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of taking the rough with the smooth, but from my hon. Friend's point of view, there is never any smoothness in respect of Europe--it is roughness all the way.

Mr. Marlow : If my hon. Friend does not mind my correcting him, he has got it wrong. I am in favour of Europe, but unto the Europeans that which is Europe's and unto the United Kingdom and the sovereign territories of Europe that which should be their sovereign matters. We have the Single European Act, and we all understand that there is agreed majority voting on the single market. What we are rightly concerned about and what I wish my hon. Friend would be concerned about is the creeping competence of the European Community. It is trying to gain majority voting competence over issues and areas that we never contemplated would be controlled in that way.

Mr. Nicholls : I assure my hon. Friend that I understood that that was his position. He said that it was never intended under the Single European Act that, for example, immigration questions should be brought within the Community's competence. To some extent, it depends on the way that one uses the language. My hon. Friend may see this as primarily an immigration matter ; I see it more prosaically, as no more than a recognition that, if there is to be freedom of movement of workers within a common market, it seems to make sense logically and morally to allow them to take their dependent relatives with them. Whether the term "dependent relatives" should be extended widely is another matter.

I accept the point that the hon. Member for Greenock and Port Glasgow (Dr. Godman) made about section 14 of the Merchant Shipping Act 1988. I hope that he will accept that, at this time of night, I should write to him about that matter, rather than try to deal with it at the Dispatch Box.

Question put and agreed to.


That this House takes note of European Community Document No. 5786/89 relating to freedom of movement for workers ; supports the broad objective of free movement for workers within the Single Market ; and endorses the Government's intention of seeking amendment of inappropriate provisions.


Motion made, and Question put forthwith pursuant to Standing Order No. 102(5) (Standing Committees on European Community documents).


That this House takes note of European Community Document No. 8066/88 relating to waste ; and supports the Government's intention to seek to ensure that the provisions of these Directives are necessary to protect human health and the environment from the danger arising out of waste disposal.-- [Mr. Sackville.]

Question agreed to.


Motion made, and Question put forthwith pursuant to Standing Order No. 101(5) (Standing Committees on Statutory Instruments, &c.)


That the draft Hovercraft (Application of Enactments) Order 1989, which was laid before this House on 22nd June, be approved.-- [Mr. Sackville.]

Question agreed to.

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Northern Ireland

That the draft Appropriation (No. 3) (Northern Ireland) Order 1989, which was laid before this House on 29th June, be approved.-- [Mr. Sackville.]

Question agreed to.

Representation of the people

That the draft Representation of the People (Northern Ireland) (Amendment) Regulations 1989, which were laid before this House on 6th July, be approved.-- [Mr. Sackville.]

Question agreed to.

House of Commons (Services)


That Mr. Tristan Garel-Jones and Mr. David Hunt be discharged from the Select Committee on House of Commons (Services) and Mr. Alistair Goodlad and Mr. David Lightbown be added to the Committee.-- [Mr. Sackville.]


NHS Reform

1.2 am

Mrs. Alice Mahon (Halifax) : I beg to ask leave to present a petition containing 5,500 signatures. It represents the voice of the people of Yorkshire and Humberside telling the Government of their fears for the future of the National Health Service. They have reached the clear and logical conclusion that, if their NHS hospitals are set up as hospital trusts and become businesses with information systems, giving the costs of every treatment in detail, and can borrow money in the City, set their own wage rates and hire and fire staff at will, they are set for total privatisation, and the people want none of it. The Government should listen to their voice. The petition states :

To the Honourable the Commons of the United Kingdom of Great Britain and Northern Ireland in Parliament assembled. The humble petition of the people of Yorkshire and Humberside showeth that they are opposed to the Government NHS White Paper proposals, particularly on the opting out of local hospitals.

Wherefore your Petitioners pray that your honourable house does not approve these proposals and maintains the NHS as a truly national service. And your Petitioners, as in duty bound, will ever pray, etc.

To lie upon the Table.

1.5 am

Mr. David Hinchliffe (Wakefield) : The petition which I wish to present to the House has been organised by members of the National Union of Public Employees and signed by about 5,500 people from various parts of Yorkshire and Humberside who oppose the proposals that are contained in the White Paper on the National Health Service. The petitioners believe that the Government are effectively breaking up the NHS by proposing to allow the formation of independent hospital trusts whereby individual hospitals, or health units, opt out of local health authority control. They are concerned that the setting up of a series of separate, individual competing units will result in the ending of the comprehensive nature of Britain's health care and believe that it is nonsense to introduce a system whereby the health provision and treatment available in any locality will be dependent upon the business acumen of individual health managers.

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The petitioners are worried that the proposals in the White Paper are part of a longer-term plan to pave the way for health care provision that is based entirely on market forces. They stand by the original principles of an NHS based on need and not ability to pay. Accordingly, they urge the House to reject the White Paper in its entirety. I am happy entirely to endorse their wishes and concerns. The petition states :

To the honourable the Commons of the United Kingdom of Great Britain and Northern Ireland in Parliament assembled. The humble Petition of the People of Yorkshire and Humberside showeth that they are opposed to the Government NHS White Paper proposals, particularly on the opting out of local hospitals.

Wherefore your Petitioners pray that your honourable House does not approve these proposals and maintains the NHS as a truly national service.

And your Petitioners, as in duty bound, will ever pray.

To lie upon the Table.

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Health Service (Cornwall)

Motion made, and Question proposed , That this House do now adjourn.-- [Mr. Sackville.]

1.6 am

Mr. Matthew Taylor (Truro) : I welcome this opportunity to express my concern about the conditions and future of the National Health Service in Cornwall. I thank the Under-Secretary of State for being in his place in the early hours of the morning to respond to my concerns. The hon. Gentleman is most welcome. It is not always easy to wait for other debates to finish, to wonder what time we shall finish and to keep awake. I make no apology for holding the Minister here, however, because I believe that health is of immeasurable concern to my constituents. The Health Service is the issue on which I have received the largest post bag in recent months.

It is sad that people nationwide, but especially in Cornwall, have grown to expect the problems that are associated with long waiting lists. Despite considerable investment in the county, which I acknowledge and welcome, we have failed to keep pace with growing needs. Cuts have been made, but not as a result of a rational examination of the county's health needs. Instead, they have been the result of an immediate cash crisis. Even now, we are concerned about the future of the Tehidy hospital and the possible privatisation of St. Mary's hospital within that context.

The publication of the White Paper, with proposals for general practitioners' contracts, has horrified people as never before. The concern of many Cornish doctors centre around the likelihood that the proposals outlined in the White Paper, especially on the proposed doctor's contract, will be detrimental to the welfare of rural practices in particular and to the people whom they seek to serve. The purpose of the document appears to be to increase competition between the providers of health care in the hope that this will mean a better service and the better use of resources. Unfortunately, for the people of Cornwall, the Government are so certain in their faith that competition is the answer to everything that they have seemingly failed to assess the effects of their policy on different and peculiar parts of the country. People who are ill are not interested so much in having the right to exercise choice about the form of treatment that they will receive and which hospital they will attend. Instead, they want confidently to expect that they can rely on receiving quality care when they need it and within easy access of their home.

In my view, the current proposals could all too often mean no choice at all. The Secretary of State, when defending the reforms in early May, recommended a study of the magazine entitled Medeconomics . I am glad that I took the trouble to follow his advice. I found that those who write for the magazine had examined a small rural practice in the south-west which is based in Constantine in Cornwall. The article looked at the proposed changes, and in its conclusions said :

"Unfortunately, there seems to be little scope for these GPs to increase their income. The isolated areas in which they work means that outside appointments are difficult to come by. The GPs have none. The list is a stable one biased towards a higher than average proportion of elderly patients and there is little prospect of change.

Once the GPs know how their remuneration package will change, they will need to take careful stock of their position.

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If economic realities prove harsh in the future, they should not overlook the possibility of eventually ending the practice and joining partnerships in a more populated part of the country." In other words, the magazine, which I read at the recommendation of the Secretary of State, says that they may have to give up. That is a practice that has been referred to me by doctors in Cornwall as an example of best practice and of the kind of service that other doctors would ideally like to offer to their patients.

The doctors' contract will have a devastating effect on rural health care. The measures to tie the level of pay to list sizes and the reduction in basic practice allowance will not benefit rural doctors, but will penalise them in order to offer incentives to busier practices in wealthier areas. In many practices in Cornwall, it will be impossible for doctors to acquire more patients, leaving practices either financially untenable or at least less attractive. What kind of choice is that for those for whom it is their only source of health care for many miles? Unlike the views of Conservative think tanks, competition as such is far from central to rural patients' hopes for the NHS. How many areas have different practices with easy access between which a choice can be made? How many areas have a range of hospitals which doctors can play off against each other?

The reforms for rural practices appear to run counter to the Government's expressed aims. Rewards for larger list sizes puts in to reverse the attempts by successive Governments of all parties to encourage GPs to take fewer patients on to their lists so as to improve individual care. How can preventive medicine truly be encouraged, when it is best achieved with a small list size and time with the patient? In the rural areas of the south west, the distance between split-site surgeries, the difficulties that the patients have with transport and the travelling time required to visit patients are all real problems that the Government have singularly failed, as yet, properly to address.

A poll conducted by the Cornwall and Isles of Scilly local medical committee found that 98 per cent. of patients registered with GPs in Cornwall think that there will be little or no improvement in patient care following the changes proposed in the White Paper. Incidentally, 96 per cent. view it as nothing but a cost-cutting exercise. Not only are patients disaffected with the Government's proposals, but all the polls show that the very people who are expected to implement them are also overwhelmingly against them. The result of the ballot of GPs announced last week was a clear indictment of the new GPs' contract devised by the Government. At a meeting of the Cornwall division of the BMA in April, the White Paper was also overwhelmingly rejected. My experience of meetings with GPs has shown to me their overwhelming condemnation of the Government's proposals. I believe that that condemnation springs not out of interest in their wallets, as the Secretary of State has tried to suggest, but out of concern about the impact that they will have on the treatment of patients. Indeed, at the meeting organised by the BMA in Plymouth, which I attended, I witnessed the most unexpected sight of a doctor breaking down in tears over the proposals, when he tried to ask a question. It shook the Conservative Member of Parliament, who had been asked by the Secretary of State to attend that meeting and defend the proposals, as much as it shook everyone else in the audience.

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Many of the doctors and patients who are now protesting so vehemently are people who have told me that they have voted Tory all their lives. They have been driven to the point of condemning their Government, because they are so acutely aware of the vital services that rural practices and hospitals offer and of the vulnerability of the situation in which such practices and hospitals now find themselves.

I wish to take the opportunity to call on the Minister, together with his colleagues, to publish immediately a paper on the future of rural doctors, detailing how the proposals will affect them. I look forward to hearing specific comments from the Minister in response to the points that I have made on this. At the very least, it must be clear from what I have said that Ministers have yet to prove their case. They have failed to convince any of those involved that there are not major pitfalls in the proposed reforms. One wonders why, at the very least, the reforms cannot be tried out experimentally in a few districts before being imposed on them all.

I ask the Minister to comment also on the position of GPs who spend much of their working week in community hospitals. Will that time be included in the number of hours that GPs are required to be available in their surgeries? The Minister is well aware of my concern on this point. Indeed, the Minister's recent response to me on this subject seems to hold the clear suggestion that at least at the margin there will be financial penalties for engaging in community hospital work. Those community hospitals are considered to be of great importance by many of my constituents. I hope that the Minister will be able to find ways to protect their position.

I turn now to the crippling problem of lengthy waiting lists. At the end of March this year the waiting list in Cornwall for orthopaedics was 1,207 for in-patients, of whom 434 had been waiting more than a year for treatment ; a further 231 were waiting for care as day-patients. In general surgery, a total of 1,768 people were waiting to go into hospital and 1,264 were waiting for day care ; 459 people had waited more than a year for in- patient treatment and 224 were waiting for out-patient treatment. Those figures are poor, as are the figures for the number of consultants per patient in the county. I do not believe that the Government's current plans will reduce those waiting times.

How, in practice, can people be sent to another hospital with a shorter waiting list without at the very least breaking their contact with their own community and with their friends and relatives when there is only one main hospital in the whole county? The Government may well conjure up a way of doing so by forcing on doctors, through practice budgets, the task of limiting the numbers treated. However, that does nothing for patients who want treatment. It does not speed things up ; it simply disguises the problem. It breaks down the trust between GP and patient as the useful alliance between GP and patient in attempting to get treatment turns to a relationship in which the patient cannot be sure whether the doctor who says, "You do not need treatment just now," is thinking of the practice's accounts or of the patient's needs. That will be intolerable for patients on a waiting list and it should be unacceptable to all of us.

The Government have an opportunity to do something about this matter and to instil some hope in those who had begun to despair of the situation ever improving. Cornwall district health authority has bid for two extra posts of the

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100 extra consultant posts that the Government have said that they will provide for the whole country. If granted, they could well lead to a reduction in the waiting list and I implore the Government to meet their request. We need more specialist staff.

Ministers and the Department acknowledge that we have special difficulties and needs at present. Like it or not, those problems come down to the level of funding and the provision of staff and, as I have said, the opportunity to improve things is there.

A specific issue concerning funding for the Cornwall health authority is the issue to which I turn next. Cornwall health authority is an unusual position in that it does not currently receive the total funds due for its population. Some of this funding due to Cornwall goes instead to north Devon and to Plymouth. This is because of the area known as the overlap, where people in Cornwall use Plymouth and north Devon hospitals and facilities for acute services. Cornwall does, however, provide these people with community health care and for the needs of the handicapped and elderly. I would hope that all the funding due to Cornish people would now go to Cornwall as it does to other areas in similar situations. This is probably worth an extra £17 million, which currently goes to Plymouth health authority. The Cornwall health authority can then purchase services from Plymouth and north Devon hospitals for the overlap area, as happens elsewhere. More comprehensive packages of service can be possible if Cornwall health authority has responsibility for all the various aspects of its health care. I ask the Minister for an assurance that Cornwall be fully funded for its total resident population.

A final issue, and one of much local concern, is the funding of our air ambulance. Cornwall has the first air ambulance in the country, which receives no Government funding. The generosity of the Cornish people is fulfilling what should be the role of central Government in providing necessary health services. I have pressed the need to take account of the special costs of providing transport services in a rural scattered area. The advantages of an air ambulance in providing such services are considerable. It can reach geographically isolated areas rapidly and areas not served by land ambulances, even as far as the Isles of Scilly. The journey back time can be much shorter than that of a land ambulance. More importantly, it is a highly mobile resource which can be moved, around the county to stand back-up for an area when land ambulances are fully committed.

In a geographically large area, even one land ambulance called to an accident can leave a vast part of the county without effective ambulance cover. The air ambulance is uniquely able to prevent that. If the Minister doubts that, I recommend that he looks at the map on the wall of the Truro ambulance station to see just how wide an area one ambulance may have to cover at any one time, particularly in north Cornwall.

Added to those basic principles is the fact that it appears to have a proven record of success. When the air ambulance is available, the response to emergencies within 20 minutes is 95 per cent. but only 90 per cent. when it is not available. Thus the Government target of 95 per cent. response rate within 20 minutes is met only with the air ambulance in operation.

Currently it costs £22,000 a month to fund the air ambulance. That is cost-effective as, although the cost is equivalent to that of seven land ambulances, it would take

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17 to provide the same level of back-up due to the distances involved. It is a vital and unique experiment in the provision of health care in a rural scattered area. It is unique in this country and the first figures seem to demonstrate that it is a success--it is saving lives.

So why is it that a service which has proved so necessary should have to live with the uncertainty that arises from being dependent on donations by the general public however generous they may be? The Government should respond to the generosity of the Cornish people who have given so much to this scheme by recognising this and agreeing to provide funding themselves. Extra financial allowances have to be made for the transport difficulties of a long rural area surrounded by sea, yet I understand that Government funding is being provided for the London air ambulance rather than the Cornish one. Currently, an evaluation of air ambulance services has been proposed by Ministers, but so far, although I have pressed for Cornwall to form an essential part of it, Ministers have been reluctant, partly on cash grounds. Yet Cornwall has a unique service. I would welcome at least an initial commitment by the Minister to find funds for an independent evaluation of the Cornwall air ambulance. I hope that he can make that promise tonight.

If, once again, funding is refused, Cornwall will conclude that the Government have no interest whatsoever in this innovative method of improving health care in rural areas. I repeat tonight an invitation I have made before. Will the Minister agree to come as my guest to see the service offered from Truro?

I have outlined some of the issues on which I would like a specific response from the Minister. I contacted his offices and spoke to him earlier today to give him the opportunity to examine some of the issues that I hoped to raise. I look forward to his reply and I hope that he will offer a message of encouragement and a promise of Government action that I can take back to my constituency. There is great advantage in having had the opportunity of the debate and I am grateful for that. At the very least I know that the Minister and his civil servants have taken a special look at the needs of the county. I hope that in future when they examine the needs of the Health Service in Cornwall they will remember some of the things that they have heard tonight.

1.24 am

The Parliamentary-Under Secretary of State for Health (Mr. Roger Freeman) : I congratulate the hon. Member for Truro (Mr. Taylor) on securing time for this Adjournment debate on the Health Service in Cornwall, in which he has always shown a keen interest. I also note that my hon. Friend the Member for St. Ives (Mr. Harris) is in his place. He also takes an extremely close interest in health care in his county.

The subject is wide, and I hope that I shall be able to deal with all the points that the hon. Member for Truro raised. I thank him for his courteous opening remarks and for forewarning me of some of the issues that he would raise.

It is as well to start with a general overview of the way in which things have improved recently. Cornwall and Isles of Scilly comes under the purview of the South Western regional health authority, which is responsible for the allocation of resources, for approving districts'

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programmess and for reviewing their performance. Cornwall figures large in the region's plans. The district general hospital at Treliske, which is in the hon. Gentleman's constituency, is subject to major capital development. Phase 4 is under construction at a cost of more than £8 million, and a further phase is planned. A new acute geriatric assessment unit has been approved for the West Cornwall hospital in Penzance at a cost of £2 million.

On revenue, Cornwall is the second highest spender in the region, with an allocation of nearly £98 million for 1989-90, which is a real-terms increase of about 2 per cent. over the previous year. Since 1978-79, the region's recurrent resources are expected to have risen by about 35 per cent. in real terms, and Cornwall has benefited from these large injections of cash. Cornwall has also managed to release more than £4 million in its cost improvement programmes cumulatively during the past three years for use in developing and improving services. I congratulate it on that achievement. All these extra resources have fed through into additional services by more patients being seen in better accommodation. The number of nurses, doctors and other front-line staff has risen steadily, as has their proportion. Patient activity has continued to grow. In-patient, out-patient and day care activity have all risen significantly. These figures are evidence of substantial improvements to health services in Cornwall recently, as I am sure the hon. Gentleman will acknowledge. In spite of the significantly increased number of patients who are being seen and treated, however, waiting lists have grown. The hon. Gentleman gave some statistics, and I do not disagree with the impression that he has given the House. We have recognised the problem, as has the region and the district. That is why Cornwall and Isles of Scilly was one of the 22 districts which this year received special attention from an independent management team to help find a way in which to reverse the trend.

The waiting lists are no reflection on the hard work put in by Cornwall's consultants ; they are simply an expression of demand rising even faster than available resources and improvements in efficiency can match. To help ease the pressure, I understand that the district has put in a bid for two of the 100 additional consultants who were promised by my right hon. and learned Friend the Secretary of State when he launched the White Paper "Working for Patients". All regions in England have been asked to submit bids for additional consultants by the end of this month. My Department will then assess priorities with the steering group on "Achieving a Balance", and we aim to make an announcement in October.

Meanwhile, I understand that the district will add a new consultant post in urology to its staff in September. During the past three years, Cornwall has been allocated more than £450,000 from the waiting list fund which, by the end of this year, will have been used to treat some 3,000 additional in-patients and day cases. Among the many local initiatives, I am impressed by the success of Cornwall's first air ambulance service in terms of public support. It has caught the imagination of the public, who have responded magnificently with financial support. However, I must resist the hon.

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Gentleman's specific call for special funding for the service. It is a local initiative and a local service, and it is therefore a matter to be handled by the health authority. However, I am examining the possibility of some help in evaluating the service, in which there will be wider interest. I expect to reach a conclusion on that in due course and I shall ensure that I write not only to the hon. Gentleman, but to my hon. Friend the Member for St. Ives, who I am sure has an interest in the subject.

The hon. Gentleman raised the subject of community hospitals and general practitioners.

Mr. Matthew Taylor : Before the Minister moves on, I must say that over the past 18 months, I have repeatedly tried to get a Minister to come down to have a look at the authority. Perhaps this is the moment for the Minister to agree to do that.

Mr. Freeman : I am trying to answer the points raised in the debate. I very much regret that I cannot commit myself to visiting the authority in the near future. I very much hope that I shall be able to do so at the appropriate time.

I was referring to community hospitals and the responsibilities of general practitioners towards those hospitals. General practitioners spend part of their time working for community hospitals. They are paid for that valuable service and we all recognise how important that is. However, we believe that, if general practitioners are to work full time, they must be available for 26 hours over five days a week and that includes surgery consultations, clinics and home visits.

As I hope I have made clear to the hon. Gentleman in the form of a recent letter, and as I want to put on the record now, where those general practitioners are working in community hospitals--I recognise their importance, especially in the rural areas--we believe that they should apply to their family practitioner committees for a waiver of the five-day requirement, so that they can spread their commitment of 26 hours a week over four rather than five days. I hope that the hon. Gentleman will find that a constructive comment.

The hon. Gentleman also raised questions about the general practitioners' proposed contract, especially for rural areas. I want to deal first with rural practice payments, to which the hon. Gentleman referred. The payments recompense the general practitioners for the additional time and expense that might be incurred in caring for patients in rural areas. The main criterion for payment is, briefly, that at least 10 per cent. of patients on the general practitioner's list are resident in his or her rural practice area and live at least three miles from the main surgery. Each of those patients attracts units of monetary value depending on the distance and difficulty in reaching him or her.

Earlier this year, we agreed with the General Medical Services Committee that the special nature of practice in truly rural areas should continue to be recognised in the system of fees and allowances. We also agreed that the current scheme was not as well targeted as it could be. The whole question of payment to general practitioners in rural areas in England, such as Cornwall, is therefore being referred to the central advisory committee on rural practice payments. That is what the doctors' leaders wanted and we are considering how to carry this forward. Meanwhile, the current scheme will continue in operation.

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The hon. Gentleman implied that general practitioners and some of their patients are in great turmoil. I believe that general practitioners should await not only the proposed contract, which must be laid before Parliament--and will be in the autumn--but more importantly, the report of the doctors' and dentists' review body, which must price the contract. I hope that I can deliver a message on the contract through you, Mr. Deputy Speaker, to the doctors of Cornwall tonight. My message is that they should wait and consider what action they feel they must take in the light not only of the contract, but of our conclusions on rural practice payments and the doctors' and dentists' review body. Doctors will then be able to reach rational judgments on whether they should change their practices, particularly their working practices, and the size of their patient lists.

We understand that doctors in rural areas will have smaller lists. It is very difficult for patients to change doctors. It is not the Government's intention to frustrate

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the provision of general practice service to patients in rural and scattered areas. We want to improve the quality and quantity of that service.

I welcome the hon. Gentleman's implied support for our funding proposals and also for contracts. Following the Resource Allocation Working Group, we will fund districts such as Cornwall and the Isles of Scilly on the basis of residence in the district. It will then be up to the health authority, through the medium of contracts, to pay for the provision of services outside districts such as Plymouth. We believe that that will be a fairer and more flexible system. The hon. Gentleman and my hon. Friend the Member for St. Ives will join me in welcoming the aim of the White Paper, if not the specific proposals, and the doctors' contract--to improve the quantity and quality of health care, not only in Cornwall but in England as a whole. Question put and agreed to.

Adjourned accordingly at twenty-five minutes to Two o'clock.

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