Seanad Éireann - Volume 88 - 15 February, 1978
Medical Practitioners Bill, 1977: Second Stage.
Question proposed: “That the Bill be now read a Second Time.”
Minister for Health (Mr. Haughey) Minister for Health (Mr. Haughey)
Minister for Health (Mr. Haughey): 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—an ad 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 present ad 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.
Mr. Molony Mr. Molony
Mr. Molony: This is a major piece of legislation for the medical profession and I am sure it is satisfying for the new Minister for Health to have the opportunity as one of his first Parliamentary acts to introduce this Bill. I would like incidentally to wish the Minister well and also success in his lofty ambition to be the best Minister for Health the country has ever known. I think very few people, even people involved in the Parliament of a country, realise the amount of work that must go into the preparation of a Bill even before the parliamentary draftsman gets his hands on it. A tremendous amount of work and effort must have gone into the preparation of the report that led to this Bill and I would like to join with the Minister in complimenting the members of the committee set up by Deputy Corish on a job very well done.
As the Minister has said, the purpose of this Bill is to establish a new governing body, as it were, for the medical profession. In Ireland every profession has the right to govern itself. In governing a profession the council of each profession is charged with the responsibility of ensuring the educational standards of its new members, of keeping its members informed of current developments in their profession and of representing the views of that profession to the public. It is also responsible for ensuring proper standards and conduct of its members in the profession.
There was a very interesting discussion in the Dáil on Second Stage on the question of whether a council or a governing body of a profession should consist solely of members of a profession. I am not a doctor but as a professional person I am sure I would not be the most objective person  to consider something like that. It warrants consideration in this day and age and, as a colleague has mentioned to me, it was rather a pity that the committee that made the report that created this Bill did not include outside interests. I know that the Minister has some powers to ensure that the new council will have some outside interests on it and I compliment him on that.
I am surprised at the number of people from all sides of the Dáil who commented on the fact that the 1927 Act had stood well the test of time. With the greatest respect to all the people who said that, I suggest that the 1927 Act stood well the test of time because nobody ever went about changing it. The changes proposed in this Bill, and they are very wide ranging and fundamental changes for the governing of the medical profession, were not changes that were necessitated by developments in medicine last year or the year before. The fact is that there have been enormous changes in the practice and profession of medicine and it was important, perhaps decades ago, that changes be made. The existing council comprising 11 members in my view could not hope to deal adequately with the problems and the work which the governing body of a profession like medicine would have to undertake. I do not know how many doctors are practising here but I am sure there are more doctors practising than there are solicitors and the Council of the Incorporated Law Society consists of more than 30 members. The members of that council have to contribute a great deal of their own time and effort to the work of the council and for that reason the expansion of the new council to 25 members is a good and sensible thing and is something which is to be recommended.
The proposed membership of the new council is interesting and it reflects the differences that have occurred in the practice of medicine. As the Minister has rightly pointed out, the importance of post-graduate courses in medicine, and the importance of specialist interest in medicine, has caused the necessity to include  specialist interest on the board. I am concerned that the specialist representation on the board has gone a little too far. It is important that a medical council would represent, in so far as possible, the overall profession of medical practitioners. It is important that the council should to an extent represent the break-up of the members of the practising profession. I do not think anybody would deny that the general practitioner or family doctor forms the greater portion of all those practising medicine. The council has many matters of a general nature to deal with and I feel that some of the specialists concerned could have been catered for adequately on committees which the council has the right under the Bill to set up.
The general practitioners represent the main contact which the medical profession have with the community. They represent—I say this with no disrespect to other people involved in medicine—the truly human side of medicine. They practise the art of medicine as opposed to the cold clinical science of medicine which is practised by the specialists and the academic medics. Only a minimum of three out of 25 of the new council membership will consist of general practitioners. One will be appointed by the Minister and two elected. I am concerned that that is not enough and I should like to give further consideration to this and, perhaps, it is something that might be discussed further on Committee Stage. Anybody who takes an interest in Seanad elections would be interested to observe the type of elections that will have to take place to the new council because there are going to be more panels and sub-panels in that than ever had to be sorted out in this Chamber. People interested in future Seanads might take note.
I should also like to compliment the Minister on the amendment made in the Dáil that of the four members to be appointed to the council by the Minister three of them shall not be registered medical practitioners and shall represent the public interest. The fact that these three people do not have to be registered medical practitioners  does not mean that they will not be medical practitioners of some form or another or that they will not represent quasi-medical interests. I hope the Minister will use this opportunity to represent consumer interests. There was considerable discussion in the Dáil on this. The framework that is there at the moment is ample to ensure healthy representation of outside interests but it is going to rest with the Minister to exercise that opportunity and ensure that he ends up with the most desirable product, as far as the country is concerned generally. There is obviously a case to be argued for para-medical groups to be represented on the new council but it is important that outside interests, particularly people concerned in the field of social welfare and that type of interest, should be represented on the new council.
Part III of the Bill is concerned with registration. This is of considerable importance in any profession but it is of outstanding importance in medicine. The fact that it is a crime for somebody to put himself out as a registered medical practitioner has obviously not proved a sufficient deterrent because we have seen many instances over the past number of years of people purporting to be registered practitioners who were, in fact, no such thing. As matters stand at the moment it is possible for any Member of this House not a doctor to set up in Merrion Square and put outside, “Senator so-and-so, Medical Practitioner”. There is no objection to that and there is very little the Minister can do to stop it. The only control he has is to increase the penalties for people who purport to be registered medical practitioners. The importance of the register lies in the fact that members of the public who want to see whether a doctor is actually qualified or not can look to the authority of the register and if the doctor is on it he knows that that doctor has satisfied the basic education and training which must be satisfied for the person to achieve the distinction of going on to the register.
I am concerned that the opportunities which exist for tightening up looseness  in relation to the register have not been fully used and the opportunities to control matters in a better fashion have not been taken in the Bill. There was a lot of discussion in the Dáil on this and I do not want to go into the details of it but a simple solution occurred to me. The procedure as it now stands is that somebody qualifies and then he is entitled to go on to the register. The Minister introduced a very useful amendment insisting that a doctor display his certificate of entitlement or certificate of registration in his office so that the public can see it. Of course, one may go on the register this year and come off it in ten years' time, but one still has that slip of paper that says one is on the register. In our profession, and in other professions, an annual practising certificate is issued to members and there is no reason why the Medical Council should not issue to its members annual practising certificates.
This would prove a very useful way for employers, be they health boards or other doctors, to check somebody's qualifications. Anybody who purported to be a registered medical practitioner could as proof of his entitlement to claim such produce this certificate and show that he was currently registered. This is a problem that arises because of the enormous increase in the numbers of doctors and people practising medicine and also because of the free movement of doctors within the EEC territory. It is a problem which could become a good deal worse. The Minister should consider including in the provisions of the Bill an obligation on the council to issue annual practising certificates to doctors. The position could be tightened further if there was an obligation on the council to circularise details of any doctor who had been struck off in the course of the year for one reason or another.
The registration particulars in the Bill differ only slightly, and not in any significant way, from the provisions of the 1927 Act. The 1927 Act was introduced at a time when the numbers practising were very small and when we were a smaller community in terms of contact with each other and, particularly, contact with one professional  person and another. Greater changes are required than the changes proposed in the new legislation.
Part IV is concerned with the education and training of doctors. As the Minister has said, there is a very significant change in this new legislation from the 1927 Act. The council is no longer simply concerned with the undergraduate training of doctors but is now concerned also with the adequacy of post-graduate training. As I interpret the Bill, it appears that the council's duty in this respect is concerned with the training of those who undertake a formal post-graduate course. Could the Bill not go a little further than that?
Most professions provide a service to their members in keeping them up to date with developments in their profession but the existing Medical Registration Council does not do this. In medicine, probably more than in any other profession, it is very important that people are kept informed of changes. New treatment programmes come up as a result of research; new drugs come on the market and, worse still, there are existing drugs arriving on the market under new brand names. It is very important that doctors be informed objectively as to the worth of these drugs and as to the advisability and importance of new treatment programmes that may be discovered. I know that doctors are the target of propaganda and of the advertising campaigns of the wealthy drug industry. I stand to be corrected on this, but I believe that a doctor's main source of information about new drugs comes either from the drug industry itself— which has a strong interest in the matter—or from medical periodicals. It has been said—I am not going to say that it is true—that medical periodcals are likely to be subjected to some influence by the drug companies because of the tremendous amount of money they derive from advertising revenue. I am not suggesting that any Irish medical periodicals actually respond to such influence but it is important that we bear in mind that the dice are loaded so far as the purveyors of medical information are concerned. It is important that  some totally independent agency, like the Medical Council, are charged with the responsibility of keeping members of the medical profession informed objectively about new drugs, new treatment programmes and, generally, keeping doctors up to date on developments that take place in research.
I should like to refer briefly to the establishment of the postgraduate medical and dental board. I was pleased with the Minister's remarks to the House on this because a lot of concern was expressed amongst various outside medical and dental interests that this had suddenly appeared at the dying stages of the Bill's passage through the Dáil. I am pleased that the Minister is willing to consider and sponsor amendments to section 40 and the following sections concerned with this board. I know he has been in touch with many of these boards and I hope the consultations he had with them have borne fruit and that we will see some changes in these sections.
The next Part of the Bill deals with fitness to practise, a very important aspect of the work of any governing body of any profession. The Minister has said that professions have the privilege of governing themselves but that privilege is chargeable with great responsibility because they must ensure that the members act with a certain conduct and standards that befit the profession. Like other professions, probably even more so in medicine, doctors can do great damage if their standards are not sufficiently high. We have been extremely lucky here in that the practice and profession of medicine has been extremely high, but it must never be forgotten that the conduct of a tiny minority of misguided practitioners could do untold harm not only to the reputation of the profession but to the public.
I have already referred disapprovingly to the suggestion that the 1927 Act stood the test of time. In respect of disciplinary matters, the 1927 Act was a cod and has been a cod for a number of years. There is some evidence that malpractice of a few doctors could have serious consequences for the  public. About 12 months ago an article was published by the medical correspondent of The Irish Times in which he outlined the difficulties that had been encountered by the profession and the public because some doctors were misconducting themselves. I regard this matter as extremely serious but I understand nothing has since been done about it. I know there have been reports about it since. I should like to draw the attention of the House to this problem and ask for the Minister's comments on it. Doctor Nowlan's article in The Irish Times, of 23 February 1977, stated:
The activities of 12 family doctors —eight in Dublin, four in Cork— are threatening the very existence of one of the addiction treatment programmes run by the National Drugs Advisory Centre. They are also exposing the community at large to the risk of a relative explosion in the still small number of drug addicts.
The article went on to detail, in a very comprehensive fashion, the problems they were concerned with, the damage being done by these practitioners and how the problem might be overcome. It was written in the hope that the provisions of the Misuse of Drugs Bill, which was going through the House at the time, would help curb the problem and would give power to somebody to try to put a stop to this malpractice.
In an editorial published in The Irish Times on 30 November 1977, under the heading, “Rogues in the Herd”, the opening paragraphs read:
It is nine months since this newspaper carried a report drawing public attention to the fact that a small number of doctors in Dublin and Cork were prescribing addictive drugs more or less on demand for young drug abusers.
That report was carried not out of any desire for public alarm or sensationalism, but because a number of experts close to the problem of drug abuse in this country— doctors, pharmacists, Garda officers and health officials—were deeply concerned about the potential for disaster which lay in this pernicious form of medical malpractice.
 It has been shown in Britain that only a hnadful of doctors, either avaricious or woefully misguided, had been responsible for the relative explosion of lethal drug addiction during the Sixties in that country. Their malpractice was virtually identical to what a few doctors in this country have been doing.
Earlier this year the Oireachtas passed a useful new Misuse of Drugs Bill, but the provisions of that Act have still not been activated, pending the drafting of appropriate Ministerial regulations. It is time that those provisions were implemented.
So far as I am aware, no regulations have yet been made, or certainly have not been published. Can the Minister report progress in that matter? It is not entirely desirable that we should have to rely on some agency under the Misuse of Drugs Act to quell a problem like this. The responsibility for control of members of a profession must lie with the governing body of that profession. I am not going to blame the existing Medical Registration Council for failure in this respect because they have had difficulties. The provisions for discipline in the 1927 Act were rigid and are of very little use for application in medical life today. In addition, the existing Medical Registration Council have suffered the same difficulties as other professional governing bodies have with regard to the constitutionality of their actions when functioning as a quasi-judicial body, which is what they do when they sit in judgment on a colleague.
The provisions of this Bill are welcome. There are a couple of small points that concern me and a couple of improvements could be made but I am very concerned about malpractice, small and all as it is. It is a matter of very serious concern. I hope we do not have to wait for the passage of this Bill and the establishment of the new Medical Council before a stop can be put to this serious matter. It is a pity, when speaking on a Bill such as this, that it is necessary for me to highlight the small number of doctors who have been misbehaving themselves. I come from a family in which there are a number of general practitioners  and I know that the work which general practitioners, particularly rural family doctors, have contributed to society has been enormous. I know that the work of medicos here at every level has been unselfish and it is proper that they be complimented on their work and I should like in this small way to pay tribute to them.
Mr. McGlinchey Mr. McGlinchey
Mr. McGlinchey: I should like to welcome the Bill and particularly the proposal to set up this new Medical Council. Like Senator Molony, I express the hope that consumer interests be given representation on it. When the Health Act was being considered some seven years ago, I was one of many people who strongly opposed the presence of doctors on health boards. I felt they would be biased in their approach, particularly doctors employed by health boards. Having served on a health board since its inception, and been chairman of it for a number of years and currently chairman of a hospital executive, I was very wrong in what I claimed seven years ago. It is obvious to most people that the success of health boards has been due to a great degree to the contribution the medical profession has made to them. However, if we had only doctors on health boards I do not think they would have been very successful. The lay people on the boards have made very useful contributions and have contributed in no small manner to the success of these boards.
On the new Medical Council I hope there will be some lay people to look after the consumers' interests. The Minister has said that the main purpose of this council is to control the discipline of the profession and the education at undergraduate and post-graduate levels. As far as discipline is concerned one must consider that when there are complaints against doctors they generally involve lay people and for that reason I hope some voice will be given to them when this council is established.
I hope the new Medical Council will investigate some abuses that are occurring as far as the medical profession  are concerned. One is the indiscriminate issuing of medical certificates. Most of us must agree that medical certificates for days off work are the easiest thing to get. As a result we are suffering in industry, the civil service and so on. We are losing a tremendous number of working days. I would like to see a situation here where there would be some form of inspection. An employer, if he or she suspects that a medical certificate has been issued wrongly to an employee, should have the right to call in a department inspector for a second opinion. If this was done doctors would be slower to issue medical certificates and patients would be slower to look for them.
I would also like to see the new Medical Council doing something about the over-prescribing of drugs and medicines. Most of our GPs are completely over worked and the easiest way of getting a patient out of his or her surgery is to prescribe some medicine. It has reached a stage where drugs are implanted in people's minds, they read advertisements in the papers every day, and see them on television and they are indoctrinated into believing that unless they get some form or drug their ailment cannot be cured. I am of the opinion that the over-advertising of drugs and medicines presents as serious a problem, almost, as that of alcohol and cigarettes. I hope that the council instead of recommending refresher courses for doctors, will make them compulsory at least once every five years. With changing times it is absolutely essential for doctors to have refresher courses.
The main point that should be dealt with is the over-working of general medical practitioners. We find, particularly in rural Ireland, that doctors are completely overloaded. Many of them take on partners and extend their practice but nevertheless the situation is that a doctor spends five or six hours in his or her surgery before attending to calls. A lorry driver is not allowed to drive more than eight hours a day and I presume the reason is that he has his own life and the life of others  in his hands. But a doctor may work for 20 hours a day without any curtailment whatsoever. Surely a doctor is responsible for life and death every hour of the day. Something must be done about this. The panels of some doctors are very high and the Medical Council in the first instance should instigate an investigation, a simple matter to do through the payments board. They would then know exactly how many hours a day a doctor works from the fees he claims and from the times he claims them.
I cannot understand why the Medical Union should be consulted before an extra doctor is allowed into the general medical service. I am not aware of the Medical Union ever opposing an extra doctor being admitted into the service but, apparently, if they oppose that appointment the health boards may not agree to the extra doctor. That is wrong and it should be investigated. I hope the officials the Minister talked about appointing to this council will be lay people. The officials of health boards have proved to be very independent minded and in the main are very successful. If doctors are appointed as officials to the council there is a danger that the whole council will be one-sided.
When the new consultant register is drawn up the Medical Council will have another important role to play. They will be in a position to recommend to undergraduates which field to specialise in, particularly the fields where there is a grave scarcity at the moment. In the hospital in my constituency we have been looking for a radiologist for two years. We have advertised in most medical magazines in the world but have failed to get one. There are also vacancies in ENT and in orthopaedics. There are many specialist fields that undergraduates should be encouraged to go into. This is something that the Medical Council can do when this register is compiled.
I would like to think that the Medical Council will also be in a position to control consultants' fees. At the moment the public have no way of knowing what a consultant may charge. This is very wrong. This has been a hobby-horse of mine for many years.  In 1960 there was a limit to what a consultant could charge—£25. In 1961 the limit was increased to £30 and a short time later it was abolished altogether. We now have a situation that a consultant may charge a patient whatever he or she wishes. Recently, a consultant told me that his fee to a private patient was entirely a matter between himself and the patient. I feel that when a consultant has the use of a hospital provided by the State and the use of staff paid for by the State, there should be some control of some kind. In country hospitals a charge of £150 to £200 for a few days in hospital is astronomical and it is wrong. I hope when this new Medical Council are in operation they will have a look at consultants' fees.
I would like to finish by expressing the hope that the Minister has a long and successful reign as Minister for Health—one of the most important ministeries in the country. I am very glad to see him back in the House and knowing his record I know he will add a new dimension to his Department.
Mr. Keating Mr. Keating
Mr. Keating: I wish to start where Senator McGlinchey left off. I am not sure if the Minister has been in the Seanad before—if he has I have missed him—but this is the first time I have had the opportunity of welcoming him. It occurred to me to speculate aloud as to whether he would wish himself a long reign as Minister for Health. He would certainly wish himself a successful one and we all wish him that. On this first occasion I certainly want to add my voice of congratulations and good wishes.
What I have to say will be made up of two separate parts. The first is a rather piecemeal set of comments on the Bill. I see from the debate as it is taking place in the Seanad and also looking at the Dáil Report that inevitably the debate has brought in other issues. There are indeed such sections as section 69 of the Bill which permit us to range a little more widely, not in my case in a completely undisciplined way, over the whole question of the role of the medical profession in our society.
I want to make some points seriatim  about the Bill. I want to add my voice to those voices which have have urged the Minister in making up the council of 25 persons to use the four persons appointed by the Minister, at least three of whom “(i) shall not be registered medical practitioners, and (ii) shall, in the opinion of the Minister, represent the interests of the general public”. I am glad to see that there. It is not mandatory. They may or may not be doctors. I hope that the Minister will ensure that there is the voice of non-medical persons on the Medical Council. It is perfectly possible to pick people of such general goodwill, intelligence, knowledge of our society and moral intellectual stature who in no way would inhibit or damage the work of the council but would bring a necessary point of view from outside.
Reputable professions regulate themselves and regulate themselves well. The veterinary context is extremely similar. Within reason, it seems appropriate that the medical profession ought to do so. I do not think that the demand for self-regulation by professions ought to be pushed by them to the stage of refusing at least the scrutiny of outside persons who are carefully selected. I do not think that when a profession considers the cost of contribution that could be made from properly selected outside persons that they in fact would object to them. I hope that my voice, added to the voices of others, will do something to encourage the Minister to choose persons who are not doctors.
I am skipping to the question of the duties of the council. There is one aspect of this which I have thought about for many years. I have thought about it in the context that before turning to the veterinary course I did the pre-veterinary year in UCD, in the mid-forties, in a very large class of some 300 people. I remember going back in the mid-sixties to find out where they were. Very, very few were in Ireland. That was at a time when our third level education was starved for funds; when certain sectors of it were not funded at all, for example, in agricultural engineering. We were then turning out very many doctors  for export. By the time someone has been through first, second and third level education culminating in a medical degree—it is very hard to put a figure on it off the top of one's head —there must be an investment of between £30,000 and £40,000 in that person. Most of the investment nowadays is by the State, though some obviously is by the family.
It is not a practical proposition to say to the Medical Association: “regulate their numbers”, nor is it a practical proposition to say it to the medical schools because they are in the gross business and they will never say: “we should limit our intake”. They are delighted to get all the students they can get. It seems that the supreme body of the profession, particularly in the context of the EEC and free movement, ought to look at this question. If my approximate figure of, say, £40,000 total investment in the individual is correct, the emigration of 25 graduates represents £1 million. It is not as much as it used to be, obviously, but we are still into significant amounts of money in relation to the total funding of third level education.
One function of the council should be the use, not of medical people because they are not the people to do it, of economists, sociologists and people like that, to try to make some estimates about numbers and then to try, not in a draconian way but in a rather more long term way, to guide the production of graduates so that it more nearly approximates to the national need. I say that in the context of the EEC because it is very unlikely, with the structure of incomes in the nine Community countries, that we will see large numbers of Germans, Belgians or Danes or even British people coming to put their plates up in Ireland. It is very unlikely, even if the cultural barriers, the language barriers or the income barrier, were not too great that they will move in that direction. There is a real possibility that we, as the poorest country of the Nine, would be producing some of the doctors to service the richer countries at our expense.
 Senator McGlinchey spoke about the difficulty of getting a radiologist in County Donegal. That may not be from an absolute shortage but because of the movement of people to areas where pay is higher. We have to look at ways of seeing that our people are catered for first and that we do not produce very large numbers for export. If we leave aside the estimate of £40,000 of total cost and say that in the university years there has been something like £10,000 of public money invested in the person then the question can seriously be asked whether they intend to emigrate and practise in another country and if so should they not make some sort of reparation over a reasonable period to the State which invested that much money in them and which will get no return from them if they emigrate.
In regard to the loosening of our ties with the United Kingdom in an EEC context this is two sided. First, because those ties have consisted of personal knowledge, friendship, place of study and so on, they go far beyond their past statutory basis. They will not be broken so easily anyway. We have the language basis for maintaining them closely. In fact, what we have gained from a close association with Britain we have lost by being insulated by Britain from the Continent because, to some extent, the excellence of new medicine is a function of the welfare society and it is the richest countries that have the largest volume of the best work, America, Germany, France and so forth. I hope that the loosening of the ties with the UK will be compensated for by a much greater closeness of contact with the other strands of European medicine which has had such a remarkable history. Indeed, it might be a function of the council to look into the question of the general education of graduates, the question of a second language in a specialist sense up to a level that they can freely participate in the medical developments of France, Germany or some other Community country.
The Minister, I understand, has accepted the suggestion to establish a separate post-graduate medical and dental board. That is wise because the  task of a council is a different task from a post-graduate board. They are sufficiently different that if they were both to be incorporated into a single organisation it would produce inefficiency.
In regard to the question of a post-graduate medical and dental board I would like to make a few observations. I will talk in general terms a little later about the characterisation of the medical profession as it was carried out in the Dáil by Deputy Noel Browne and the response made to him by the Minister when winding up the Second Stage of the Bill. Whatever we think of medicine we have to be fairly dissatisfied with the dental situation in this country. Dentistry is so technologically related and so rapidly changing that if you do not have very good post-graduate structures, both for retraining people and for pushing out the new techniques and the new materials, you simply are not in line with available knowledge and practice and you have an unacceptable level of dental service.
In a very rapidly changing context, with the entire pharmaceutical industry and the medical physics industry and all the other new industries related to the medical and dental professions that have grown up, all producing exceedingly rapid changes, as well as the burden of research inside medicine and dentistry themselves, the structuring of both post-graduate studies and the concept of life-long study for practitioners is extremely important. Therefore I think the separation is right. I compliment the Minister on doing this.
I want to disagree a little with Senator Molony. He talked about a looseness in regard to the register, I say this as a member of a different profession, the veterinary profession, that where two trends, as in medicine, as in dentistry, are to be distinguished —especially in the medical and veterinary areas—there are the people who want to tighten the register very much to limit those who may practise. In our society, traditionally, anyone who thinks he can do mankind good and if he can persuade people to come and pay him for doing it, may offer to heal people. That is a basic liberty that I do not wish to see restricted too much.
If one looks at the history of medicine,  admirable and high-minded as it is in many ways, one sees the most ferocious resistance, on the part of what you might call the official medical profession, over and over again to innovation. A time comes when revolution and the innovation of the past become the orthodoxy and indeed, the codified, sterile orthodoxy of today. Let us always keep rules for the fringe people. I do not know, for example, how acupuncture works. On the face of it, I do not know that I have ever seen anybody indicating how it works. There are lots of things in orthodox medicine that are pretty magical still and it is not yet totally a science. It is an art and a science.
Mr. Molony Mr. Molony
Mr. Molony: The Senator misunderstands my point. I was referring to the tightening up of the register as it stood for registered medical practitioners.
Mr. Keating Mr. Keating
Mr. Keating: I note the Senator's correction. I will go on to make the wider point. I think that certainly one needs a rigorous register but one has to be careful that it is not ever used in a restrictive way or in a way that denies a basic liberty. I do not want to see the medical profession too closed as a profession. I do not want to see anything that will restrict the liberties of people who are high-minded, serious people in the fringe area.
I want also to follow up a thought of Senator McGlinchey. I remember a time, at the beginning of my awareness and participation in politics, 30 or more years ago, when the question of a public health service supported by public funds was a very hot issue and when the majority of the medical profession who were then profoundly hostile to it. One has seen in the interval almost a 180 degrees change of direction on the part of the profession because they see two things. Part of this conversion is high-minded and for the best possible reasons. It is simply impossible to practise medicine now without enormous state subventions. Part of it is cynical and opportunist because people find an opportunity to build a monument to themselves with public money. I say this as someone  passionately concerned with the very large funding of health services by the State.
We are seeing an interesting thing happening all over the developed world. We are seeing that a larger and larger percentage of gross national product is going into the health services. This is a matter for the whole basic attitude of the profession. It is almost a moral, certainly an ethical, question for the profession because while that has been happening the actual levels of health have not improved very much. The readily eradicable diseases have been eradicated. The chemotherapeutic revolution, the marvellous range and effectiveness of the antibiotics have happened and have produced some remarkable results, but we have a movement in opposites. While this tremendous improvement in the area of infectious diseases has taken place and the eradication of eradicable diseases we have not seen a dramatic improvement in the health of the population. We see huge amounts of public funds, large institutions, large-scale medical resources of personnel, money and equipment being devoted to preventing people from destroying themselves further than they are at present by the abuse of drink, cigarettes and food.
I hope I am echoing the Minister's thoughts as I understand them. It is surely a basic ethical question for the medical profession as to whether this partition of funds is right, whether, for example, the present level of giving certificates, to which Senator McGlinchey referred—I agree with him—is right, whether the level of drugs being prescribed is right, whether the extent to which the practitioner now is visited by the drug firm's traveller and receives his information and the drugs from the traveller and they pass with appropriate alteration of the labels over the doctor's desk and into the hands of his patients is right. I totally support the funding for bricks, mortar and equipment, but we must ask if the existing bricks, mortar and equipment are being efficiently used. It seems that the explosion in the scale of hospitals, the scale of equipment and the scale of investment,  the number of people coming forward now that they can afford to do so, for medical aid and the number of people available to give it has placed management questions on the agenda for the medical profession which they do not seem to be equipped to answer.
I know of cases where horrendously expensive equipment, the purchase of which I entirely defend and the right of Irish people to have access to it, is being grossly underused because the management structure into which it is being inserted is not adequate. While we must expect and welcome in our society the growth of spending on health, we must make a demand on the medical profession that they do more than repair the ravages of our stupidity in regard to smoking, drinking, food and the other things we now profess are destroying us. They must turn in a much more fundamental way of prevention.
I note in that direction that in section 69 the function given to the council of keeping the public informed on matters of general interest. I can only add one more voice to those who urged the council to orient the profession in its basic ethics and in its education towards prevention and towards a rigour in regard to the use of the large public funds to which they are entitled, which is not currently evident either in regard to drugs or in the giving of certificates.
We have had a rather savage characterisation of the medical profession from Deputy Browne, an ex-Minister of Health and a doctor all his life. There was a defence—I think it is fair to call it—of that profession in the closing speech of the Second Stage debate in the Dáil by the Minister. The truth lies between these two approaches. Deputy Browne is angry and is venting anger on a whole profession in an undifferentiated way. On the other hand, we would be wrong to be complacent. We all know that the GP who works far beyond any normal working hours and beyond any reward, works too hard. He very often makes no money out of medicine; he charges very little and does not collect half his bills. We know that that person is giving a noble service to the community. We also know the drunk in  medicine, the bigoted ignoramus, peddling the superstitions of his grandmother as contemporary knowledge; we know the shameful people and noble people. This is perfectly natural inside this profession because this profession has more power than others to change society and is also a reflection of society. It shows all the complexities, all the superstition on the one hand and all the belief and science on the other, all the greediness and all the nobleness, all the bigotry and all the altruism. A blanket condemnation is no good because I do not think it is true. Neither do I think that the general claim “What kind people they are” is good.
Dublin, especially, has a very remarkable history in medicine. It was once one of the great cities in the world. We did not hold that position; we could not possible do so in economic circumstances. To go on talking as if we still had a very remarkable medical profession in world terms is to deny the great progress made elsewhere and to become complacent. We have a profession which reflects our society. There are some excellent aspects of it and some disgraceful aspects. We have great opportunities now. I welcome this Bill as being practical, constructive and a real step forward but we must not go on pretending we are still one of the great medical centres of the world. We must not pretend that we have a profession which is much better than the statistical norm of our society. Neither is it worse. It is probably a little better.
We have here a framework for real progress. I note that this Bill has been received with general approval and that the Minister has been willing to listen to those who make suggestions. The Bill will be the better for it. Far from the Minister appearing indecisive in that regard, he has demonstrated nothing but an open-mindedness in his acceptance of some amendments. In general, it is a very good measure but I hope the Minister will use his power —I cannot see how else it will be done except by the mechanism suggested— to open a little window to let the consumer and the public at large have a closer look. I say this in the certainty  that when they have a closer look they will be reassured and that the medical profession, as represented in the Medical Council as a controlling body, have nothing to fear from such scrutiny and only reassurance to gain.
Professor Conroy Professor Conroy
Professor Conroy: First of all, I should like to welcome the Minister. He has been with us before but this is his first time here as Minister for Health. His is a very difficult and onerous position to hold in today's world, faced as he is with the natural and just demands for improvement and expansion of medical services, the pro vision of many medical facilities which are available nowadays. We are faced at the same time with the enormous and open-ended spiralling costs which the provision of such services involve. I note that the running costs alone of a newly approved hospital in a neighbouring country will come to something in the region of £1 million per month. It is a 900-bed hospital. That is the sort of bill which can be expected in future. No doubt it will be more expensive when it is ready. Therefore, the future for any Minister for Health is, an extremely difficult one caught between these two grandstands. Nonetheless, it is also vital. Our health is perhaps the most important thing we have. I wish the Minister well. I am very glad that one of the first steps he has taken in the legislative sense is to bring in this Bill which will help to lay the ground work for other advances. It is a fortunate fact that it is in itself a necessary and a timely Bill.
We are in a situation in which the old relationship between Britain and Ireland with regard to medical registration and medical discipline clearly needed overhaul and reconsideration and, indeed, the corresponding committees in Britain and America had recommended that the formal link between us should be broken. On our side we also consider that the time has now come to break this link, without, I hope, interfering in any way with the very good and close relationships which exist between the medical professions in both countries and, in particular, the very  good relationships between the medical professions in Northern Ireland and the profession here.
I do not know what the procedure is with regard to a declaration of interest in this House, but I should perhaps state that I am a medical man, married to a medical doctor, a professor in one of the institutions named in this Bill and in other ways presumably an interested party. Having said that, I would like to say I am very proud to be a member of the Irish medical profession. It is a profession in which we can take an enormous and justifiable pride in the sense that we have, as other Senators have said, many doctors in general and hospital practice who work extremely long hours and give very conscientious and devoted service of a very high order. It has too an international reputation which is fully deserved. We no longer are, nor can we expect to be, one of the centres of excellence in the world. The time has passed for that.
Nonetheless, Dublin together with Edinburgh still retains an international reputation which stands extremely high. Although we cannot compare with the enormous sums of money, huge facilities and great back-up support, that medical hospitals and medical schools in the United States or Germany possess, nonetheless, within our resources, we do an extremely good job. In particular, we do an extremely good job at teaching. We still have an international reputation for excellence in our teaching. We have people coming from all parts of the world to the various hospitals here to do post-graduate medicine. As well as that, we have an international undergraduate medical school which is one of the largest, and I would claim one of the best in the western world and, indeed, internationally. We are very fortunate in this. We take it very much for granted but perhaps this is a good thing.
One other aspect I would mention is the goodwill towards this country which exists throughout the world in no small measure because of our  Irish doctors, nurses and other members of the medical profession who have gone abroad, perhaps for a few years before coming back here, perhaps with the missions, perhaps to settle permanently. No matter where one travels in the world one is very likely to meet somebody who will say: “Oh yes, my doctor is Irish, or the nurses are Irish or the matron is Irish”. By and large, in fact unanimously, to my knowledge they give a very good account of themselves and thereby do this country a great deal of good.
Let us not forget the prime purpose of this Bill which is, of course, the protection of the patient. There are aspects which in effect give protection to the doctors and the medical men involved, but primarily it is for the protection of the patient. It is with that principle in mind we should first of all examine it. Here we can reasonably and justly say that the various bodies involved such as the various colleges, medical institutions and the Department have gone to an enormous amount of trouble and work and there has been a great deal of free interchange of information and a great deal of reasoned discussion. At the end of it all we have a Bill which will serve the purpose of protecting the patient in the best possible manner. It is a very thoroughly researched and carefully worked out Bill—a Bill which was subject to careful consideration in the other House and people on both sides would, I think, agree that the Minister showed great reasonableness and a great willingness to discuss and accept amendments and suggestions, and in a very non-partisan manner, directed solely towards the benefit and protection of the patient.
The Minister mentioned the General Medical Act, 1858. It is the immediate origin of the various Medical Registration Acts, but we should not entirely downgrade ourselves here because a much earlier Parliament, which was, whatever its defects, in some ways our predecessor, passed one of the first, if not the first, Act regarding medical education and fitness to practise. That Bill was introduced in 1766. It was a Bill for the erection and establishment of county  infirmaries and, associated with it, were provisions whereby the surgeons attached to the infirmaries had to have a certain degree of education and fitness to practice. We still have the county infirmaries with us today and we can take pride in the fact that we were one of the first, if not the first, to originate the idea that doctors involved in treating people should have certain specific standards laid down for them.
There are certain new aspects now in medical registration and education generally in relation to the EEC. We now have legislation enacted elsewhere and the standards accepted by the EEC will be the standards we too will have to accept.
I am delighted our Minister for Health attended the first and very much overdue meeting of the EEC Ministers of Health. It was high time the Ministers got together because there are quite a number of implications both in health terms generally and immediately in a Bill like this. We talk about maintaining the minimum standards. Allowing for all possible bias, few would disagree that the standards of medical education here, the training and general capability are at least as high as those elsewhere in the EEC. We must be very, very careful indeed to make sure it is not just a question of our measuring up to other standards. We must have full input into any regulations or provisions mutually agreed through the EEC to ensure that not only our own standards are maintained but that the standards of those members of the other EEC states who will then become entitled to practice here, if they are not already so entitled, will be of a similar high standard. There are excellent doctors in other EEC nations. I am not casting any reflection on them. I am just saying that at the moment we have very high standards and we should make sure that they are not in any way lowered. For example, there are moves in other EEC states to abolish the clinic examinations and one wonders, from a medical point of view, whether that is a very wise development. There are many other similar matters which I hope the Minister  and his advisers will bear in mind when agreeing precise directives of the other states of the EEC.
Turning to specific points in relation to the Bill, the council of the medical profession will have 25 members. The Minister, in consultation, has obviously gone to enormous trouble to ensure that there is wide representation. This representation must, of course, not only include the various medical bodies involved, the teaching bodies and so on, showing a geographical spread, but must also endeavour to cover the various facets of medicine. This is extremely difficult to do satisfactorily because the corresponding body in the UK has, I understand, 98 members. Such a body would obviously be far too large but I agree with the Minister increasing the body here from 21 to 25 members. Even then, there are certain difficulties and anomalies which arise.
For example, under section 9 (2) there is the question of one person alternately representing the specialties of anaesthetics and radiology. This is a very reasonable compromise in the circumstances, but let us bear in mind that they are very different specialties. For example, today the anesthetist not only looks after the care of the patient under anaesthetic in the theatre but very frequently he is in charge of the intensive care unit into which a person is taken when suffering from a coronary thrombosis. He is concerned with some very acute and difficult ethical problems in relation to the treatment of such persons, in relation to such questions as life support systems, when one can turn off, at what point can one decide or agree that a person is in fact no longer living, that he is dead. It may seem strange but it is very difficult medically to define death. I understand that the legal profession have the same problem.
Mr. Haughey Mr. Haughey
Mr. Haughey: Theologically.
Professor Conroy Professor Conroy
Professor Conroy: Theologically. We used talk about how long after death the soul left the body. Once we could simply say that a patient had stopped breathing and therefore he was dead. Now we know that the heart can go on beating for a few minutes and a  person may survive. Then, for a time, people thought that the various electrical brainwaves indicated very clearly whether a person was alive or dead. In fact a person suffering from barbiturate poisoning is apparently dead because he is not breathing, his heart has stopped and there are no electrical waves. But such a person can, within a matter of minutes, come back towards life and the brain waves can reappear and he may even survive. It becomes very difficult to tell just when a person is dead and that has enormous implications when one is talking about heart transplants, kidney transplants and so on.
Coming back specifically to the Bill and this section, I am not altogether sure that there can be full representation by a person from either anaesthetics or radiology. We see the same situation in regard to pathology, obstetrics and gynaecology in the next section. There are many problems— no doubt the Minister will be dealing with them in another Bill—with regard to obstetrics and gynaecology. I am not altogether sure the specialties can be very conveniently put together. However, it has been stated that it will be possble to set up special sub-committees. I would hope that the council would do this to cope with any difficulties of the nature and ensure that a full input of information is available from all the various specialties, including some it has not been possible to mention. Nuclear medicine is obviously one. In the circumstances, the Minister has been very wise to give this little degree of extra flexibility, this increase in numbers, rather than keeping it to a very small body of 21 members. I would agree also that, if you make it too large, it becomes, from a practical point of view, cumbersome and self-defeating.
I welcome the idea of lay persons being members of the council. This is a tremendous innovation. It has been the custom for professions totally to surpervise their own professional bodies and this idea of bringing in lay people is a very excellent one, a very welcome idea and one which might well be extended further. It is, perhaps,  particularly relevant in medicine that there should be this input from people who are not registered medical practitioners, who have not themselves got specific training in medicine, who are representing, as it were the patient. After all, that is what this Bill is primarily about.
I would hope—it is not mentioned anywhere specifically in the Bill—that the Minister would take the opportunity either here or through the persons he appoints, or somewhere else in the council, to ensure also that there should be representation of women on the council. It is a simple fact of life that the vast majority of the members of the professions, and certainly the vast majority of those in the leading positions, are traditionally, and for various other reasons, men. It is, I suppose, primarily the business of the professions to see that there is some representation of women but I would hope the Minister too would facilitate this representation.
The Minister has taken powers to remove the members of the council from office and, although this may be in some way a controversial point, I think it is very necessary that a Minister charged with the duties and responsibilities with which the Minister for Health is charged should have this power. I would take it that if it were ever necessary—I hope it never will be necessary to use the powers but it is important that they should be there —to use these powers any responsible Minister for Health would have some time limit in mind and would within 12 months, or whatever, reconstitute the council.
To defray the expenses of the council, the council will be enabled, with the consent of the Minister, to charge such fees as it may from time to time determine. I am not quite sure if Senators fully realise the implications of this or, indeed, the origin of it, but one of the reasons for the Merrison Committee being set up in Britain, with its implications for us, was the considerable dispute which arose when the General Medical Council decided that it would charge annual fees. There is a considerable degree of emotion behind this  particular section here. Many doctors claim that having paid the fee once for life they should be entitled to continue to be registered. I think most of us would agree that in this day and age one must expect, and many other bodies expect this, to have to pay an annual fee. Again, I am just a little concerned here. I presume the council would obviously be responsible for ensuring that excessive expenses, which could conceivably arise, not only under various other sections but also under section 69, would be kept carefully in check or, if necessary, the Minister would keep them in check, because, clearly, these fees are intended in relation to the registration of doctors and the carrying out of the direct powers of the council and not for other diffuse expenditure.
The display of the certificate is a very sensible idea. Perhaps there is something in Senator Molony's suggestion of an annual certificate because clearly problems would arise if someone had lost his certificate, been removed from the register, or whatever. I am just a little concerned here about a small practical point. Many doctors practise from more than one premises. The section states that the said certificate be displayed at the place where he conducts the practice of medicine at all times during which his registration continues and at no other time. What happens to a doctor who has a surgery in the centre of a town and is also practising from a hospital? I wonder if something like “a certified duplicate thereof” or words to that effect would cover the point. I would also like to know what happens if a doctor is removed from the register? How will a patient know he has been removed? Will the doctor have to return his certificate or what is intended in practice?
The question arises under this Part III registration section that the national in any member state of the EEC will be entitled to practise in any other member state and this is obviously reciprocal and I am not aware that the matter has been thoroughly thrashed out. The Minister has mentioned that one country insists that a doctor should be on one register only at a time. I  just wonder how this would apply if you had a doctor practising along the Border areas. We should be very slow to agree to any suggestion that a doctor in Ireland should be on one register only within the EEC at any one time. In France they get over this to some extent by the presentation de service which covers temporary practice, but this is very limited indeed. It really refers to a doctor attending a patient in an emergency, a person with a heart attack, involved in a road accident or something of that nature.
The situation there has to be looked at very carefully. There is also the question of linguistic covenants. This is coming in with relation to temporary registration. I wonder to what extent linguistic covenants will be relevant if a doctor from the mainland of Europe comes here to practise and makes an error because of his lack of knowledge of the language. Would he be reprimanded or otherwise dealt with under this Bill in terms of his lack of fitness to practise or should there be a specific regulation to this end? I understand one or two countries would like to bring this in but I am not quite sure whether, under EEC regulations, it is possible to have any such safeguard.
Section 28 (1) provides that:
A person who has been awarded a primary qualification shall not become registered in the register otherwise than by way of provisional registration, unless he has been granted a certificate of experience by the body which awarded him that primary qualification.
This is an excellent and necessary provision but, at the same time, it is not easy in practice to fulfil this provision satisfactorily. What are the powers of a medical school over a given hospital as regards the interns? What are the powers of the medical school as regards the experience offered by that hospital? What are the powers of the medical school if that given hospital decides that the doctor shall spend six months of his time in medicine and six months in obstetrics and none of his time in surgery? What happens if the given medical body declines to grant the individual a  certificate? I think there would be legal problems here to which the intern might well be able to turn and I would hope the council or, in the Minister's amendment, the medical schools, or the bodies given the primary qualification, could have little more power here as regards the certificates of experience they will not accept. There is also the question of hospitals overseas. Do we accept the experience gained in a hospital in the United Kingdom or hospital experience gained in Canada or even further afield?
The register for medical specialists is a very necessary and appropriate register. There are very considerable differences here between the customs in this country and in Britain as regards specialisation and the customs which have been the norm in France, Germany, Holland and Belgium. I am not saying that one is necessarily better than the other because the idea of specialists has been very much a European idea. In this country we have tended to think about consultants and the two words are not necessarily synonymous. I would hope that in practice it will be possible to work out acceptable arrangements. I think there are many problems here facing the council and I am glad that the Minister has left something to be decided in the future without coming to any absolute requirement here.
I am unhappy about one matter in the Bill. Under section 34 (2):
Whenever the Council takes any action pursuant to subsection (1) of this section for the purposes of keeping any register correct, the Council shall forthwith notify the person concerned, or his next of kin, as the case may be, of the action taken and of the reasons therefor.
and we have notifications of change or correction of the register and so on. I cannot help feeling that for such purposes it should be at least registered post rather than just a notification by pre-paid post. I have known of at least one individual put off the register simply because of failure in the post. There should be some more  satisfactory and firmer situation here. Perhaps the council will make it its business to do this.
The Postgraduate Medical and Dental Board is a little unusual in that it brings in the idea of dentistry in what is really specifically a Medical Practitioners Bill. It has been traditional that medicine and dentistry should in many of these matters be considered together and it is appropriate the board should be considered under this Bill. I understand the Minister will make certain amendments. I fully understand the difficulties he has with regard to the appointment of members of the board and the necessity to fulfil many different requirements in order to have a satisfactory and comprehensive board. I do not doubt this will be carried out appropriately by the Minister. It must be noted, however, that the functions of the board under section 41 will be extremely wide:
The Board shall carry cut such functions, other than functions assigned to it by this Act, as may be assigned to it from time to time by the Minister in relation to post-graduate medical and dental education and training.
We move on then to the kernel of the Bill, fitness to practise. Most members of the medical profession and most people who have taken an interest in the matter would agree that this Bill is a vast improvement on the situation which pertained previously. It provides for far greater protection of the patient and, indeed, also of the doctor. Previously the situation was that a doctor could be brought before the council only for the most grave cause and then the council would be obliged, in effect, to terminate the doctor's ability to practise by crossing him off the register. Now we have the situation whereby, on the one hand, it will be possible to bring people before the council whose fitness to practise may be in some doubt, without anything very grave having occurred, for the council to investigate the matter.
It will also be possible to investigate the situation where there may be a doubt as to the physical or mental ability of the practitioner to engage in medicine. Previously in practice this  was very difficult to do. It will also cover the sort of problem which Senator Molony has mentioned. In other words, the spread of the Bill will be far wider. It will give far more protection to the patient and, at the same time, the powers of the council as regards either punishment or advising or somewhere in between are so extended that it will be far easier for the council to provide an appropriate remedy to any situation coming before it. Again, and here perhaps even more important, is the suggestion that when there is such an inquiry in the process of being set up the person who is the subject of the inquiry—I am referring now to section 44—should be given notice in writing by the registrar, sent by pre-paid post to the address of the person on the register. Again, one would think that at the very least it should be registered post in such very grave circumstances.
I note that the council will have power to decide that the findings will not be made public without the consent of the person who has been the subject of the inquiry. This is necessary and correct but I am not clear how it will be enforced. Will there be any powers of, as it were, contempt of court, or something of this nature, as there are powers as regards the production by witnesses of documents and so on? I would assume that great care will be taken with any medical records appearing and that the confidentiality of such records will be fully protected.
In section 46 (a), one can only be in absolute agreement with the situation there but I am a little unhappy about 46 (b) which states:
Has failed to pay a retention fee charged by the Council under section 25 of this Act after the Council had not less than two months previously by notice in writing sent by pre-paid post to the person, at his address as stated in the register, requested payment of the fee on more than one occasion,
It is a totally different matter to be crossed off the register or otherwise rightly dealt with, if the practitioner is guilty of professional misconduct, or if, for some reason or other, he is unfit  to engage in the practice of medicine because of a physical or mental disability. But to couple these grave causes so closely with circumstances which could merely be an inadvertence of failing to pay an annual fee within eight weeks or so of its becoming due seems to be a rather onerous section. I wonder if this is really intended? If it is, I would hope that a procedure of making certain the practitioner has been contacted by registered post should be followed.
There are provisions under section 46 (3) whereby a practitioner can appeal to the High Court with regard to the proceedings here. This again is a very novel and welcome provision. In this case it is primarily for the protection of the practitioner. My own feeling about the tendency of the profession has been that having once decided to discipline one of their members they tended, if anything, to err on the side of severity. It is a welcome and indeed a necessary provision under our Constitution that a practitioner should have the opportunity to appeal to the High Court. It is protection and, at the same time, it makes it very clear that in effect this council is a court in itself.
Under Part VI, it is intended that the register should be maintained and published at intervals of not more than five years. This seems very sensible when it is coupled with an annual supplement. I would hope that steps would be taken to see that the annual supplement is published as rapidly as possible. It is ridiculous publishing a copy of the register every year. An enormous amount of unnecessary trouble was taken and it could be fully and adequately covered by the production of an annual supplement.
I am very interested in the provisions of section 69 and particularly 69 (2) which states that it shall be a function of the Council “to give guidance to the medical profession generally on all matters relating to ethical conduct and behaviour”. It is necessary that there should be a statutory body which should have this particular power or function as one of its duties and functions. There has been perhaps an absence at times of one given body in the profession with  this power—a necessary one which I hope and am sure will be used.
Finally, subsection (3) refers to the following: “...to inform the public on matters of general interest...” I presume there are other bodies which will inform the public on health matters generally but there is something to be said for this. The council tended very much to be an obscure body—and it is high time that the public should be properly informed regarding the functions and activities of such a body.
I would have wished that there might have been some consideration —possibly it will come in one sense or other within the ambit of the council—of the relationship of the medical profession and the ethics of such matters, not only of the prescribing of drugs but the availability, manufacture and advertising of drugs. Such matters, with particular relevance to one or two of the speeches today, should come within the ambit of the council, but perhaps that is not feasible under this Bill. However, I hope the Minister will bear such a possibility in mind.
There is a very ancient oath of which we have all heard, and it is generally assumed that most doctors take it—the Hippocratic Oath. In fact they do not except in a few medical schools. Nevertheless, parts of it are very relevant today, even though it was first formulated in 400 BC. It is, “The regime I adopt shall be for the benefit of my patients according to my ability and judgment”—that is about all a doctor can do—“not for their hurt or for any wrong”. Then it goes on, “I will give no deadly drug to any though it be asked of me nor will counsel such”—that is very relevant today—and especially, “I will not aid a woman to procure abortion”.
I welcome the Bill. It is a sensible and good measure.
Mrs. Hussey Mrs. Hussey
Mrs. Hussey: I wish to welcome the Minister to this House. I welcome particularly the new emphasis on preventive medicine which the Minister is placing before the public. I hope he sees contraception as a logical and  essential part of preventive medicine.
The Bill has got a long and careful passage through the Dáil, which is evident from the Minister's speech and from reading the debates on the various stages. There is a general determination to make this important council very effective and efficient because it will be with us for a long time In view of the investment which society makes in medicine and the importance of the role of the doctor in the community, this is nothing less than right. I hope that my comments will be a constructive part of the debate.
I was very glad indeed that Senator Conroy mentioned his concern that women would be included on this new Medical Council, not only under the section allowing the Minister to appoint four people three of whom shall not be medical practitioners, but right across the board. I hope that the Minister, who has already demonstrated his goodwill towards the representation of women on public bodies, will perhaps convey to the various appointing and nominating bodies on this new council his concern that there should be an input from women in the medical profession as well as lay women on to this council.
Women, as everybody is aware if one thinks about it for five minutes, are the vast majority of the patients, the consumers of medicine in this country, because every married woman who has children spends several periods in hospital. Then if her children need hospitalisation she is the one to bring them, so that women have far more to do with the consumption of medicine in this country and, therefore, they need considerable representation on such an important body as this.
I would draw the attention of the Minister to a matter that has come up again in today's newspapers, even though I am sure he knows all about it already. It is a small example of the importance of women on medical boards like this. There is a great deal of concern about the plans for the new Beaumont Hospital regarding crèche and playroom facilities. Mothers bring children to hospitals.  There are very few women in a situation where there is somebody at home to mind the other children. They bring a child who may be ill and, therefore, fractious, plus other children, to an out-patients' department and because of the nature of out-patients' departments they sit around for hours. I see the great problems there are in having an appointment system working but nevertheless there is nowhere for those mothers to get the children looked after in any kind of comfort. I will add to that the necessity for crèche facilities in large hospitals for the children of the staff, men and women. That sort of concern worries many women in women's groups and in the nursing profession and I would like to see outlets for that kind of social concern on bodies like the new council.
It is an indication of the problem that in our maternity hospitals all of whose patients by the very nature of things are women and the majority of whose staff are women, the person in charge is called the Master. What would happen if the person in charge was a woman? Would she be called a Mistress? It is an interesting speculation but it is an indication of what the situation is.
Another feature is the fact that there is no woman on the council of the IMA, one of the results of that being the complete absence of interest in the whole question of contraception at the AGM of the IMA at Killarney last year when they did not turn up to vote. I think they have failed the women of this country. Certainly I think the medical profession has a great deal of guilt to bear for its treatment of women in that respect.
My main area of concern with this Bill is, in fact, in the area of the post-graduate medical and dental education section. It is an extraordinary omission. I have read as much as I could of all the Dáil debates and I have listened very carefully here today and nobody has mentioned the growing concern in Britain and the lack of concern in this country for the wastage of talent in the medical profession. In Britain there is a growing debate on the fact that the number of entrants of women into  medical schools has grown every year. It has been paralleled in this country. It follows the fact that women could get into medical schools only less than 100 years ago but they have shown by both their determination and high standards that they are very interested indeed in being doctors and very good at getting through the actual training courses.
I refer to the British Medical Journal in January 1978 which had two serious articles and discussions on this very problem, one by Peter Richards of St. George's Training Hospital in London and the other by Bernese Beaumond, MSC, on a survey of the kind of drop-out rate among female doctors. These were carried out because the British Government became increasingly alarmed at the appalling drop-out rate from the medical profession of women when they got married. If I might just mention one or two details of that, the figure I have been given for the cost of training a doctor is £28,000 per doctor, that is as it stands at the moment. The majority of that is paid in direct grants from the taxpayer to the universities and to the hospitals. Some of that amount is paid by the parents.
The British survey shows that among British doctors less than 40 per cent of married women doctors are in full-time medicine. There was an Irish survey carried out in 1975 by Doctor Nessa Joyce which showed the figures to be slightly worse here. Since there has been a dramatic increase since 1975 in the intake of women into medical school the situation must be much worse.
The reasons young married women doctors drop out of the medical profession is a very wide area of discussion and I certainly do not intend to attempt to go into it now because I am sure I would be stopped before I started. It would be a very broad discussion indeed and I think it is a matter for concern. I would like to give one figure on this, that in 1976 200 young women and 226 young men entered Irish medical schools. With the help of some medical colleagues and with the help of some figures I have worked out that  of the 200 girls who entered medical school in 1976 approximately 140 will graduate eventually. There is a drop-out rate but apparently 140 or so will graduate, and I might add graduate with consistently high standards. The standards of girls in gaining gold medals for various things are remarkably high and are equal to if they do not exceed that of the men.
To train that class of 1976 alone, if my sums are correct, will cost us at least £400,000 by the time they eventually graduate. That is not allowing for inflation. It you look at the picture over a period of ten years—ten years from now—we are talking about £40 million that we are investing in the future of young women doctors. That is not allowing for increased costs and is a very low estimate indeed. The reason I am trotting out economic arguments and figures is that I know they have what is called “man appeal” rather than the so-called emotional arguments which I consider equally valid but I think we must take note of the economic argument which in these times is the most compelling one. In my opinion the arguments of self-fulfilment for women doctors and their contribution to the general excellence of the medical profession are qually important considerations.
I would like to say here and now that I am not advocating that mothers of young children should go out to work full-time. Far from it; I am certainly not advocating that. But there is a problem in the medical profession because at the age of about 25 when most young women are getting married and having babies that is the time when the absolutely crucial post-graduate medical training starts and is going on. In Britain they have been studying various ways of tackling this by making a longer post-graduate training period done on a part-time basis for women doctors with young children. It has been found to be very difficult but it is a special problem posed by the structure of medical education.
I was happy to note in the Minister's document on social insurance for the self-employed that he mentioned en  passant a possibility of having to consider the ten or so years when a woman would be bearing and rearing children as an input into society and should not be penalised by losing pension rights and so on. I would submit that this sort of problem in the medical profession is another facet of the fact that women doctors are discriminated against because they have children. It leads to the situation mentioned by Senator Conroy that there are very few women at the top of the medical tree in this country. Therefore, on all the medical boards and medical councils they are absent in large numbers. It is an inevitable trend that women want to do medicine. It is considered that the introduction of honours mathematics as a requirement to get into the medical schools will be a very temporary check on the entrance of girls. I have no doubt that there was some idea that it might stop girls at least temporarily, but girls are very determined to go to medical schools and will, in fact, get around it and do their honours maths. When they do them, they do them very well.
I would be delighted if this problem was under consideration by the medical profession but I am afraid there is no such indication. The pronouncements of eminent medical men in the last year on the problem of the intake of women into medicine were very depressing. One man made these comments when he was President of the IMA, the BMA and the Canadian Medical Association, all simultaneously. He said it was a very serious problem and asked what were we going to do about the problem of wastage of women-power and he questioned whether medical schools should consider limiting the numbers of women. That would be both illegal and immoral. He could not possibly get away with that and I am glad to say that one of the most prominent medical schools here answered it quite quickly and said they had no intention of doing that kind of thing. It is a very negative way of looking at this.
More recently the Council for Post-graduate Medical and Dental Education published a report which was  most anxiously awaited and there is no indication whatsoever in that report that they are even thinking about this as a problem. It is most depressing. This is something the Minister must consider when he is setting up a board like this and when we are considering whether or not the profession should regulate its own affairs. We are paying for the affairs of the medical profession. The Vice-Chairman of that Post-graduate Medical Council is one of the people who made the remarks about limiting women going into medical schools and that is not insignificant.
I would hope, therefore, that the Minister would bear in mind when he is appointing the 25 members of the postgraduate board the fact that the medical profession needs forcibly to have their minds broadened on this issue and indeed to tackle it. I would very much like to see the medical profession being made to face this as their problem and not as a problem only for people outside the profession who are, in fact, paying for this wastage.
I would echo Senator Keating's remarks on the conservatism of the medical profession. For that reason also I was happy that the Minister did not entertain somebody's comment that in entry to medical schools they might consider the children of doctors if it came to a choice of having to pick suitable people. What the person concerned actually said was that the children of medical fathers should get preference. One must not perpetuate a middle-class medical profession or a conservative medical profession the way it is. As soon as the Minister has set up his new postgraduate medical council which is terribly important right across the board, I should like them to set up a sub-committee to deal specifically with the problem of the wastage of the medical profession by the loss of the young women doctors upon marriage. Something must be done about this. I am not a revolutionary feminist; I hope that there are a lot of reasonable feminists, men and women, in this House. Let us have a peaceful evolution with great benefit all round instead of conflict which only leads to wastage and annoyance generally.
Mrs. Cassidy Mrs. Cassidy
 Mrs. Cassidy: The vigorous approach of the Minister towards the state of the nation's health, and indeed his very real concern for the problems of individiduals, is like a breath of fresh air in the dusty corridors of the Department of Health. I find the composition of the Medical Council interesting. The Bill increases the number of representatives on the council from 11 to 25, nine of whom are to be appointed by the institutions concerned with the education of members of the medical profession, ten are to be elected by members of the medical profession and six are to be appointed by the Minister, of whom three will represent the interests of the general public. It is a very interesting list but not a comprehensive one since there does not appear to be any provision for the inclusion on the council of a member of the nursing profession.
I would draw the House's attention to the change in the Title of the Bill. While the 1927 Medical Practitioners Act seeks to make provision for the registration and control of persons practising medicine and surgery, this Bill seeks only to provide for those persons engaged in the practice of medicine. Are nurses not engaged in the practice of medicine? Of course the immediate answer is that they have their own representative board—An Bord Altranais. But, are they not entitled to be represented on this Medical Council since the Nurses Act of 1950 which set up An Bord Altranais provides that it is an Act to make further and better provision for the registration, certification and control and training of nurses and requires that of the 23 members of that board, while 12 at least must be nurses, six must be doctors. To say that the nurse in our community plays a very important part is to state a truism. In fact, with the family doctor she is the medical profession's real contact with the community.
One notes the inclusion of psychiatry on the list of representative specialities. Psychiatric medicine has become to the layman, at least, a frightening concept for two reasons since we tend to associate it with the indiscriminate prescription of drugs—I am not talking now about the use or abuse of  drugs by young people, but the prescribing of drugs for conditions of stress among middle-aged people, particularly mothers. I wonder how many of our social ills can be laid at the door of our urban planners who over the last decade have tended to regard the family as consisting merely of parents and children only. In the last decade our urban planners have torn the heart out of this capital city. They have uprooted whole communities and have sent them to live in the concrete jungles of suburbia. They have taken away people's roots and, therefore, their sense of security. This is completely against our traditions.
I would like to digress, if I may, and quote from a book written about some of our early inhabitants—the Celts, talking about the institutions and way of life of the Cetic peoples of Ireland. It is a book simply called The Celts by Norah Chadwick, published in 1970. It talks about “privilege and responsibility alike, rested on kindred, the Deirbhfhine, of the freeman, extending for four generations. This tie of the kindred was the strongest of all their early institutions. The kindred stood or fell together.” We have come a long way from that concept. In fact, we have even come a long way from the traditional concept of the Irish matriarch telling her beads in the chimney corner. We now tend to regard her as sitting in the chimney corner taking asprins while she is slugging gin. Of course there is a great deal of exaggeration in both those pictures but is there not a small element of truth which might tend to make us stand back and regard the problems before we attempt to prescribe in a blanket form for them?
Psychiatry is rather a mystery to the lay person because lay people tend to equate it with the treatment of the mentally handicapped. That is, of course, a misconception and it arises from the fact that many mentally handicapped patients, almost half of those being cared for by the State, are being cared for in psychiatric hospitals. They are there because there is nowhere else for them to go and this is because over the last quarter of a century successive  Governments have insisted on treating the mentally handicapped child as a latter day Peter Pan, as a person who never grows up, and have failed to make adequate provision for the mentally handicapped adult. I hope the Minister will be the person to cut the Gordian knot of red tape and so allay the frustration of parents and of voluntary organisations who have been frustrated so long.
It is not a question of spending more money, it is a question of spending what we spend in a selective manner. I have digressed from the point but it does us all good to be reminded from time to time of the need to highlight the rights in natural justice of those amongst us who by the very nature of their disability are unaware that such rights exist.
Dr. Martin Dr. Martin
Dr. Martin: May I add my voice to the genial chorus of Senators who have welcomed the Minister to the House today and also compliment him on this Bill on which I have very few reservations? Of course, the full length and breadth of the Bill will not actually be visible to us until we reach Committee Stage. Like previous Senators I will confine myself, as is customary on Second Stage, to general principles. The first one which has been touched on a little is the question of the role of the environment. One of the most important insights that recent decades have brought home to us is the fact that medicine is not merely concerned with the curing of diseases once they have occurred. In the past ten years or so it has been borne in upon us much more that medicine should be a question of treating the environment as well as treating the patient. Very often the treating of the environment will preclude and make unnecessary the treatment of the patient. Two vivid examples of that have occurred in the last two speeches. Senator Cassidy referred to the fact that whole communities have been uprooted in the centre of the city and ruthlessly sent with their loins girt out to these jungles of concrete in the suburbs. That is one manifestation of an environment which more or less lays down a prescription for illness,  certainly for certain psychic instabilities which ultimately will require treatment which will require medicine in the old fashioned sense.
Another example, which struck me as quite a brilliant example and certainly draws attention to the need for the female intelligence in legislation, was that whole question about the crèche in the hospital. These things are very relevant to what this Bill is about, the crèche not only for the harrassed mothers who bring in sick children who are already fractious but for the other children to be kept happily out of the way while that child is being treated, very often after a long wait. That is a human problem that it took the entire Dáil and the length of the Seanad to come up with when Senator Cassidy raised it. There are important economic arguments lying behind the fact that we have so many drop-outs with regard to female doctors. That is a very important point and it is also related to the possibility of crèches in hospitals. It seems a very mundane thing but when one looks at it a little more closely it is utterly central to a larger concept and philosophy of what medicine is about. I presume that is what the Minister for Health has been doing in the past seven or eight weeks with his many vivid appeals to the community to regard health as something one has got if one is lucky and which one treats with respect and intelligence so that one may keep it and that medicine in the very large and most wholesome sense has to do with that.
Consequently I see section 69 as being very very central to this. It is the new section brought in and it is the one that I would urge the Minister to see carried through with every possible energy and vitality. That section allows the council to advise the public with regard to health and direct doctors ethically, medically and in other ways with regard to the discharge of their duties. For instance, it is a fairly annual event here to have the Central Bank issue various encyclicals to the public about how the money situation in the country is going and whether we should spend more or spend less, or borrow more or borrow less, this,  that and the other. In other words, they sound off from time to time— I do not know if anybody listens to them but I am sure somebody does— but they issue these general statements, reassuring statements in some ways to show that at least somebody is thinking about the overall picture.
I should like to see this Medical Council as reconstituted and particularly as acting under section 69 frequently issuing directives to doctors, to hospitals, the post-graduate and undergraduates area of the teaching operation and to the people as a whole about a whole range of things, not just the dangerous drugs, though they are very important. We should be told about the tiny drugs that are not dangerous necessarily when taken in small doses, and about the whole question of environmental diseases as such. For instance, there are very few of us who have not heard either at first hand or at second hand of workers in factories who have had their lungs destroyed by dealing with certain kinds of paint or having to inhale certain kinds of fumes. These still exist. I was recently at the funeral of such a man who died at the age of 40 leaving a large family. At a certain stage of his life he worked in a factory where his lungs had been irreparably damaged. It was a pitiful thing to see his widow and his young children, very young children. Certainly that kind of situation arises out of an inadequate sense of what medicine is about. This large advisory and directive role granted under section 69 seems to be one of the most important aspects of the Bill. It will only be an important aspect if the council is chosen well, if the Minister insists that that its terms of reference demand from it action, energy, insight and frequent reports.
An aspect of the Bill which is not quite clear to me is, suppose they want to discharge their duties under that section in a very radical and determined way will the money be available for them? For instance, will it be possible if this council decides that it wants to secure statistics on certain diseases, recurrent diseases being treated year in year out in hospitals,  diseases arising perhaps from industrial situations or arising perhaps, taken on a mundane level, from accidents in the home, or arising from sheer environmental conditions, they will be given money for research? None of us can miss the fact that if one stands in Grafton Street for 20 minutes and the traffic has barely moved within that time that one is inhaling a hell of a lot of toxic elements with the breath of life. Suppose the council decide to take on that role and pursue it actively will occasional money be allowed to it for research projects of that kind, for the collection of statistical evidence and in how far will its play be backed by the Government? How much muscle will it have if decides to issue directives to teaching hospitals, to general hospitals, to regional hospitals, to general practitioners with regard to certain recurrent diseases which are being foolishly treated in the short term but which perhaps could be tackled in the long term, as we have had to tackle such diseases as tuberculosis in the past? That aspect of the Bill seems to be very important, one which should be enthusiastically welcomed, but on the understanding that it is going to be something that will be more than just a directive or a regulation on paper.
The second aspect of the Bill, a very important one also, is that which has to do with the general powers referred to in the Minister's speech, the disciplinary powers of the council. The generality of medical practise here is admirable and is above most other countries. It compares extremely favourably with any countries near to us, but there are abuses in it. As a matter of fact, there are connected with this, and pace Senator Molony when we come to legal reform, certain areas where there is a mystique surrounding the doctor, and the man of law, the solicitor and very often the barrister, which prevents the ordinary man-in-the-street from reaching him at all. As an illustration I should like to mention that I know of a solicitor who is sitting on a matter relating to somebody's houses and will not put forward the documents for stamp duty for the past five years. This man has already suffered  loss of interest up to £1,500. He has tried everything short of sending round a couple of “heavies” or getting in a few men with violin cases from Chicago to deal with the situation. He has no other resort. Ultimately, he can apply to the Incorporated Law Society but he is loath to do that because even then dog tends not to eat dog in these matters.
That creates, within the public mind, a great deal of suspicion and frustration. The ordinary person feels that he is not adequately equipped to attempt to bring a man in such a learned, venerable and ancient profession to book. The means of doing that are very inadequate. This is where we must again think carefully, and along the lines suggested by the Minister, because we have seen the opposite situation take place in America, and very rapidly. Within about ten years there the doctor has become the prey to every nut who wants to bring a legal prosecution against him for maltreatment or mistreatment of a patient. At present, the medical profession in America is terrified of the law courts. They are afraid to prescribe. They have to marshal an army of specialists around the unfortunate man in bed so that they can present a unified front when it comes to defending the treatment they have prescribed. Of course, the assembly of that army has to be paid for by the unfortunate inhabitant of the bed at the end of the day.
In other words, a situation has arisen where the sacrosanctity of the medical profession eventually was breached by an exasperated public and the result is that the last case is considerably worse than the first. That kind of situation could develop in Ireland. There is no sign of it yet. The disciplinary powers granted and referred to in the Minister's speech are very important. I do not think they should be just occasionally invoked. They should be frequently and visibly invoked, particularly the provision which is so admirably framed and states:
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.
I should like to see those minor powers of censure and admonishment used. If the public felt they were there and saw them being used—I do not mean that they be used in a draconian way or in a gratuitously punitive way —with common sense and frequently, not only would it correct the worst abuses of the medical profession from the point of view of practitioners but it would certainly reassure the public enormously. It would head off the kind of dangers into which America has plunged. I believe it is a very serious situation indeed there. I am sure Senator Conroy could give far more vivid illustrations of this than I can. Again, that is an aspect of the Bill that not only we welcome but which we wish to see carried through genuinely on the ground, to coin a phrase of the late Mr. Faulkner.
Finally, the only discordant note that I strike is in relation to the Minister's assurance regarding the 25 members for the postgraduate, Medical and Dental Board. In his view there is no alternative to merely appointing them. The Minister is a man of noted ingenuity and I wonder if there is not some alternative to it. For instance, in defending that position he names a whole series of bodies and points out that there is a great range of interests to be consulted in the matter. Would a number of them be allowed to put forward representatives of their particular interest? In other words, instead of appointing the entire number and incurring the charge, which will be made, admittedly by malicious, misguided and unworthy people, that this presents the Minister with a spectular opportunity for the distribution of patronage, would it not be better to——
Mr. Haughey Mr. Haughey
Mr. Haughey: They are unpaid.
Dr. Martin Dr. Martin
Dr. Martin: They are unpaid but people still like these jobs. There are many people who are quite well off but like the kudos of being in such a position. I am thinking of the general principle. I have no doubt whatsoever of the Minister's good faith but I was  wondering about the kind of charge which could be levelled. For instance, the Minister mentioned the huge proliferation of interests. He named 15 different associations which are involved and which would have a reasonable right to be represented. Then he named generally 37 other bodies which would claim such a right. Clearly, there is no way in which all of them can be accommodated. The Minister pointed out:
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 employment 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.
At my computation that is 11. Would it not be possible for the Minister to grant to those 11 interests the right to elect or nominate one of their number and let the Minister nominate the remaining 24? That does not seem to be an insurmountable difficulty. Surely it could be done. As they are unpaid positions and as there is no reason why the Minister should particularly enjoy the job of appointing 25, rather than having some of them nominated by the relevant bodies. I ask the Minister to think again on that matter. He has signally democratised the council and it would be only worthy of that gesture if he were to carry it through on to this board for post-graduate training. It is early days yet, this is only Second Stage and there is time at least to think about that possibility.
Those points having been made I should like to join with other Senators in complimenting the Minister on the Bill. I was particularly struck by the daring and creativity with which he decided on Report Stage in the Dáil to make a change of course. It seems to be a good change and one which has been saluted from this side of the House. It takes courage to change one's course at that late stage when a measure is going through and in this  case that change is justified. Indeed, his general posture with regard to his campaign as far as the public is concerned, is that every person is in a sense the custodian of his own health and that a great deal of the unnecessary burden being laid on doctors, hospitals and the resources of the nation could be saved if as a people we learned a little more discipline and enlightenment with regard to the entire treatment of our individual and communal health. With those reservations I welcome the Bill.
Mícheál Cranitch Mícheál Cranitch
Mícheál Cranitch: Fáiltím roimh an mBille seo agus fáiltím roimh an tAire féin. Fáiltím roimh an mBille seo ar an gcéad dul síos mar gheall ar a bhfuil ann agus sa dara áit, os rud é go dtugann sé seans do na Seanadóirí, labhairt ar chúrsaí sláinte, ar chúrsaí leighis, ar dhochtúirí agus ar dhochtúracht i gcoitinne. I wish to refer to the following two sentences in the Minister's speech:
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.
How true and important that statement is. As a race we have a longstanding interest in medicine, cures and health in general. In fact, if all our proverbs on sláinte were brought together we would have a fair guide for the health of every individual, young and old, strong and weak, here and elsewhere. One thinks of the sean-fhocal “Is fearr an tsláinte ná na táinte”. There we have the very basis of the values, health is put before riches and wealth of all kinds. It is the most important thing as far as the human body is concerned. I am sure whoever thought of that particular sean-fhocal had in mind not alone health of the body but the health and well-being of the mind also.
In fact, we have a sean-fhocal for practically every sort of condition. Even the weakling will always be consoled by hearing that: “Is fad saolach  iad lucht múchta”, those who appear to be delicate and weak are often long-livers for the obvious reason that they take great care of themselves. We have not alone a sean-fhocal but traditional cures and treatments for various diseases. In fact, one is never short of finding anybody who can give a cure for any sort of a disease one has. Even some of our surnames are derived directly from those who practised medicine hundreds if not thousands of years ago.
In this context I should like to refer to Senator Cassidy's contribution. She made a very important point as regards the traditional Celtic attitude towards medicine and health. Some other time we may have an opportunity of developing that point. We are indebted very deeply to the approach the Minister has been making already as far as the well-being, health-wise, of our people is concerned. Those of us who have read reports of his speeches in recent months are edified by his approach. He has given very sound advice regarding good habits and a proper attitude towards our well-being, physically, mentally and socially. He has helped us to see such things as smoking and drinking to excess in their proper perspective. I would not be surprised if, as a result, calls on doctors throughout the country will be minimised. That is all to the good because if we want to be healthy we have to know these things and practise them. It is good of the Minister to make these statements and we can only hope that more people will read them and act accordingly.
There is a big responsibility on a Minister for Health nowadays because not alone must he look after his own Department but various other Departments impinge on his areas. One thinks of the Department of Agriculture. Food from the farm is not exactly what it used be when I was growing up, because we now have forced vegetables and so on and various artificial manures are being used. I wonder what sort of effect that will have on the food value of the produce we get. There is also the question of milk. Cows are being treated for all sorts of diseases by injections, drugs and so on  and one wonders what effect that will have on milk, one of our basic foods. I am sure the Minister has all those things in view but it is no harm to mention them. I am sure he will keep an eye on those things and monitor them as he goes along.
We also have the question of factories that could possibly cause diseases to the workers. We had a case in Cork recently where there was a big hubbub regarding a factory where asbestos was one of the materials being used.
An Cathaoirleach An Cathaoirleach
An Cathaoirleach: It is the opinion of the Chair that the Senator is going slightly wide of what is in the Bill which deals mainly with the medical profession itself.
Dr. West Dr. West
Dr. West: Surely anything that happens in Cork is important.
Mícheál Cranitch Mícheál Cranitch
Mícheál Cranitch: I accept your ruling, a Chathaoirligh. I referred to those things because they have to do with health in a big way. The question of environment comes in with regard to pollution and the question of education also arises. In years gone by we had elementary lessons on health in our textbooks which the children understood. These lessons were always read by their parents and they had a very good effect. In dealing with education I should like to commend the wonderful service being given to the schools. Under the schools medical examination, one of the most wonderful things we have, a special physician visits the school every three or four years. The pity is that he would not come a little more often. He examines every child in the school whose parents wish him to do so. It has the great advantage that this doctor examines the child from head to toe looking for something. It is not a question of a person coming along to the doctor and saying “I have a pain here or a pain there”. He is being examined for that to the exclusion of something else which may be far more important. As regards school medical inspection, a child is examined and the doctor is looking for something so that he can put it right.
The responsibilities of doctors at the  moment are indeed very great. Great pressures are put on them to prescribe more and more drugs. Indeed, in conversation last year with a young Italian doctor who had other views on healing I came to the conclusion that western Europe is probably oversaturated with drugs. We become more and more dependent on them, and the great temptation on the part of the doctor is to follow that practice of prescribing drugs. One sometimes wonders if there is over-prescriptions as far as drugs are concerned. There must be some other means of healing besides taking drugs to excess.
I wonder if I would be in order in referring to—this concerns medicine too—the practice of what we call acupuncture. It comes from the east; it is a thing that I think should be looked into. This Italian doctor, of whom I spoke, practises acupuncture. His point—I suppose we must agree with it—was that we have not got the monopoly of ideas regarding medicine and healing in western Europe, Certainly the easterns have got something too.
An Cathaoirleach An Cathaoirleach
An Cathaoirleach: I am sorry but acupuncture is not in order either on this.
Mícheál Cranitch Mícheál Cranitch
Mícheál Cranitch: Cad é?
An Cathaoirleach An Cathaoirleach
An Cathaoirleach: Níl sé in órd labhairt ar an rud sin.
Mícheál Cranitch Mícheál Cranitch
Mícheál Cranitch: Ceart go leor. Go raibh maith agat. We must practise healthy attitudes in life. Health is, after all, everybody's business. In trying to be healthy we can give good example to our friends and neighbours. The Romans had the idea right, like our own ancestors when somebody said, mens sana in corpore sano. That is a thing we should aim for. In the Gospel, I suppose, our Saviour seemed to be healing for most of His period on earth, certainly during the last years of His public life. Here, we must pay tribute to the doctors and nurses, especially Irish doctors and nurses, for their great compassion and dedication to their work.
Great pressure is put on the doctors  and nurses—the breaking-up of our social system was referred to by Senator Cassidy—to practise such things as abortion and euthanasia, murder at the initiation of life or murder at the end of it, put it which way you like. They are certainly standing up to the pressures and we admire the doctors and nurses for the great service they are giving. We commend the Minister for what he is doing. The final word to end my contribution is to the Minister—Sláinte chugat agus cabhair agus dealbh go deó nach rabhair.
Mr. Markey Mr. Markey
Mr. Markey: Any Bill which is for the protection of the patient and also the doctors is to be welcomed. A review, such as we are given the opportunity of today, is certainly appreciated. If this Bill is ultimately for the protection of both patient and doctor then the patient must receive first consideration. It is, of course, in the public interest that there always be an adequate maintenance of high standards in the medical profession. There should be full credibility of acceptance of the medical profession by the public at all times. Lastly, but by no means least, there is the question of public funds which means, of course, that the person who pays the piper must always be in the position to call the tune. That, in this issue before us, is the general public.
The Minister is giving access on the proposed Medical Council to people representing the interests of the general public. It is a pity that his predecessor did not give that opportunity on the committee which was established to bring forward the recommendations we have before us. I see that these recommendations have been adopted unanimously by the members of that committee. Recommendations, when they come forward unanimously from any profession who sit to deal with any issue, always strikes me as being perhaps a little bit too good in the sense that the profession will not knock itself unduly. It might well have been to the benefit of this Bill had there been on that committee some members who could be claimed as representing the general public interest. We could have had certain  observations made by them which could have taken the form of minority recommendations before the Minister and which could have seen light in perhaps some amendments in the Bill before us. I am not unduly concerned about the numbers that will be on the council. Twenty-five members may well be proved in time to be on the small side. There is a tremendous amount of work to be done by this council. If they tackle it in the way in which I think they should they will find plenty of activities in which they could engage themselves.
The question of communication between doctors and public and vice versa is vitally important. This will operate mostly through the council. A two-way communicational system, as envisaged here, must depend, on the part of the public, on a certain confidence that what they have to say will find its way through the council to the medical profession. There is great advantage for the medical profession as regards changing standards or changing medical environment, if the public are acquainted with these changes.
We must always bear in mind that generally members of the medical profession and their patients come from different social classes. This is something which is part of our history. There is in that difference in social classes perhaps an in-built reluctance on the part of the public to complain on occasions when they should about certain malpractices and certain failings on the part of doctors. It is necessary that there should not be an over-respectful attitude on the part of the public towards doctors. We have in our society something which in this respect we can be proud of in one instance but which brings disadvantages on the other hand when it comes to an open and frank communication between members of the medical profession and the public. In regard to the question of communication it is essential that whatever language is used, it should be in ordinary layman's language in a two-way communication. Whatever is conveyed should be put in simple form that will not be vague or confusing to members of the public. It is important, in the interests of the  medical profession, that they should be conscious of this simplicity requirement. They should, of course, be always conscious of the importance of an adequate public relations exercise on their part.
It is easy to write into any new system a complaints procedure, but largely how that complaints procedure operates depends on a number of factors. The first factor here is that the procedure must be simple. It must be quite open and available to any member of the public who has a grievance, be it a genuine grievance or only a felt grievance. They should not in any way feel intimidated about putting a complaint to the Medical Council about a member of the medical profession. If there is this over-respectful attitude, which I commented on earlier, or even this fear on the part of the public to make their own opinions and complaints felt, it breeds certain complacency on the part of the medical profession, which is not good in the overall medical situation.
It is important that at the end of the road, as regards complaints procedures, the findings should be made public and be made easily understood by everybody concerned. It is noticeable, in the case of any profession where complaints are made about it, that there is this public feeling that the profession will stand by its own members in the first instance and will always be reluctant to admit mistakes. That is wrong. There is a great obligation on this new Medical Council to ensure that there is full acceptance of the medical profession by the public.
The question of the registration of doctors is outlined in the Bill. It falls on the Medical Council to be quite strict in the implementation of these registration procedures. There have been instances where people who were not fully qualified were practising as doctors. We had an instance some time last year where a health board suffered quite an embarrassing experience. It behoves the Medical Council to have very close liaison particularly with the health authorities to make sure this does not happen again. Even allowing for all the constraints that are written into this Bill to ensure  that there is an adequate standard of discipline and an adequate standard of acceptability all round for the medical profession the public will still be a little reluctant to make complaints and to take to court genuine grievances they feel they have.
We are a small community and we are all acquainted with each other. This breeds a certain reluctance on the part of the public to criticise unduly. Ultimately any advantages there are to be derived from the Medical Council will depend on the willingness of the medical profession to ensure that the regulations which they are given the opportunity to frame for themselves will be imposed and that they will impose disciplinary measures on any members of their profession who step over the line. I welcome this Bill and I wish it every success.
Mr. Kiely Mr. Kiely
Mr. Kiely: I would like to welcome the Bill and to congratulate the Minister on his appointment and especially for the concern he has for our health. The establishment of the proposed Medical Council for clearly defined objectives is the direct result of an urgent need that has been developing over the past few years and will benefit both the public and the medical profession. With so many doctors and specialists engaged in medical activities throughout the country it is essential that their activities be co-ordinated and regularised in a modern and proper manner.
This Bill will update the law in regard to the registration of the medical profession as well as improving the disciplinary procedures and extending the powers of the Medical Council regarding education and training, especially in the post-graduate field. This is essential because of the immense problems modern medicine has brought into society. One of the great problems of modern medicine is that the public can go into surgeries and acquire prescriptions for medicine or drugs. There are also major killer drugs such as ethyl alcohol and nicotine sold in a glamourised manner to confuse society. I am sure that this Bill will control such practices and, which is  most essential, I feel the public should be educated as to their great danger.
I welcome Part III whereby the council may set up separate registers of medical specialists, which indicate doctors who are trained to a level entitling them to be regarded as specialist physicians, surgeons, anaesthetists, psychiatrists or any of the other recognised specialties. This is essential. A person was employed as a house surgeon in an orthopaedic hospital not far from me a couple of years ago. He produced documentation as to his qualifications and was registered by the Medical Registration Council. Subsequently it was proved that he had no such qualifications for the appointment. Fortunately he undertook no major operations in the hospital; I dread the consequences if he had. I welcome this part of the Bill because I am sure it will ensure that there will not be a recurrence of this unfortunate happening. I also welcome the part where the register will be open to the public for examination and that they will know who is registered, who is qualified and who is specialised in the different fields. I conclude by welcoming the Bill and trust that it will benefit the public and the health of our country.
Minister for Health (Mr. Haughey) Minister for Health (Mr. Haughey)
Minister for Health (Mr. Haughey): I want, at the outset, to express my appreciation for the manner in which the Seanad has dealt with the Second Reading of this Bill. Senator Molony, leading for his particular side of the House, set a tone for the debate that followed. He welcomed the Bill and made some very useful comments. His lead was followed on all sides of the House. The contributions made by Senators were very helpful and very constructive and for that I am particularly grateful.
I want to assure all the Senators who contributed that the points they made will be very carefully considered. I may not have the capacity to deal with them all by way of reply but I would like to assure the House that that should not be taken as any indication that they will not be carefully adverted to by me and by my advisers in our consideration of the Bill as it  proceeds on its way. It will undoubtedly have to go back to the Dáil again because we will be making amendments here in the Seanad. I am quite sure of that. I will be proposing some and I welcome any amendments which the House may decide in its wisdom to accept.
Senator Molony was concerned about dangerous drugs and the misuse of drugs. I would like to point out to him that there is a National Drugs Advisory Board, which have the responsibility for disseminating objective information about drugs. They test drugs and report on them to the profession. I hope that this gives the profession a satisfactory service but if there are any ways in which they can be of greater service and assistance to the profession I have no doubt that they will carefully consider that aspect of their work.
With regard to the newspaper article to which Senator Molony referred, I can only say that that sort of situation will fall in future to be dealt with under the provisions of the Misuse of Drugs Act. As the House knows, that Act was passed by the last Oireachtas. It is a useful Act and I hope it will be effective in dealing with most, if not all, of the problems and difficulties which arise out of the misuse of drugs in our modern society.
The present position about that Act is that a draft of disciplinary regulations under the Act is at present with the medical organisations for their observations. I hope that that process of consultation will be completed within a month or so and then these regulations will be promulgated.
My colleague, Senator Keating, made some comments also which I would like to deal with. He suggested that I should be very assiduous in selecting for the council persons who are not doctors. It is obvious, from the text of the Bill, that in regard to the four ministerial appointees to the council, three of them must, by statute, not be doctors. So, whether I wish to or not, the Bill will compel me to appoint at least three people who are not members of the medical profession.
Senator Keating adverted to a fundamentally important matter when he  spoke about the intake of students into the medical profession. That is something of very great significance to which attention will have to be directed. I suggest that we have had enough discussion about it at this stage. We should be talking now about what action we should take. There is no doubt that in many areas the export market which existed for doctors has been closed in the US, Canada and other places. In many European countries the situation is that there are too many doctors. Of course, there are many new medical schools coming into being all over the world. It is a situation which calls for careful and urgent attention. It is fraught with difficulties and problems, it is a complex matter but it will have to be faced up to very soon.
One aspect which we must keep in mind, and to which a number of Senators referred, is that we stand in a very special position in regard to the underdeveloped world in so far as medical education and training are concerned. I see us having an important role to play in that regard. It is an area with which Senator Conroy, in particular, is very familiar and whose advice I will be very glad to take in dealing with it.
Senator Keating also spoke about dentistry and pointed out that this Bill only deals with one aspect of dentistry, namely, post-graduate dentistry. That is true, but we have on the stocks a new dentist Bill which will deal with the profession of dentistry, I hope in a comprehensive manner.
A number of Senators referred to the total number of doctors in Ireland. For the information of the House, the number is about 4,000 and of those about 1,500 are general practitioners, 1,000 are consultants, 1,400 are junior hospital doctors and about 200 are public health doctors and community medical officers of one sort or another. Contrary to the general impression, general practitioners do not constitute an overwhelming majority of the profession.
We are providing in the Bill a very adequate representation for the general practitioner sector of the profession on the new General Medical Council. It  will also be my intention—I have given a firm undertaking to some of the medical organisations—to ensure that on the post-graduate training body, which is now being given statutory status, the general practising profession will have adequate representation. In regard to that particular body representation is of very great importance to the general practitioner section because, to a large extent, the post-graduate training will be most useful and most advantageous to the general practitioner.
A number of matters were raised by different Senators which are more appropriate to other occasions. For instance, Senator McGlinchey spoke about the failure of the hospital in which he is interested to procure a radiologist. To some extent that is a matter for the new Postgraduate Medical and Dental Board. It is more related to general health administration.
I should like to make the point— perhaps it is more relevant to the remarks of Senator Hussey than others —that this Bill is pretty limited in its scope. It basically sets out to provide a mechanism for the control, regulation, discipline and training of the medical profession. Many of the points raised referred to health administration in general rather than to the actual control, discipline and regulation of the medical profession as such. Indeed, some of the remarks will have to be left over to be dealt with on another occasion, perhaps on the Committee Stage.
Senator Conroy made a number of points of that nature, I hope he will forgive me if I leave some of his more detailed points over for discussion on the appropriate sections when we come to them on the Committee and Report Stages. He referred to a very important matter, that is, the question of co-operation between ourselves, the United Kingdom and Northern Ireland. It is important to understand that the scope for continuing co-operation is adequate in the provisions of the Bill. The education committees, which will be set up under the new Medical Council in this country and the new General Medical Council in the UK,  will both be able to have members in common. In fact, the understanding is that they will. That is where co-operation is of the utmost importance. The legislation in both countries is framed in such a way that these committees will be able to have members from each other on them.
With regard to continuing links with Northern Ireland, the most satisfactory thing I can say about that is that the distinguished President of the Royal College of Physicians is Doctor Grant who practises with distinction in Belfast, so I have no fears about our ability to keep up the traditional contacts and friendships, professional and personal, which have always existed in this area.
In so far as the EEC directives are concerned, this is something we will be talking about in much more detail as we go through the sections on Committee Stage. I just want to point out that they are not concerned with the standardising of medicine and drugs throughout the Community. They are more concerned with harmonising conditions for mutual recognition of qualifications and freedom of movement for doctors rather than medical standards.
It is perhaps of some interest to recall what happened in the UK with regard to this vexed question of the retention fee. We had considerable discussion about this in the Dáil. It is interesting to note that once money and the payment of money enters into a situation the discussion can become quite intense. What happened in Britain really was that the profession were not so much against the idea of a retention fee but rather against inadequate representation on a council which was going to impose retention fees. Really what they were getting at was the old principle of rejecting taxation without representation. I do not think that is going to apply in our situation because not alone have we our retention fee enshrined in the legislation but we also have a very adequate spread of representation on the council which will be imposing the collecting of these registration fees.
 Senator Markey and Senator Conroy both spoke and, I think, Senator Keating, about section 69. I fully agree with them that it is very important and a good thing in that context to emphasise good conduct or conduct as distinct from misconduct.
I listened with very great interest to the points made by Senator Hussey and I am committed, as are most of my colleagues in Government, to ensuring that on the bodies for which we have ministerial responsibility we will endeavour to ensure that women play their appropriate part in the affairs of these bodies, these agencies or organisations. I do not know whether any particular action is called for by me in regard to the Medical Council in this context. What we want here is a council which will adequately reflect the membership of the profession as it stands at any given moment. Presumably then what we should aim at is roughly the same proportional women membership of the council as there are women members of the profession. I would hope that, apart from what will happen when particular bodies are nominating members to the council, the election will enable women doctors to come on to the council in appropriate numbers.
It is very interesting to note in that regard that something like one-third of the medical students at the moment are women. In one particular medical school more than half of the entrants into the medical school are women. Whatever about the immediate future, certainly in process of time there will be no doubt but that the new Medical Council, because of its representative character, will fairly adequately represent the women members of the medical profession.
Senator Hussey made many very other good points about the difficulties which women face both as members of the medical profession and, indeed, as patients or people coming to hospitals. I have taken a careful note of the points she made. As I said about other contributions, these matters are more appropriate really to a general discussion on health administration than they are to this particular Bill. I assure the Senator, however, that  the points she has made of general application over the field of health administration will be carefully considered by me.
Senator Martin made a point at the outset of his remarks which staggered me somewhat. It is not strictly relevant to our discussion here but he used it as an illustration of something else he was talking about. It seemed to me he suggested there is a process whereby people are being taken from nice well-established communities in the city centre and transplanted out into what he called “jungles” in the suburbs. I do not know what his experience of these matters is but that is certainly not my understanding of what happens and I think it is a misguided way of looking at the situation. Most of us who in our time have had to represent centre city areas could not regard the old slum quarters of Dublin as desirable residential areas and certainly I do not think that, if the term “jungle” is to be used, it should be used in relation to splendid housing estates on the outskirts of the city but rather to the old slum areas of the former centre city. We can go too far in eulogising the delights of living in centre city areas. My experience in that regard differs from that of many of the people who speak about these matters today. As far as I am concerned, the clearing of the slums in centre city areas and the transplanting of the people out into good, healthy and, in most cases, satisfactory housing estates was a very desirable and worth-while process.
Senator Martin mentioned the expenses of the new Medical Council. The Medical Council will by and large provide its own finances. It will finance itself. I did give an undertaking in the Dáil, which I repeat here now, that if, at any time, I ask the Medical Council to carry out some specific function which is not within the normal ambit of their proceedings I will certainly consider making funds available for that particular purpose. But that would be an exception. In the normal course of events the Medical Council will look after its own expenses by means of the fees paid by the members of the profession.
 Senator Martin spoke about my nominating the membership of the post-graduate board. He has a point there. It would probably have been more desirable had we been able to devise some simple system whereby the various interests could nominate directly on to that board. The House should understand the history of the establishment of that board. It existed on an ad hoc basis and the Minister for Health nominated all the members of the ad hoc body and all I did in this Bill was confer statutory status on a board which up to then had existed on an ad hoc basis. I was anxious to do that because I was asked to do it by the bodies I mentioned in my opening remarks. I did not feel there was any way in which I could accommodate all the different interests by granting them direct nomination to that board. Most Senators know that the medical profession is a very highly organised one in so far as practically every branch of every discipline has its own body or organisation. There are the larger bodies and, when you come to the specialties, there are at least 40 different organisations representing them. I recoiled really from attempting to devise some procedure whereby all the different interests who would legitimately seek direct nomination could be accommodated. I think, as an experiment, what I am proposing is the best thing to do—to carry on— and that is all I am doing, carrying on the system whereby the Minister nominates this particular body, even though it now has statutory status, and see if it is possible by judicious selection to try to represent the broadest possible spectrum of interests. Senators will realise in this context that, by a careful study of the situation, I could succeed by nominating a particular individual in giving representation to three or four different bodies and professional organisations whereas if each of them were given direct nomination I would be left with four or five people instead of one and the number of 25 just would not accommodate all those who would seek nomination.
I recognise that there is some validity in the criticism Senator Martin made but, on the other hand, I have  succeeded in the course of the very mature and sensible discussions we have had with the various bodies and institutions concerned in satisfying them that, between undertakings I have given and amendments I hope to make in the Seanad, I will be able to meet all the fears the different bodies and institutions have expressed.
Senator Markey surprised me by requesting that the procedure for making complaints should be simple. I do not think that they could be simpler. Section 45 simply provides that any person may apply for an inquiry into the conduct of a registered medical practitioner. It is intended— the provisions are clear—that the procedure whereby members of the public can lodge a complaint will be of the simplest possible nature.
Senator Markey was also concerned whether 25 members on a medical council would be enough. I think they will and, as I have said, at the moment they represent a reasonable balance and a reasonable spectrum of representation. In any event, should that not prove to be the case, I have the power under section 9 (2) to vary the number. As Senators will also understand, in the case of the committees the Bill provides specifically that the council can go outside its own membership for members of particular committees except, of course, in the Fitness to Practise Committee.
I am not sure if there are any other points raised by Senators which call for general comment of a Second Stage nature. On Committee Stage we will be able to pick up all the matters referred to. Senator Cranitch dealt with the general concept of promoting positive good health and the dangers arising from various artificial aids and stimulants particularly in the agricultural industry and in farming. I am glad he mentioned that. It is not strictly relevant to a Bill regulating the medical profession but it is something which we will take note of now that he has raised it.
Again, may I repeat that I am deeply appreciative of the manner in which the Seanad has dealt with this  Second Stage and I greatly value the important contributions Senators on both sides made.
Question put and agreed to.
Committee Stage ordered for Wednesday, 23 February 1978.
Seanad Éireann 88 Medical Practitioners Bill, 1977: Second Stage.