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House of Commons

Tuesday 12 December 1989

The House met at half-past Two o'clock


[Mr. Speaker-- in the Chair ]


Associated British Ports

(No. 2) Bill--

Order for Third reading read.

To be read the Third time on Thursday 14 December.

Oral Answers to Questions


Ambulance Dispute

1. Mr. Allen McKay : To ask the Secretary of State for Health if he will meet representatives of ambulance staff to discuss pay and conditions.

7. Mr. Adley : To ask the Secretary of State for Health if he will make a statement on the future of the National Health Service ambulance service.

16. Mr. Yeo : To ask the Secretary of State for Health what recent representations he has received regarding ambulance men's pay.

The Secretary of State for Health (Mr. Kenneth Clarke) : The pay and conditions of ambulance staff are the responsibility of the NHS management executive and I have no intention of meeting staff representatives myself to discuss this with them.

As for the future of the ambulance service, health authorities will remain responsible for operational arrangements.

Mr. McKay : Will the Secretary of State give his blessing to the talks that are likely to take place on Thursday? Will he assure the House that neither he nor any Government Department will interfere with those talks in any way, and that any increase will not have to be met from the existing budget but will be Government-funded? Failing that, should we not take the matter to arbitration and stop pussyfooting about?

Mr. Clarke : I followed with interest the announcement of a fresh meeting on Thursday, which I heard of when I left the Chamber last night. The management made its final offer to the trade unions in the Whitley council and the other negotiating body last week. The management made it clear this morning that its last offer is final. Nevertheless, it has agreed to talks, and I hope that Mr. Poole will have something new to say when he arrives at the talks on Thursday.

Mr. Adley : Will my right hon. and learned Friend confirm that approximately 10 per cent. of ambulance

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service work deals with emergencies and that approximately 90 per cent. is important but routine transportation? If that is the case, does it not make sense to respond to demands for parity with the other emergency services by restricting parity to those who provide an emergency service? Does he agree that, not to put too fine a point on it, NUPE's record on public service industrial disruption is second to none?

Mr. Clarke : The final offer made by management last week would provide £500 each year on top of the general offer for those with paramedical training. People involved in the service tell me that they are sure that the future lies in developing the accident and emergency part of the service and giving the necessary training, status and pay that follow to those who require it. Northumbria and Wiltshire have found that the same rules need not apply to the important but routine services that account for 90 per cent. of the work. NUPE's campaign reminds me of some of its other activities. The union has taken extreme action against patients from time to time in the past.

Mr. Yeo : Does my right hon. and learned Friend agree that Conservative and Opposition Members who are concerned about the NHS should oppose industrial action under any circumstances? Does he further agree that the best way in which people can have their claims reasonably considered by management is to withdraw any form of industrial action?

Mr. Clarke : I agree strongly with my hon. Friend. In comments on the dispute, it has sometimes been lightly assumed that people who fall outside the TUC guidelines and are not emergency cases can lose the service without suffering hardship. Many elderly and sick patients have great difficulty getting to hospital for the treatment that they require, because of the industrial action that has been targeted at them. That is no way to solve problems of pay and conditions in the NHS. For that reason, management was right to keep revising its offer until it put forward the final offer which, I am glad to say, is still being considered by one of the trade unions involved.

Mr. Corbyn : Will the Secretary of State take this opportunity to pay tribute to the ambulance staff in London who have maintained a 999 service without pay for the past two months, while the Army and police simply could not cope? Does he think that the best way of dealing with the problems of the ambulance service in London is to pay and equip the staff properly and stop abusing them and trying to break the union and the dispute as he has done?

Mr. Clarke : I gladly pay tribute to the work of the ambulance service in London and elsewhere when it is working normally, as it was until the dispute started. Obviously, we are grateful to it for the accident, emergency and other services that we are accustomed to it providing. But the idea that it continues to offer those services in London is a myth that has been completely exploded by events. We should also pay tribute to the Army, the police and the members of St. John Ambulance and the Red Cross. The people of London must be grateful to them for the provision of the accident and emergency services which the trade unions sought to deny them.

Mr. Shersby : Does my right hon. and learned Friend agree that there is already a significant pay differential

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between ambulance staff with paramedical skills and those without? Does he further agree that that fact has not come out during the dispute?

Mr. Clarke : There is, and the offer by management concentrates on recognising those skills yet further. That has not been brought out ; nor have many other facts. The figure of 6.5 per cent. is no longer used by anybody, but until recently it was being trailed about as the offer made to ambulance men in London. The present 18-month offer is worth at least 9 per cent. to everybody, but for those people in London who acquire the paramedical skills that we want more people to have, it is worth more than 16 per cent. That is why I trust that on Thursday the unions will tell management that they accept the offer.

Mr. Robin Cook : Is the Secretary of State aware that in the week before Christmas the London ambulance service can receive 200 calls an hour? How can the Government hope to respond to those calls with only 100 Army and police vehicles? Does the Secretary of State realise that Thursday's talks are the last chance to make sure that those calls are answered, and that he cannot leave it all to Roger Poole to make a success of the talks?

Has the Secretary of State yet answered the letter from the hon. Member for Rossendale and Darwen (Mr. Trippier), a Minister of this Government, who has written from the safety of his constituency to say that he can see the logic of the ambulance staff claim? If the Secretary of State cannot even convince the man who was once his Parliamentary Private Secretary, is it not time that he stopped pretending that everybody but himself is wrong about the dispute?

Mr. Clarke : I would take the hon. Gentleman's concern about the accident and emergency service in London more seriously if he would condemn the actions of those who have withdrawn it and made it necessary for the police, Army and voluntary bodies to provide that necessary service. I am astonished that Labour Members are prepared to maintain the fiction--that the service is being offered by the unions--which union leaders have largely abandoned.

My hon. Friend the Member for Rossendale and Darwen (Mr. Trippier) may not yet have received a reply from me. If the hon. Gentleman is trying to purport that my hon. Friend supports the ambulance men's industrial action, I do not believe him. The information on which he relies sounds like the same sort of partial quotation that has come from too many people in the trade union and Labour movement during this dispute.

NHS Reform

2. Mr. David Evans : To ask the Secretary of State for Health what is the latest figure he has for the number of hospitals, health districts and specialist units which have expressed an interest in becoming a self- governing National Health Service hospital trust.

Mr. Kenneth Clarke : One hundred and eighty-eight units have expressed interest in NHS trust status, including a number with more than one hospital. Seventy-nine of those units intend to proceed with preparing applications for the first wave, of trusts, which we would expect to be established in April 1991. However, applications will not be invited until Parliament has approved the necessary legislation.

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Mr. Evans : Does my right hon. and learned Friend agree that the Opposition's scaremongering, directed almost entirely at senior citizens, has proved to be complete nonsense and that hospital trusts will be publicly owned and paid for by the taxpayer? Will he confirm that the campaign of preprinted cards which Labour Members told us would arrive at the Department in their millions has been a complete shambles, with only about 50,000 arriving? Does that not show that Conservatives are the caring party and Labour the scaring party?

Mr. Clarke : The NHS trusts will be NHS hospitals providing free treatment paid for from taxation. Local people who run them will strive to improve the service, particularly to elderly people, because theirs is the fastest-growing area of demand to which an ever-growing amount of resources will be distributed. I agree with my hon. Friend that the cards were a complete fiasco. Back in August I read accounts of the hon. Member for Livingston (Mr. Cook) promising me hundreds of thousands of them. In the end, even with the complete membership of the Labour party undoubtedly filling in and buying the postage stamps for as many as possible, they could produce only 50, 000.

Mr. Kennedy : The Secretary of State is fond of saying that self- governing trusts will enhance patient choice. He will agree that for that to make any sense, a proper information system must be available. There have been reports that some of those considering self-governing trust status have submitted figures to the Department of Health suggesting that some hospitals will require as much as £3 million to upgrade computer systems. What estimate has the Department made of the proper systems technology that will be required for the aims to which it aspires in the proposals to be reached?

Mr. Clarke : The entire National Health Service requires investment in information technology. Quite apart from the White Paper, it will be necessary for this giant organisation to invest in catching up on modern methods of collecting management information and then using it. It is not necessary for our reforms for there to be vast investment in computers and software ahead of the 1991

implementation. The development of computers and software should proceed at a sensible pace with systems being worked up and proved in practice before they are widely adopted. As we develop the idea of NHS trusts, we shall explain to those interested that they should not be misled into believing that millions of pounds worth of information technology are a prerequisite of a more sensible method of matching resources to patients in the service.

Mr. Flannery : Why does not the Secretary of State admit that it is useless to massage the facts and figures about hospitals showing an interest, as he calls it? I wrote to the Secretary of State asking for the names of the people in Sheffield hospitals who had shown an interest so that I could provide them to all the people of Sheffield. The Under- Secretary of State replied that that information was private. Eventually, we met representatives of Sheffield health authority, which admitted that a group of working parties composed only of consultants had asked for it

Mr. Speaker : Briefly, please.

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Mr. Flannery : There is no democracy in that. It is a travesty of the truth. Why does not the Mininister come clean?

Mr. Clarke : If and when we receive a formal application for self- governing status from Sheffield or anywhere else, it will be worked up by those sponsoring it and subjected to public consultation next summer. There is no point in the hon. Gentleman trying to get partial information at this stage about expressions of interest which he no doubt wishes to see to confuse still further the political debate that he is trying to set off in Sheffield. The hon. Gentleman should wait until we have proper applications that explain what the proposal is really about. That will make it more difficult for the hon. Gentleman and his friends to go on about opting out of the National Health Service and other such nonsense.

Patient Services

3. Mr. David Nicholson : To ask the Secretary of State for Health whether there has been any experience within the National Health Service of using contracts for patient services.

18. Mr. Amos : To ask the Secretary of State for Health if he will make a statement on the use of contracts for patient services within the National Health Service.

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : We believe that about 60 per cent. of health authorities have used contracts to obtain patient services from the public and private sectors. As part of the development work to prepare for the implementation of "Working For Patients", the Department is currently supporting projects working on various aspects of contracts.

Mr. Nicholson : My hon. Friend will recall that yesterday's debate and my contribution to it emphasised the importance of raising quality and standards in the National Health Service as it moves forward. Will he confirm that contracts placed by district health authorities will have to take account of service standards and quality of care as well as cost? Does he agree that they will enhance the power of general practitioners, as they will be consulted and the new system will have to reflect their referral patterns?

Mr. Freeman : I very much agree with my hon. Friend--

[Interruption.] It is no great surprise. A great advantage of contracts is that the health authorities, which will be responsible for drawing them up, will be able to specify quality targets for the supply of not only hospital services but community health services.

Mr. Amos : Will my hon. Friend confirm that, under the proposals to improve the Health Service, district health authorities such as those in Northumberland would be obliged to maintain a reserve of resources to meet the demands of special cases? Will he confirm that that will satisfy the criteria relating to GPs' freedom of referral and patient choice?

Mr. Freeman : I can confirm that. We expect health authorities to begin consulting GPs about the existing referral pattern of their patients now, so that the authorities can draw up contracts reflecting that pattern. Given that referrals may take place outside the contract

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pattern, a contingency fund will be provided in all health authorities--including those in my hon. Friend's constituency --to cover such non-contractual referrals.

Dr. Kim Howells : How are local health authorities supposed to place contracts with anyone when they are in a position like that of the authority in my constituency? It has already spent £1.5 million over its budget, and is so desperately short of resources that it has no beds for victims of the current flu epidemic.

Mr. Freeman : My right hon. and learned Friend the Secretary of State recently announced an increase of 8.4 per cent. in cash terms for the hospital and community health services next year. That is a substantial increase in the resources available to district health authorities. After April 1991, health authorities will have the job of placing contracts to acquire health services, and they will have the resources to do that.

Mr. Nicholas Brown : Given his previous answer, will the Minister join me, and a consultant at the Freeman hospital in my constituency, in condemning as wild and bizarre the decision to spend about £200, 000 transferring heart patients from that centre of excellence in Newcastle to Wythenshawe in Manchester? What a waste of money. Should not the money be invested in the region?

Mr. Freeman : As I am sure the hon. Gentleman knows, that is a supra -regional service. People who require complicated heart operations should not necessarily seek service within their own districts ; such complicated and expensive treatment should be provided as quickly as possible wherever it can best be provided.


5. Mr. French : To ask the Secretary of State for Health how many dentists are employed by the National Health Service now and in 1979.

Mr. Freeman : There were 15,300 dentists in the National Health Service in England in 1979, and just over 18,000 last year.

Mr. French : The whole House will welcome the excellent news about additional resources for dentistry. Will my hon. Friend confirm that that means that the teeth of the nation--particularly those of the nation's children--are receiving more attention and are consequently in better condition, and does he agree that that is a good reason for smiles all round?

Mr. Freeman : I am grateful to my hon. Friend, and I can confirm that, over the past 10 years, the teeth of the nation have been in far better shape. There has been a dramatic reduction in decay caused by dental caries in children under the age of 16--a fall of about 40 per cent. between 1973 and 1983--and a reduction in the number of adults with false teeth from about 30 per cent. in 1978 to about 20 per cent. in 1988.

Mr. Ron Brown : Does the Minister accept that people are not smiling so much in Scotland? Although it is not his responsibility, he will understand that Scots are angry about the closure of Edinburgh dental school. Will he have a word with his Scottish colleagues, and advise them to keep the school on? We need it : it is important to the health of Scotland's people.

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Mr. Freeman : The hon. Gentleman should take a broader national view. The number of dentists that Britain will need over the next two decades will increase, but at present we are training too many.

Miss Emma Nicholson : As one who spent the morning at the dentist, I am not sure that I welcome extra money being spent on dentistry. Does my hon. Friend agree that the number of dentistry courses has increased dramatically over 10 years,--from 27 million to 32 million--which is a welcome sign that the expense of dentistry is clearly not putting people off having their teeth repaired?

Mr. Freeman : My hon. Friend is right. There are more courses, and people are going to the dentist more often. The use of fluoride toothpaste, particularly by children, has made a big difference to the health of their teeth.

Community Care

6. Mr. Cohen : To ask the Secretary of State for Health what representations he has received on the White Paper on community care ; and if he will summarise the views expressed.

11. Mr. Alfred Morris : To ask the Secretary of State for Health what representations he has received on the community care White Paper.

The Minister for Health (Mrs. Virginia Bottomley) : We have received several representations following publication of our White Paper "Caring for People : Community Care in the Next Decade and Beyond." Most have expressed a general welcome for our proposals.

Mr. Cohen : Have there not been many protests about the proposal to privatise care for the elderly? Are the Government not about to treat home helps in the same way as National Health Service cleaners, by undercutting the low-paid and penny-pinching in the service that they provide? Why is it that the care of the elderly and the disadvantaged is acceptable to the Government only if it makes a profit?

Mrs. Bottomley : Unlike Opposition Members, the Government have no obsession about the ownership of services to help the elderly and the frail. We are establishing a framework of care for the next decade and beyond. Individuals want their needs to be properly assessed and choice of provision. Wherever possible, they want to stay in their own homes. We want resources to be used effectively and properly, high standards to be maintained and choice and dignity provided to those who need care.

Mr. Alfred Morris : Will the Minister clarify the Government's intentions regarding section 3 of the Disabled Persons (Services, Consultation and Representation) Act 1986, which was so ably promoted by my hon. Friend the Member for Monklands, West (Mr. Clarke)? Also, if in the words of the White Paper,

"promoting choice and independence underlies all the Government's proposals",

will the Minister accept amendments to the National Health Service and Community Care Bill to allow local authorities to pay disabled people to employ the personal assistants they so often need to preserve their

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independence? If the Bill becomes law, just how much are the Government prepared to spend on community care during its first year of implementation?

Mrs. Bottomley : The existing provision for disabled people will be unchanged by the introduction of our proposals for care in the communiy. What is important is that all people will have their needs assessed before care is provided.

As for the hon. Gentleman's second point, the key aim is to provide effective care and to make plans in collaboration with health authorities. The local authorities have been given the responsibility to provide care in the community. They will be required to produce and publish their plans. But it is important that they should work closely with health authorities to ensure that disabled people, whom the right hon. Gentleman has championed so greatly over the years, receive the services that he and I wish them to have.

Mr. Nicholas Winterton : Does my hon. Friend accept that it is a crying shame that community care proposals have been tagged on to a Bill that relates to the NHS, when community care relates mainly to local government? Will my hon. Friend, and my right hon. and learned Friend, consider ring fencing community care expenditure so that it is not lost within the general expenditure allocated to local government?

Mrs. Bottomley : I resent my hon. Friend's comment that these matters are being "tagged on" to the end of the National Health Service and Community Care Bill. In my view, they are extremely important proposals. The Bill provides an ideal opportunity to establish our plans for those who need health care alongside the plans for those who need social care--a group that my hon. Friend, too, has championed greatly over the years.

As for my hon. Friend's question about a specific grant, the key point is that we want to establish local accountability and flexibility. We want to promote diversity according to local needs and opportunities. If my hon. Friend is concerned that local authorities may not arise to the opportunity and the challenge, I point out to him and to others that this is a moment for which they have long waited. Local authorities will be entrusted with these responsibilities. They will be required to produce and publish their plans. We intend to ensure that they deliver everything that my hon. Friend and I wish them to deliver.

Sir Michael McNair-Wilson : Does my hon. Friend agree--

Hon. Members : Oh!

Mr. Speaker : Order. The hon. Members who have just come in should realise that it is bad form to walk in front of the hon. Member for Newbury when he is asking a question.

Mr. Skinner : Send them to Sardinia.

Mr. Speaker : Order. Settle down please.

Sir Michael McNair-Wilson : Is my hon. Friend aware that voluntary bodies such as the Children's Society are disappointed that the provisions of the NHS and Community Care Bill do not consider the needs of carers and users of the services, and that there is no scope for the incorporation of review and complaints procedures in the current draft of the Bill? Does my hon. Friend intend to

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add those to the Bill at a later date, or will she bring forward a code of good practice that will be published after the Bill becomes law?

Mrs. Bottomley : I urge my hon. Friend to look at the White Paper again, because explicit mention is made of the needs of carers, and the important part that they play. We are working closely with voluntary organisations and local authority associations so that when we bring forward a code of practice they will give the recognition to carers that he and I want them to be given.

Mr. Tom Clarke : Will the Minister take a second opportunity to reply to my right hon. Friend the Member for Manchester, Wythenshawe (Mr. Morris), who asked a specific question about the Disabled Persons (Services, Consultation and Representation) Act 1986? How many people have made representations supporting the full implementation of the Act, and how many of them supported sections 1, 2 and 3 which give rights to consumers and carers? Or do the Government take the view that community care is everybody else's responsibility--the independent sector, voluntary organisations and carers--but not theirs?

Mrs. Bottomley : The Bill offers a major step forward for carers and consumers of services. We have made it very clear that an assessment will be required before care can be provided. We are turning our backs on the old system, in which the provision of resources was often irrelevant to the needs of the individual. Frequently, under the system it was more likely that residential care was provided, rather than the domiciliary care that is often more appropriate, and more in line with the dignity of the individual. Our measures move on from the disabled persons Act, but we shall continue to review it. The Bill will be a major step forward, and will provide an opportunity to hear the views of consumers and carers.

Mr. Thurnham : Does my hon. Friend agree that we do not need ring fences in community care, but we need the local authorities to concentrate on their responsibilities, and to bring down the ring fences that stop voluntary bodies, such as Crossroads, playing a full role?

Mrs. Bottomley : One of the difficulties with ring fences is that they tend to lock services in a historical framework. We want collaboration and innovation, with various agencies working together to ensure that a better service is provided for the frail and the disabled.

Rev. Martin Smyth : Will the Minister kindly tell us what plans exist to increase the number of occupational therapists in the community? There is already a shortage in hospitals, and if more people are to go into community care, will more also be required in the community?

Mrs. Bottomley : I can say that there has been a substantial increase in the number of professionals involved in the provision of care in the community in recent years. I anticipate that we shall also need an increase in the number of occupational therapists.

Yorkshire and Humberside Health Authority

8. Mr. Cran : To ask the Secretary of State for Health what is his Department's cash allocation for Yorkshire and Humberside health authority for 1989-90.

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Mr. Freeman : The Yorkshire regional health authority received an initial revenue cash allocation of £951.2 million in 1989-90. There has been a real terms increase in expenditure of about 31 per cent. for Yorkshire over the past 10 years.

Mr. Cran : Does my hon. Friend agree that that is record expenditure, and that it represents spending of £280 per man, woman and child in Yorkshire and Humberside? Does he also agree that, based on last year's experience, that will probably provide treatment for more than 4,500,000 patients in that region alone? Does my hon. Friend agree that patients are a more accurate guide to the success of the NHS than the politically motivated comments of Opposition Members?

Mr. Freeman : Expenditure for the NHS as a whole is about twice the figure that my hon. Friend quoted. He has cited only the hospital service. My right hon. and learned Friend the Secretary of State for Health expects to make a statement shortly on regional health authority allocations, which will show continued advance in real terms for the NHS in the regions.

Mr. Lofthouse : Is the Minister aware that seven district health authorities in the Yorkshire region confront a deficit which will have a serious effect on patient care?

Mr. Freeman : I am aware of the financial problems of certain districts in Yorkshire. It is the responsibility of health authorities to manage their affairs within the resources allocated to them. Under both Labour and Conservative Governments health authorities have been cash limited. It is their responsibility to manage. Our reforms, which bring the allocation of funds on a weighted capitation basis to districts, will provide a fairer and more automatic system of fund allocation.


9. Mr. Win Griffiths : To ask the Secretary of State for health when he last met the representatives of the British Medical Association ; and what was discussed.

12. Sir Fergus Montgomery : To ask the Secretary of State for Health when he last met representatives of the British Medical Association ; and what was discussed.

Mr. Kenneth Clarke : I last met representatives of the British Medical Association on 18 October, when we had a friendly and constructive discussion about the implementation of our proposals in the White Paper "Working for Patients".

Mr. Griffiths : Is it not a shame that the right hon. and learned Gentleman will not face up to the truth--that his proposals, which are causing the BMA and virtually every other medical organisation anxiety, are just a smokescreen for underfunding the service? He says that he is spending much more, but that means nothing to patients who are sent home with life-threatening diseases. In my constituency, a patient with cancer of the oesophagus was sent home three times because an intensive care bed was not available for him. Will the right hon. and learned Gentleman provide more money for medical staff rather than for more administrators, which is what his scheme envisages?

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Mr. Clarke : We are providing money for the NHS on an unprecedented scale. Neither the British Medical Association nor anyone else has put it to me recently that underfunding is the sole problem. We have just announced an increase for next year which is 5 per cent. ahead of inflation. That represents an increase in funding during the past two years of more than £5 billion.

My discussions with the BMA concentrate on ways in which we might spend that money more sensibly and carefully to get the best for patients, to cut waiting lists and to improve on facilities the lack of which, of course, are still encountered because of the way in which the NHS is run at the moment.

Sir Fergus Montgomery : Does my right hon. and learned Friend recall that, at a previous meeting with the BMA, he managed to get it to admit that it had misled the public about indicative drug budgets? In view of his great success at that meeting, will he arrange others in the hope that the BMA will withdraw other scare stories that it has put about?

Mr. Clarke : The claim that some people might not get the drugs they needed caused more alarm among patients than any other allegation made last summer. I share my hon. Friend's feelings about the fact that that allegation has been disposed of.

Meetings with the BMA are now much more friendly and constructive. Now that the House has given the National Health Service and Community Care Bill a Second Reading, I trust that everyone who shares our enthusiasm for the NHS will get down to sensible talks about how best to implement the reforms to get the best out of them.

Mr. Ieuan Wyn Jones : Does the Secretary of State agree that not one general practitioner practice in Wales which would qualify under his proposals has indicated any desire to have its own budget? Does he agree, therefore, that the central plank of his proposals are utterly irrelevant to Wales?

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