- Email: [email protected]
Bill on Surrogate Motherhood
825
Commentary from Westminster Restriction
on
Entry of Overseas Medical Graduates
FROM April 1, the Social Services Secretary, Mr Norman Fowler has announced, doctors and dentists from abroad will not be able to practise in Britain unless they are citizens of EEC countries or have D 50 000 available to invest in their own practices. In other words, as Mr Fowler told the House of Commons, overseas doctors and dentists are to be subject to the same immigration restrictions as other groups ofpeople from abroad. This step represents a final abandonment of a policy, begun in the late ’60s, of welcoming doctors from abroad "to make good the shortfall in supply which arose from the inadequate number of graduates from our own medical and dental schools". The new regulations will not affect the position of foreign doctors already practising in Britain, Mr Fowler promised. 18 000 of the 72 000 qualified doctors now in Britain were trained abroad. According to the between 1600 and 2000 foreign doctors come to Britain each year to study. Doctors and dentists seeking entry to Britain for postgraduate training in hospitals will be admitted for a period ofup to four years, but they will be allowed to stay after that period only if extensions of stay are granted under the normal immigration and employment provisions. A similar period of permit-free time for postgraduate training will be available to overseas nationals graduating in Britain. Under EEC rules, doctors from Common Market member states will be exempt from the new regulations. The changes, according to Mr Fowler, are a sensible step to take at this stage. He explained to the Commons that the medical expansion programme begun in the ’60s was now largely complete. The Government’s 1983 review of dental manpower, and more recent Departmental examinations of medical manpower (which included doctors’ representatives), had led Ministers to the conclusion that the United Kingdom was "essentially self-sufficient in its supply of doctors and dentists". But at present overseas doctors and dentists have almost unrestricted access to work in Britain, Mr Fowler said, adding that Britain still wished to retain the important role it had traditionally fulfilled of providing postgraduate training to foreign doctors who can come here for periods of specialist training before returning to put those special skills into practice. The new restrictions would ensure, however, that foreign doctors did not come to Britain with expectations which the Health Service could not fulfil. Conservative backbenchers-most of whom know next to nothing about the NHS, its commitments, or its staffingwere naturally pleased with the statement. The British Medical Association, whose knowledge is naturally sounder, were also pleased. The Association has expressed concern for some time about the exemption of overseas doctors from immigration controls, a BMA spokesman commented. The changes would allow the numbers of British medical students to be aligned very much more easily to the career posts available to them. Uncontrolled immigration of foreign doctors made this difficult to achieve, and could lead, in the BMA’s view, to unemployment of British graduates, which was extremely wasteful. The Association welcomed, however, the continuation of postgraduate training arrangements.
DHSS,
The Opposition in Parliament found the new rules to be an evasion of the issues. Labour’s spokesman, Mr Michael Meacher, complained that the Government’s estimates of the numbers of doctors needed in Britain were based on inadequate information and on targets which were themselves unsatisfactory. 2000 doctors and 10 000 nurses were unemployed in Britain, Mr Meacher declared. Yet the numbers of doctors per 1000 population were 2507o higher in France than in Britain, 50% higher in the United States, and 100% higher in Italy. Meanwhile, the Government has not collected statistics on medical unemployment for the past three years. In 1982 the Government had committed itself to doubling the numbers of consultants by 1997, which would require a growth rate of 4’ 7507o per year. But in the year to September, 1984, the last for which statistics were available, the growth rate of 2’ 3% was less than half the necessary figure. Mr Meacher complained that the vaunted postgraduate training arrangements for overseas doctors were in fact haphazard. These doctors were often shunted off to study unfashionable specialties in the regions and often ended up not receiving the training for which they had come and which they had a right to expect. The chairman of the Commons Social Services Committee, Mrs Renee Short, echoed Mr Meacher’s complaints about failure to expand numbers of consultants, and called for early publications of the Government’s much-heralded but as yet unseen policy green paper on the future of general practice, which must have serious implications for the numbers of doctors needed in the future. Mr Fowler conceded that many overseas doctors do not at present receive "the most relevant medical training" as postgraduates in Britain. They found themselves in areas such as geriatrics and psychiatry, which were important but not often relevant to training needs. Mr Fowler promised that he planned to have talks with the BMA and other doctors’ representatives with the object of improving the situation. The Overseas Doctors’ Association, which is likely to be party to those discussions, does not have high hopes of the results. "We are totally against the steps Mr Fowler has taken," was the response of the Association’s chairman, Dr A. Karim Admani: "we are disappointed." The Association proposed alternatives to Mr Fowler a year ago. It suggested a moratorium on immigration of doctors for two or three years while manpower targets were established. After that period the ODA proposed there should be an agreed figure for overseas doctors to train in Britain, and that the figure should be set by the NHS. Doctors admitted for postgraduate training under that scheme should then get proper, relevant training, under a sponsorship scheme. "At the moment there is not any real training," Dr Admani added. "But under Mr Fowler’s proposals doctors will still come here to work in understaffed, underfinanced hospitals without learning much that is useful to them. They will still be exploited, and then they will be sent back after four years". In fact, eighteen months out of the four years was now spent looking for a job. The ODA is to meet Mr Fowler again in May, and places some faith in his promise that the four-year period could possibly be extended.
Bill
Surrogate Motherhood Government has published its Bill on
to outlaw THE commercial surrogate motherhood, and the measure is expected to be law before Parliament rises for the summer recess. Under its provisions, those who organise commercial
826
surrogacy or advertise such services will be liable to fines of up to £2000 and three months in prison. But childless couples who come to private arrangements with surrogate mothers, and the surrogates themselves, will not be liable to prosecution, nor will doctors who treat them, provided they do not advertise such services. RODNEY DEITCH
Conference Human WE
Rights,
Health
Rights
have an International Commission of Health Professionals for health and human rights (ICHP).* Inaugurated in Geneva on Jan 28, the ICHP was conceived some four years ago as a purely medical commission. A small meeting in London last week was given illustrations of the sometimes well-trodden ground where health professionals’ work and human rights interact. But health itself is now a human right; at that level the ICHP’s task worldwide looks daunting. With torture as his example and the Compton and Parker reports on the abuse of detainees in Northern Ireland as his focus, Dr John Dawson (British Medical Association) urged that health professionals keep their distance "so that doctors and nurses can work independently of the State’s requirements for conformity with expedient measures". Ethics, he had earlier observed, is "a luxury of a developed society", so "creating a gap between the doctors and the State" is one of the tasks faced by doctors elsewhere. Dawson’s point is well illustrated by the abuse of psychiatry in the Soviet Union. Dr Sidney Bloch (Oxford) noted that the very structure of the specialty in that country makes fertile ground for abuse. There is a strict hierarchy, with power in the hands of a few psychiatrists who are not only communist party members (and only one in five Soviet psychiatrists is) but also have proven records of unquestioning party loyalty. Furthermore ideology gets preference over surgery in Soviet medical curricula and is prominent in the Soviet medical oath. When Professor Snezhnevsky broadened the diagnosis of psychiatry to include a "sluggish" variety objectors soon had to toe the line. "Incipient" schizophrenia was a diagnosis available to US psychiatrists until recently, and the Serbsky Institute’s ideas may have been sincere. However, it is in the uses to which they are put and in the treatment of those who protest that the difference lies. Dr Alejandro Reyes (Chilean Health Group) reviewed his country’s sad history. The Chilean College of Physicians had so lacked distance from the State that they played a crucial part in the overthrow of President Allende, who, with more than a hundred other doctors, died in the military coup. The College has had second thoughts, so is now ignored, Reyes said. The new regime has put an end to health reforms, but it is worse than that: in the shanty towns any attempt at self-help, be it in schools or clinics, is seen as a threat-as, indeed, are those professionals who try to help. Almost as he spoke, more teachers and human rights activists in Chile were now
being tortured and killed (Guardian, April 1). Mr Paul Sieghart, from Justice (the British section of the International Commission of Justice) described how international law, formerly reluctant to cover the internal affairs of sovereign states, has now built up a considerable corpus of codes, conventions, and charters on a mass of human rights, one of which was a right to health. This right has been surprisingly well defined in Europe but everywhere is qualified by "availability". ICHP’s secretary general, Dr Paulo Parra at the inaugural conference, had expressed interest in many other matters (transplantation, embryo research, euthanasia, for instance). Many other bodies have been tackling these topics, as they have psychiatric abuse and torture too. Perhaps ICHP’s first task is to defend the right of health professionals in the shanties of Santiago, the psychiatric hospitals of the Soviet Union, or wherever, to dissent from and to publicise unethical practices and policies. *ICHP,
34 Blvd du
Pont-d’Arve, PO Box 157,
1211 Geneva
4, Switzerland.
Notes and News GOVERNMENT’S PLANS FOR CURBING MISUSE OF DRUGS AN increase in drug misuse is not a phenomenon confined to the UK nor to Europe and the US. Communist Bloc nations and many developing countries too are experiencing for the first time a steep rise in domestic drug problems, according to a report prepared by the Ministerial Group on Misuse of Drugs. Many explanations have been given for the British increase in drug misuse: ready availability of drugs, personality defects, poor home background, peer group pressure, poor relationships, lack of self-esteem, youthful experimentation and rebellion, boredom, and unemployment. The Government considers that no single factor, nor any combination of factors, has particular significance, but the onus for prevention of misuse is clearly placed on reducing the supply of drugs. The report summarises the Government’s strategy on five fronts for tackling drug misuse: to reduce supplies from abroad, tighten controls on drugs produced and prescribed in the UK, make policing more effective, strengthen deterrence, and improve prevention, treatment, and rehabilitation. The number of addicts formally notified to the Home Office in 1983 (5850) was 42% up on 1982 and in 1984 the figure went up again by a further 25%. Research has suggested, however, that the numbers would have to be multiplied anything from 5 to 10 times to gain a true impression of the number of addicts in Britain. It also seems that drug misuse, which used to be confined to a rebellious city subculture, has now become far more pervasive. In spite of record drug seizures, the street price of heroin is lower in real terms than 4 or 5 years ago, and its average purity has remained highsuggesting that there is no shortage of the drug. And ready availability increases the opportunity for non-users to experiment for the first time. The Government has increased its annual contribution to the United Nations Fund for Drug Abuse Control (UNFDAC) to 100 000 in an effort to help the drawing up of master plans to combat the problem internationally. Most of the heroin captured in the UK derives from Pakistan, so cooperation between the two governments has been intensified in an effort to reduce opium production. Liaison officers have been posted to Karachi and The Hague to strengthen operational intelligence about drug smuggling. And domestic enforcement procedures at ports and airports have been intensified. The increase in seizures of cocaine has also been viewed with concern by the Government, since cocaine addiction has rapidly overtaken heroin addiction in the US and there is a glut of cocaine produced in South America which must find a European market. The report also summarises the health and education measures taken by the Government to prevent drug misuse, including the latest public campaign warning young people of the dangers of recreational use of drugs. Health authorities have been urged to improve their services for drug misusers in the light of their assessment of local needs. At March 1, 1985, a total of over &poun7d;7 million had been allocated to 95 projects run by statutory and voluntary bodies in England under a Central Funding Initiative. Guidelines for good clinical practice in the treatment of drug misusers2 have been drawn up by the Medical Working Group on
Drug Dependence. . MEDICAL MANPOWER A REPORT from the Advisory Committee for Medical Manpower Planning, published on March 26, gives different projections of the future pattern of supply of and demand for doctors in the United Kingdom. Many factors would affect the future balance. including the level of output from medical schools, the extent to
likely
1
Tackling Drug Misuse: A Summary Stationery Office, 1985.
2. Guidelines of Good Clinical Practice
Medical 1984.
Working Group
on
of the Government’s
Strategy. London
HM
in the Treatment on Drug Misuse. Report of the Drug Dependence. London: HM Stationery Office.
Commentary from Westminster Restriction
on
Entry of Overseas Medical Graduates
FROM April 1, the Social Services Secretary, Mr Norman Fowler has announced, doctors and dentists from abroad will not be able to practise in Britain unless they are citizens of EEC countries or have D 50 000 available to invest in their own practices. In other words, as Mr Fowler told the House of Commons, overseas doctors and dentists are to be subject to the same immigration restrictions as other groups ofpeople from abroad. This step represents a final abandonment of a policy, begun in the late ’60s, of welcoming doctors from abroad "to make good the shortfall in supply which arose from the inadequate number of graduates from our own medical and dental schools". The new regulations will not affect the position of foreign doctors already practising in Britain, Mr Fowler promised. 18 000 of the 72 000 qualified doctors now in Britain were trained abroad. According to the between 1600 and 2000 foreign doctors come to Britain each year to study. Doctors and dentists seeking entry to Britain for postgraduate training in hospitals will be admitted for a period ofup to four years, but they will be allowed to stay after that period only if extensions of stay are granted under the normal immigration and employment provisions. A similar period of permit-free time for postgraduate training will be available to overseas nationals graduating in Britain. Under EEC rules, doctors from Common Market member states will be exempt from the new regulations. The changes, according to Mr Fowler, are a sensible step to take at this stage. He explained to the Commons that the medical expansion programme begun in the ’60s was now largely complete. The Government’s 1983 review of dental manpower, and more recent Departmental examinations of medical manpower (which included doctors’ representatives), had led Ministers to the conclusion that the United Kingdom was "essentially self-sufficient in its supply of doctors and dentists". But at present overseas doctors and dentists have almost unrestricted access to work in Britain, Mr Fowler said, adding that Britain still wished to retain the important role it had traditionally fulfilled of providing postgraduate training to foreign doctors who can come here for periods of specialist training before returning to put those special skills into practice. The new restrictions would ensure, however, that foreign doctors did not come to Britain with expectations which the Health Service could not fulfil. Conservative backbenchers-most of whom know next to nothing about the NHS, its commitments, or its staffingwere naturally pleased with the statement. The British Medical Association, whose knowledge is naturally sounder, were also pleased. The Association has expressed concern for some time about the exemption of overseas doctors from immigration controls, a BMA spokesman commented. The changes would allow the numbers of British medical students to be aligned very much more easily to the career posts available to them. Uncontrolled immigration of foreign doctors made this difficult to achieve, and could lead, in the BMA’s view, to unemployment of British graduates, which was extremely wasteful. The Association welcomed, however, the continuation of postgraduate training arrangements.
DHSS,
The Opposition in Parliament found the new rules to be an evasion of the issues. Labour’s spokesman, Mr Michael Meacher, complained that the Government’s estimates of the numbers of doctors needed in Britain were based on inadequate information and on targets which were themselves unsatisfactory. 2000 doctors and 10 000 nurses were unemployed in Britain, Mr Meacher declared. Yet the numbers of doctors per 1000 population were 2507o higher in France than in Britain, 50% higher in the United States, and 100% higher in Italy. Meanwhile, the Government has not collected statistics on medical unemployment for the past three years. In 1982 the Government had committed itself to doubling the numbers of consultants by 1997, which would require a growth rate of 4’ 7507o per year. But in the year to September, 1984, the last for which statistics were available, the growth rate of 2’ 3% was less than half the necessary figure. Mr Meacher complained that the vaunted postgraduate training arrangements for overseas doctors were in fact haphazard. These doctors were often shunted off to study unfashionable specialties in the regions and often ended up not receiving the training for which they had come and which they had a right to expect. The chairman of the Commons Social Services Committee, Mrs Renee Short, echoed Mr Meacher’s complaints about failure to expand numbers of consultants, and called for early publications of the Government’s much-heralded but as yet unseen policy green paper on the future of general practice, which must have serious implications for the numbers of doctors needed in the future. Mr Fowler conceded that many overseas doctors do not at present receive "the most relevant medical training" as postgraduates in Britain. They found themselves in areas such as geriatrics and psychiatry, which were important but not often relevant to training needs. Mr Fowler promised that he planned to have talks with the BMA and other doctors’ representatives with the object of improving the situation. The Overseas Doctors’ Association, which is likely to be party to those discussions, does not have high hopes of the results. "We are totally against the steps Mr Fowler has taken," was the response of the Association’s chairman, Dr A. Karim Admani: "we are disappointed." The Association proposed alternatives to Mr Fowler a year ago. It suggested a moratorium on immigration of doctors for two or three years while manpower targets were established. After that period the ODA proposed there should be an agreed figure for overseas doctors to train in Britain, and that the figure should be set by the NHS. Doctors admitted for postgraduate training under that scheme should then get proper, relevant training, under a sponsorship scheme. "At the moment there is not any real training," Dr Admani added. "But under Mr Fowler’s proposals doctors will still come here to work in understaffed, underfinanced hospitals without learning much that is useful to them. They will still be exploited, and then they will be sent back after four years". In fact, eighteen months out of the four years was now spent looking for a job. The ODA is to meet Mr Fowler again in May, and places some faith in his promise that the four-year period could possibly be extended.
Bill
Surrogate Motherhood Government has published its Bill on
to outlaw THE commercial surrogate motherhood, and the measure is expected to be law before Parliament rises for the summer recess. Under its provisions, those who organise commercial
826
surrogacy or advertise such services will be liable to fines of up to £2000 and three months in prison. But childless couples who come to private arrangements with surrogate mothers, and the surrogates themselves, will not be liable to prosecution, nor will doctors who treat them, provided they do not advertise such services. RODNEY DEITCH
Conference Human WE
Rights,
Health
Rights
have an International Commission of Health Professionals for health and human rights (ICHP).* Inaugurated in Geneva on Jan 28, the ICHP was conceived some four years ago as a purely medical commission. A small meeting in London last week was given illustrations of the sometimes well-trodden ground where health professionals’ work and human rights interact. But health itself is now a human right; at that level the ICHP’s task worldwide looks daunting. With torture as his example and the Compton and Parker reports on the abuse of detainees in Northern Ireland as his focus, Dr John Dawson (British Medical Association) urged that health professionals keep their distance "so that doctors and nurses can work independently of the State’s requirements for conformity with expedient measures". Ethics, he had earlier observed, is "a luxury of a developed society", so "creating a gap between the doctors and the State" is one of the tasks faced by doctors elsewhere. Dawson’s point is well illustrated by the abuse of psychiatry in the Soviet Union. Dr Sidney Bloch (Oxford) noted that the very structure of the specialty in that country makes fertile ground for abuse. There is a strict hierarchy, with power in the hands of a few psychiatrists who are not only communist party members (and only one in five Soviet psychiatrists is) but also have proven records of unquestioning party loyalty. Furthermore ideology gets preference over surgery in Soviet medical curricula and is prominent in the Soviet medical oath. When Professor Snezhnevsky broadened the diagnosis of psychiatry to include a "sluggish" variety objectors soon had to toe the line. "Incipient" schizophrenia was a diagnosis available to US psychiatrists until recently, and the Serbsky Institute’s ideas may have been sincere. However, it is in the uses to which they are put and in the treatment of those who protest that the difference lies. Dr Alejandro Reyes (Chilean Health Group) reviewed his country’s sad history. The Chilean College of Physicians had so lacked distance from the State that they played a crucial part in the overthrow of President Allende, who, with more than a hundred other doctors, died in the military coup. The College has had second thoughts, so is now ignored, Reyes said. The new regime has put an end to health reforms, but it is worse than that: in the shanty towns any attempt at self-help, be it in schools or clinics, is seen as a threat-as, indeed, are those professionals who try to help. Almost as he spoke, more teachers and human rights activists in Chile were now
being tortured and killed (Guardian, April 1). Mr Paul Sieghart, from Justice (the British section of the International Commission of Justice) described how international law, formerly reluctant to cover the internal affairs of sovereign states, has now built up a considerable corpus of codes, conventions, and charters on a mass of human rights, one of which was a right to health. This right has been surprisingly well defined in Europe but everywhere is qualified by "availability". ICHP’s secretary general, Dr Paulo Parra at the inaugural conference, had expressed interest in many other matters (transplantation, embryo research, euthanasia, for instance). Many other bodies have been tackling these topics, as they have psychiatric abuse and torture too. Perhaps ICHP’s first task is to defend the right of health professionals in the shanties of Santiago, the psychiatric hospitals of the Soviet Union, or wherever, to dissent from and to publicise unethical practices and policies. *ICHP,
34 Blvd du
Pont-d’Arve, PO Box 157,
1211 Geneva
4, Switzerland.
Notes and News GOVERNMENT’S PLANS FOR CURBING MISUSE OF DRUGS AN increase in drug misuse is not a phenomenon confined to the UK nor to Europe and the US. Communist Bloc nations and many developing countries too are experiencing for the first time a steep rise in domestic drug problems, according to a report prepared by the Ministerial Group on Misuse of Drugs. Many explanations have been given for the British increase in drug misuse: ready availability of drugs, personality defects, poor home background, peer group pressure, poor relationships, lack of self-esteem, youthful experimentation and rebellion, boredom, and unemployment. The Government considers that no single factor, nor any combination of factors, has particular significance, but the onus for prevention of misuse is clearly placed on reducing the supply of drugs. The report summarises the Government’s strategy on five fronts for tackling drug misuse: to reduce supplies from abroad, tighten controls on drugs produced and prescribed in the UK, make policing more effective, strengthen deterrence, and improve prevention, treatment, and rehabilitation. The number of addicts formally notified to the Home Office in 1983 (5850) was 42% up on 1982 and in 1984 the figure went up again by a further 25%. Research has suggested, however, that the numbers would have to be multiplied anything from 5 to 10 times to gain a true impression of the number of addicts in Britain. It also seems that drug misuse, which used to be confined to a rebellious city subculture, has now become far more pervasive. In spite of record drug seizures, the street price of heroin is lower in real terms than 4 or 5 years ago, and its average purity has remained highsuggesting that there is no shortage of the drug. And ready availability increases the opportunity for non-users to experiment for the first time. The Government has increased its annual contribution to the United Nations Fund for Drug Abuse Control (UNFDAC) to 100 000 in an effort to help the drawing up of master plans to combat the problem internationally. Most of the heroin captured in the UK derives from Pakistan, so cooperation between the two governments has been intensified in an effort to reduce opium production. Liaison officers have been posted to Karachi and The Hague to strengthen operational intelligence about drug smuggling. And domestic enforcement procedures at ports and airports have been intensified. The increase in seizures of cocaine has also been viewed with concern by the Government, since cocaine addiction has rapidly overtaken heroin addiction in the US and there is a glut of cocaine produced in South America which must find a European market. The report also summarises the health and education measures taken by the Government to prevent drug misuse, including the latest public campaign warning young people of the dangers of recreational use of drugs. Health authorities have been urged to improve their services for drug misusers in the light of their assessment of local needs. At March 1, 1985, a total of over &poun7d;7 million had been allocated to 95 projects run by statutory and voluntary bodies in England under a Central Funding Initiative. Guidelines for good clinical practice in the treatment of drug misusers2 have been drawn up by the Medical Working Group on
Drug Dependence. . MEDICAL MANPOWER A REPORT from the Advisory Committee for Medical Manpower Planning, published on March 26, gives different projections of the future pattern of supply of and demand for doctors in the United Kingdom. Many factors would affect the future balance. including the level of output from medical schools, the extent to
likely
1
Tackling Drug Misuse: A Summary Stationery Office, 1985.
2. Guidelines of Good Clinical Practice
Medical 1984.
Working Group
on
of the Government’s
Strategy. London
HM
in the Treatment on Drug Misuse. Report of the Drug Dependence. London: HM Stationery Office.