profession expressed their desire to have this new legislation enacted and brought into operation at the earliest possible date. I hope that the House will co-operate with me in making this possible.