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House of Commons

Tuesday 7 November 1989

The House met at half-past Two o'clock


[Mr. Speaker-- in the Chair ]


Penzance Albert Pier Extension Bill

Motion made,

That so much of the Lords Message (2nd November) as relates to the Penzance Albert Pier Extension Bill be now considered.

That the Promoters of the Penzance Albert Pier Extension Bill shall have leave to suspend proceedings thereon in order to proceed with the Bill in the next Session of Parliament, provided that the Agents for the Bill give notice to the Clerks in the Private Bill Office of their intention to suspend further proceedings not later than the day before the close of the present Session and that all Fees due on the Bill up to that date be paid ;

That on the fifth day on which the House sits in the next Session the Bill shall be presented to the House ;

That there shall be deposited with the Bill a declaration signed by the Agents for the Bill, stating that the Bill is the same, in every respect, as the Bill at the last stage of its proceedings in this House in the present Session ;

That the Bill shall be laid upon the Table of the House by one of the Clerks in the Private Bill Office on the next meeting of the House after the day on which the Bill has been presented and, when so laid, shall be read the first, second and third time and shall be recorded in the Journal of this House as having been so read ; That no further Fees shall be charged in respect of any proceedings on the Bill in respect of which Fees have already been incurred during the present Session ;

That these Orders be Standing Orders of the House.-- [The Chairman of Ways and Means.]

Hon. Members : Object.

To be considered on Thursday 9 November at Seven o'clock.

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Oral Answers to Questions


West Midlands (Resources)

1. Mr. Colin Shepherd : To ask the Secretary of State for Health if he has assessed the extent to which the formula for funding of the regional health authorities adequately reflects the needs of the West Midlands regional health authority.

2. Mrs. Maureen Hicks : To ask the Secretary of State for Health what representations he has received on the allocation of National Health Service resources for the west midlands.

5. Mr. Gill : To ask the Secretary of State for Health what representations he has received regarding the future funding of the West Midlands regional health authority.

The Secretary of State for Health (Mr. Kenneth Clarke) : The new regional allocation formula reflects the relative need for health services of west midlands residents by taking account of the size, age structure, and health of the region's population. I have received several letters about allocations to west midlands region, including a number from hon. Members and one from the chairman of the regional health authority.

Mr. Shepherd : I am grateful for my right hon. and learned Friend's reply. Is he aware that there is considerable concern in the west midlands that the resource allocation does not reflect regional needs? Is he aware further that Herefordshire is one of the fastest growing areas in the region in terms both of population size and of age? Because of that, even now, the health authority is finding it difficult to sustain the level of service that the Government expect from it. Can we look forward to future resourcing which will properly and accurately reflect demographic trends and the full implications of patients from Wales going to Herefordshire for treatment?

Mr. Clarke : I agree with my hon. Friend. There is concern in the region at the moment. That concern stems largely from a debate that has arisen on the technical planning guidelines that we have given this year. I ask everybody in the west midlands to wait until allocations of funds are made to the west midlands, which will be after the Autumn Statement has been announced. I remind everyone in the west midlands that under this Government the allocation to the west midlands has increased dramatically. It is now up by 37 per cent. in real terms since we took power. That compares with a 30 per cent. increase to health authorities across the country.

Hereford has particular problems because of the age structure of its population and the other factors that my hon. Friend has described. The region will be expected to take them into account when making allocations to the district, just as we shall take all west midlands population features into account when we make eventual allocations to the region.

Mrs. Hicks : I acknowledge the welcome overall increases for the National Health Service in the forthcoming year, but will my right hon. and learned

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Friend take on board the obvious anxiety of three west midlands hon. Members who are asking three of the first five questions today and who are naturally genuinely concerned about any talk of reductions? Obviously, from what my right hon. and learned Friend is saying, we do not have cause for concern. May I therefore take that message back to Wolverhampton health authority, which has done a splendid job in managing its resources, and may I tell it that its efforts will be rewarded and not penalised?

Mr. Clarke : It seems to me--I only guess--that three Conservative Members from the west midlands have acted promptly after a letter was sent to all west midlands Members by the chairman of the regional health authority. I commend to my hon. Friend a reply that I sent to the chairman of the health authority, pointing out that no cuts of any kind are proposed and also pointing out our excellent record in increasing resources to the west midlands. I am sure that when the regional chairman gets the eventual allocations he will seek to reflect my hon. Friend's concern by allocating further growth money to the Wolverhampton health authority.

Mr. Gill : I am grateful for my right hon. and learned Friend's answers. When he considers the allocation of funds, will he use his best offices to ensure that demographic and geographic factors in Shropshire, as opposed to other parts of the west midlands, are truly reflected? Will my right hon. and learned Friend care to consider for one moment that the allocation of funds generally has been more generous to health authorities in Wales, which adjoins my constituency?

Mr. Clarke : I certainly give that undertaking to my hon. Friend. Shropshire has certainly done well in recent years. It has a new district general hospital, which now gives the county two extremely good district general hospitals and, in addition, one of the best orthopaedic units in the country, at Oswestry. The district has done very well in the allocation of funds in recent years. The region was able to give an additional £7 million, or a 9.1 per cent. increase, to Shropshire in this year alone. That is a rise of 206 per cent. in cash terms, or 32 per cent. in real terms, since the Government took office. That does not include £0.75 million that the district received in waiting list initiative money. I am sure that when the allocations of cash are made this year when the results of the autumn spending round are announced, the region will make a proper allocation to Shropshire to reflect all the demographic features of that county.

Mr. Fisher : Is the Secretary of State aware of the recent university of Leeds survey on health in north Staffordshire, which shows that 50 per cent. of men in Stoke-on-Trent die before they reach pensionable age and that in one part of my constituency the life expectancy for men is less than 62 years? How, therefore, can he justify re-weighting the mortality rates, which has led to the shift in resources of £56 million over the next three years from the west midlands to the rich south- east?

Mr. Clarke : I am aware of the study, which underlined the great need to improve the health status of the population of the Potteries. I suspect that historically the health status of people living in that industrial area has not been so good as that of the rest of the country. As I said in my first supplementary answer, since we came to power we have given a much bigger increase in funds to the west

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midlands than to the rest of the country-- and certainly greater than we have given to the south-east. Our new arrangements for distributing money are simpler than those that we had before. They reflect the comparative needs of the regions and still contemplate a comparative shift of resources away from London to other parts of the country.

However, whatever formula one comes up with, it is possible to make a case in favour of each and every one of the 190 districts in the country. The formula we are using is the fairest, taking account of all the competing health needs of the different districts.

Mr. Corbett : Will the Secretary of State make it clear whether next year under his new formula he expects the west midlands to get more or less money than this year? Is he aware that the North Birmingham health authority, with the Good Hope hospital in Sutton Coldfield, is currently £500,000 overspent and faces having to close wards and beds and to cut services? What is the Secretary of State going to do about that?

Mr. Clarke : I expect the West Midlands regional health authority to get more money next year, as it has every year during the lifetime of this Government. The exact amount will become clear when we make the allocations to the regions after the Chancellor has announced the results of the Autumn Statement, which will be shortly. The West Midlands regional health authority has never had so much money at its disposal for the National Health Service as it has at the moment. It is greatly increasing its patient care and I am sure that the hon. Gentleman's district health authority is treating more patients this year than it ever has in the history of the National Health Service. It is a weakness of the management of the Health Service that even when more money is poured into it it has mid-year crises because the management cannot match the expansion of services with the money-- [Interruption.] The reason for reforming the service is to improve control over that money so that we can have steady and sustained growth instead of the checks to growth that the hon. Gentleman has just described.

Mr. George : If the Secretary of State is still talking to Sir James Ackers--I am not sure that he will be after the right hon. and learned Gentleman's intemperate letter of 24 October--will he guarantee to hon. Members representing Walsall that the final tranche of the £2.4 million to allow the new district general hospital to open on time will actually be made?

Mr. Clarke : Sir James Ackers is one of my oldest personal friends-- [ Hon. Members-- : "Oh."] He is also one of the very best chairmen of regional health authorities in this country. It is an experience of life that when extremely good and competent people are running things there are sometimes fairly robust exchanges between them. My exchange corrected his letter, but he and I remain on excellent terms. When I next meet him I will take up with him the question that the hon. Gentleman has asked because I realise how important it is that we open this new and important facility at the earliest possible moment.

Dame Jill Knight : Could my right hon. and learned Friend shortly inform his great friend the chairman of the west midlands authority that when dealing with the new basket of money he should bear in mind that to both the public and to Conservative Members it is totally

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unacceptable that women who have reason to suppose that they may have breast cancer should have to wait many months to be sure about it because of the shortage of money, or that a man who has kidney stones, when there is a lithotripter available, cannot have his condition alleviated because of lack of money? That point worries many of us.

Mr. Clarke : My hon. Friend has made strong representations recently to Sir James and to myself about proposed changes at the Birmingham women's hospital and she was able to ensure that no reduction of service was planned there. I am sure that Sir James is aware of the shortcomings of the service to which she has referred, and as we put more money into the West Midlands regional health authority, I trust that he and the region will ensure that the district health authorities are put in a position to tackle them.

Mr. Robin Cook : Perhaps I can help the Secretary of State in his difficulties with his Back Benchers. Why does he not tell them that their dissatisfaction with funding is evenly spread across the country? Did he see last week's survey by NAHA, the National Association of Health Authorities, which concluded that all health authorities face financial pressure and that nine out of 10 are having to make cash savings in this financial year? Does he recall describing last year's Autumn Statement, which left those health authorities in the red, as a "quite spectacular boost" in health spending? Is he really asking the House to believe that that spectacular boost was all frittered away by bad management? Or is the truth the fact that no health authority got the cash it needed to meet the real rate of inflation?

Mr. Clarke : That is quite absurd. The Health Service as a whole is spending more than £2 billion over and above what it was spending a year ago. That is an increase--taking a pessimistic view of inflation--of about 4 per cent. in real terms over and above inflation. The hon. Gentleman should do his homework and stop making wild assertions about the increase being below the level of inflation. The NAHA report is therefore against the background of the health authorities having more money to spend than they have ever had before, a quite spectacular rate of growth in their resources this year and every health authority throughout the country treating more patients this year than it treated last year and expanding its services. Only the hon. Gentleman thinks that there are no shortcomings in management revealed by the fact that they still get themselves into short-term crises towards the end of the year when they have had such a huge influx of funds. It is essential that we tackle those management weaknesses, because then we can get even more out of the enormous increases in funding that the Government are putting into the service.

Working for Patients"

3. Mr. David Porter : To ask the Secretary of State for Health what are the implications of the proposals in the White Paper "Working for Patients" for education and training.

The Minister for Health (Mrs. Virginial Bottomley) : The Government are committed to maintaining the quantity and quality of education and training by and for the National Health Service. Our proposals in respect of

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medical and dental education were set out in "Self-Governing Hospitals : An Initial Guide" in June. Our proposals for the education and training of key non-medical staff groups are set out in working paper 10 published last month.

Mr. Porter : Can my hon. Friend confirm that under these proposals NHS hospital trusts will play a full and proper part in education in the Health Service and that regional health authorities which, after all, have a natural and proper role, will also play a part in continuing education in the NHS?

Mrs. Bottomley : I can strongly confirm the points made by my hon. Friend. The NHS trusts not only will play their full part in promoting education, but they will want to do so ; they will want to be seen as centres of excellence committed to the NHS, of which they are a full part. The role of the regions has been further clarified in the recent working paper to which I referred, and not only in securing but in funding education and training, not only in assisting in medical education but in the training of the important non-medical groups which play an important part in the Health Service.

Mr. Kennedy : Does the Minister agree that, as well as the health professionals who are directly affected, the patients have a legitimate interest in what will happen to the education and training of those professionals if hospitals choose to opt out? That being the case, what proposals does the Minister have for the involvement, consultation and democratic rights of patients to have a say about a change in status of an NHS hospital?

Mrs. Bottomley : There is no question of any hospitals opting out of the NHS. The NHS trusts will be full members of the service. The whole purpose of the Government's proposals is to put patients first, and patients will benefit from having highly qualified, well-skilled staff looking after them in the NHS.

Mr. Paice : I welcome my hon. Friend to her first Question Time as Minister for Health. Is she aware that the proposals and new regulations for the training of hospital doctors have put in jeopardy the future of Newmarket general hospital, which services a large part of my constituency? Will she give an undertaking that if the proposals to downgrade that hospital, because of the new regulations, come to her or to her right hon. and learned Friend, they will be carefully examined bearing in mind that such downgrading would be to the serious detriment of all the patients in my constituency?

Mrs. Bottomley : The Government obviously take the training of doctors extremely seriously as they are fundamental to the future of our Health Service. There are now 14,000 more doctors than there were in 1979 and they are all well qualified and well skilled to meet health needs. I should be more than happy to meet my hon. Friend to discuss the hospital in his constituency in more detail and to review that matter carefully.


4. Mr. Morgan : To ask the Secretary of State for Health when he expects the number of perfusionists employed by the National Health Service to reach its target.

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The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : There is no national target for the number of perfusionists, who are staff who work the heart and lung machinery in cardiac surgery, to be employed in the National Health Service. It is for health authorities to arrange appropriate staffing levels in the light of local needs.

Mr. Morgan : Does the Minister agree that that is an unsatisfactory reply? He must know that it has been estimated that the NHS needs 200 perfusionists, but at present has only 90. Will he also accept from me that perfusionists not only operate the heart and lung machines in cardiac surgery but are vital in the treatment of lymph cancer? Until the Government recognise the new technique of limb perfusion for the treatment of lymph cancer and recompense those few excellent hospitals that seek to treat lymph cancer by limb perfusion for the high cost of that treatment, we will never reach a satisfactory solution to the present tug of war between the cardiac surgery departments and lymph cancer departments of every hospital that can offer limb perfusion? People are virtually begging for that treatment, which is vital.

Mr. Freeman : We are well on target to meet the 1990 aim of some 15,000 bypass graft operations for cardiac patients. With effect from 1 September we have introduced into the NHS a new flexible pay-grading structure for technicians. They have greatly welcomed that structure and it will help us to ensure that the 1990 target is met.

Mr. Sims : Does my hon. Friend agree that perfusionists play a key role in operations ranging from heart bypasses right through to complete organ transplants? Is he aware that 22 perfusionists left the NHS within the past 12 months and that perfusionists are not specified in the grading letter to which my hon. Friend referred? They feel unrecognised and inadequately rewarded. Will he consider their case seriously to see whether he can do something about their numbers because that is vital?

Mr. Freeman : I agree with my hon. Friend that perfusionists perform a vital task in cardiac surgery and elsewhere in our hospitals. I draw to his attention the fact that they have welcomed the new flexible pay-grading structure. I shall, however, certainly reflect on what my hon. Friend has said and I shall have a close look at the letter that we issued to the Health Service.

Mr. Ron Brown : I do not believe that any right hon. or hon. Member would disagree that the argument about perfusionists is important, but surely it is more important at this time that we resolve the ambulance drivers' dispute, which has been imposed on the people--

Mr. Speaker : Order. That was a good try, but I am afraid it is miles wide of the question.

Capital Expenditure Plans

6. Mr. Thurnham : To ask the Secretary of State for Health whether he will make it his policy to remind chairmen of regional health authorities of previous ministerial assurances concerning capital expenditure plans.

Mr. Freeman : It is the responsibility of regional health authorities in conjunction with district health authorities to draw up plans for capital expenditure on hospital and

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community health services. Ministerial assurances that capital projects will go ahead are given in conjunction with regional health authorities and will be respected.

Mr. Thurnham : Will my hon. Friend remind the chairman of the North Western regional health authority that Ministers have made pledges on at least four occasions since 1983 that Bolton new hospital would start this year? We are still waiting despite the fact that more than 100 schemes have been commissioned in the north-west since 1979. Will my hon. Friend also ensure that no new formulas are used that would adversely affect the north- west because of a change in the way in which the standard mortality ratio is used?

Mr. Freeman : Perhaps I can re-emphasise to my hon. Friend and to my other colleagues from the north-west and other parts of the country where capital projects have been discussed--and I use my words advisedly--that where ministerial assurances have been given that capital projects will go ahead, those promises will be honoured.

Mr. Rooker : Does the Minister think that the present capital programme will overcome the difficulties facing patients in the west midlands who go to an optician for an eye test, discover that their sight is defective, and then require a referral to an eye hospital? Those patients have to visit their doctors, who then contact the Birmingham and Midland eye hospital, which is giving appointments 30 months hence. Is that not part and parcel of the problems that Sir James Ackers raised with the Secretary of State and was publicly humiliated for his endeavours?

Mr. Freeman : We need no lessons from the Labour party about capital expenditure plans. This Administration has increased capital expenditure to a total of £1.2 billion this year.

Self-governing Hospitals

8. Mr. Gale : To ask the Secretary of State for Health what are the implications for patient care of the proposals to allow hospitals to become self-governing National Health Service trusts.

Mr. Kenneth Clarke : Self-governing NHS hospital trusts will remain firmly within the NHS, but they will have far more freedom to take their own decisions on the matters that affect them most without detailed supervision from my Department and the health authorities. This will give a better quality service and encourage other hospitals to raise the quality of their services.

Mr. Gale : Can my right hon. and learned Friend tell us what further steps his Department intends to take to rebut the black propaganda being peddled by the Opposition and ram home to the public the fact that the Health Service reforms, while they may not be welcomed by every leader of every Health Service union, are designed to improve patient care, which is what the Health Service is there for?

Mr. Clarke : I am grateful to my hon. Friend and I will take every opportunity to do that. In fact, I am today launching a small newspaper advertising campaign to bring home to the public the improvements in the family doctor service that will result from the new general practitioner contract that the House has approved.

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Mr. Canavan : Is the Secretary of State aware of the case of the Royal Scottish National hospital, which is home to about 800 mentally handicapped patients, where in a recent ballot of employees more than 95 per cent. rejected the management's proposal for opting out? How can the Government justify going ahead with such damaging proposals when they have been so resoundingly rejected by the overwhelming majority of staff involved in the front line of patient care? The only people who seem to support opting out are a few pen-pushing bureaucrats with no first-hand experience of patient care.

Mr. Clarke : Scotland has a fully devolved system of Government and that is a responsibility of my right hon. and learned Friend the Secretary of State for Scotland. [Interruption.] The

Under-Secretary of State for Scotland, my hon. Friend the Member for Stirling (Mr. Forsyth), is present and if it were in order I am sure that he would reply in connection with the hospital to which the hon. Gentleman referred.

I am familiar with other ballots that were organised in several English hospitals for which I am responsible. On the whole, at this stage, they are something of a waste of time. What usually happens is that the local council, the Labour party or the trade unions begin by giving a preposterous description of the proposals to the staff and then take a ballot in which the staff say they do not like that rather unpleasant description of the proposals. When we have proper applications for self governing status as hospital trusts, which I shall receive and welcome after the House has given assent to the necessary legislation next summer, there will be full public consultation about what is proposed for the hospital and the improvements in the services that the hospital can offer to the patients as a result of self government. At the moment, the political ballots are distracting attention from the real work of getting ahead with the preparations.

Mr. Pawsey : May I offer my right hon. and learned Friend my thanks for two things? [Hon. Members :-- "Too many."] There would be more--

Mr. Speaker : Make it just one.

Mr. Pawsey : First, I thank my right hon. and learned Friend for approving additional consultants for the Rugby health authority and for giving the green light for self-governing status for St. Cross hospital. Does he accept that both those things are warmly welcomed and will do much to improve the quality of health care in the Rugby area?

Mr. Clarke : I am grateful to my hon. Friend. I think that when people encounter what is happening to the Health Service nowadays they feel similar reactions to the new units opening across the country and to the expansion of patient services that is taking place. I contrast my hon. Friend's question with questions asked by Opposition Members who represent districts that have had huge increases of resources for their hospitals and huge increases in the number of patients treated yet who continue to raise obscure points which they claim show that the service is going into reverse.

Ms. Harman : If the right hon. and learned Gentleman believes that opting out is in the patients' interest and that patients should have a choice, why, as Secretary of State, has he not arranged that in each of the 79 areas patients

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should have a say through a ballot? Has he made arrangements for them to have a say in any of the 79 areas that are applying to opt out?

Mr. Clarke : I have repeatedly explained that we have no applications and we shall have no applications until the summer of next year. When the applications come in they will be worked up with details of what is proposed and the plans for the development of service that the sponsors propose. I have always said--indeed, the White Paper says--that at that stage there will be full public consultation. At the moment all that is being arranged is absurd political propaganda by the Labour party followed by local ballots asking selective and tendentious questions. There will be more serious public consultation when the applications come in.

NHS Reform

9. Mr. French : To ask the Secretary of State for Health whether any additional funds are being made available for the implementation of the Health Service reforms.

10. Mr. Andrew F. Bennett : To ask the Secretary of State for Health what plans he has to increase expenditure on accountants and statisticians in the National Health Service in preparation for his plans in the White Paper.

Mr. Freeman : We have made available the sum of £82 million for implementation work this year. This includes £12 million to strengthen the finance function in health authorities and hospitals. This funding will be over and above continued improvements in patient care.

Mr. French : I welcome that news, but will my hon. Friend undertake continuously to monitor the funding needed for implementing these reforms so that unavoidable and unforeseen extra expenditure can be taken into account without precipitating a crisis that will place the entire reform programme in jeopardy?

Mr. Freeman : I can give my hon. Friend that assurance. Spending for this year, at £82 million, although a significant sum, still amounts to only 0.4 per cent. of the total budget for the NHS in England, a budget which is growing this year by about 10 per cent.

Mr. Bennett : Can the Minister explain how it is possible for the Government to find extra funding to put forward their doctrinaire plans yet not possible for them to find extra funding to settle the ambulance dispute, to reduce the hours of junior hospital doctors or to ensure that we have enough nurses? Have not the Government got their priorities wrong ; do we not need the money to be spent on patients rather than on statisticians trying to prove that the Government are doing better than they are?

Mr. Freeman : No, Sir. The additional funds required to improve the management of the Health Service are designed to improve the control of expenditure of finite resources. Good financial management is necessary for better patient care.

Mr. Couchman : Can my hon. Friend reassure the House, as my right hon. and learned Friend reassured the BMA, that no patient will suffer for lack of medication, whatever the need or cost, as a result of the impact of his proposed indicative budgets?

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Mr. Freeman : I can give my hon. Friend that assurance. There are no proposals to cash-limit drug prescriptions by general practitioners.

Mr. Morley : Is not the Minister's proccupation with accountants more to do with the fact that the Government propose to run hospitals more like grocery stores than as a service to the community? Would it not be better if he addressed himself to the fact that hospitals are run on team work and that many groups of workers--laboratory technicians, physiotherapists and X-ray technicians--feel that they do not have a career structure or salary that reflects their commitment to the communities in which they work?

Mr. Freeman : The NHS in the United Kingdom consumes £26,000 million. Surely the hon. Gentleman will therefore accept that we need the best possible methods of controlling that vast expenditure.

Mr. Latham : Will it be clearly understood by the accountants and statisticians that through extra efficiency they will be expected to recover more than the £12 million that it will cost to recruit them?

Mr. Freeman : Absolutely.

NHS Reform

11. Mr. Macdonald : To ask the Secretary of State for Health if he will make a further statement on his review of the National Health Service.

Mr. Kenneth Clarke : Excellent progress is being made on the implementation of the proposals set out in the White Paper "Working for Patients". I am confident that our proposals will lead to an even better service for patients.

Mr. Macdonald : Will the Secretary of State take the opportunity of the Health Service review to review also the financial position of Project 2000 nurses who have to work under the fear that bursaries will be transferred to loans? Will he say something to allay the fears of those nurses?

Mr. Clarke : We have made wholly reasonable provision for the bursaries of Project 2000 nurses. I think that my proposals have been welcomed by the Royal College of Nursing. We have no intention of moving student nurses to the loans proposal and intend to continue to provide for them by bursaries. We are almost exclusively the sole employer of trained nurses and it makes no sense to introduce the loan scheme to student nurses in the National Health Service.

Mr. Yeo : Will my right hon. and learned Friend join me in condemning the British Medical Association and those of its members who are maliciously suggesting that they may run out of money when they have to prescribe drugs for their patients? The main objective of that campaign appears to be to frighten patients into opposing the Government's reforms.

Mr. Clarke : I very much hope that all GPs have now stopped doing that because I know that until recently some were saying that rather vigorously to their patients. The BMA has now accepted that there was never any question of refusing necessary treatment or drugs for patients. Obviously, it is quite wrong for individual patients to be

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frightened by people who still persist in that misunderstanding. No doubt in some cases it was merely misunderstanding.

Mrs. Margaret Ewing : Contrary to the Secretary of State's earlier statement, may I assure him that, unfortunately, we in Scotland do not have a devolved system of government? Is he aware that the Scottish Office, which has responsibility for the provision and administration of the Health Service in Scotland, has advised that there will be no separate legislation on the reforms? Who will take the decisions about the Health Service in Scotland? Will it be the Secretary of State for Health or the Scottish Office?

Mr. Clarke : If I might give the perspective of an English Minister, I can assure the hon. Lady that Scotland has a fully devolved Health Service. I have absolutely no responsibilities for Scotland and I take no decisions about the Scottish Health Service at any time. Those decisions are in the hands of my right hon. and learned Friend the Secretary of State for Scotland. He and I both need changes in the legislative framework before we can implement the reforms that have been put forward in the White Paper. The way in which the reforms are carried out in Scotland will be wholly the responsibility of my right hon. and learned Friend the Secretary of State for Scotland.

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