HC Deb 21 February 1985 vol 73 cc1219-29 4.36 pm
The Secretary of State for Social Services (Mr. Norman Fowler)

With permission, Mr. Speaker, I shall make a statement on the limited list of National Health Service drugs.

I told the House on 8 November that the Government intended to introduce a system under which a selected range of drugs would be available on the National Health Service in seven categories. These were: antacids; laxatives; analgesics for mild to moderate pain; cough and cold remedies; bitters and tonics; vitamins; and tranquillisers and sedatives. I published at that time a provisional list of medicines which might be selected within each category. This was the basis for consultation, which continued until the end of January. We made it clear from the outset that our intention was to produce a list from which doctors would still be able to meet all the clinical needs of their patients.

The chief medical officers of the health Departments wrote to all doctors individually to seek their views on the list. I am grateful to all the many doctors who responded and I hope they will recognise that their views have been taken into account. My chief medical officer also brought together a group of independent experts practising in the relevant medical specialities, including three general practitioners and a pharmacist, to assist him. That group has now unanimously recommended a list of medicines that it believes will meet all clinical needs. I have accepted its advice in full and I am most grateful for its help in this important task.

This extended list of medicines will contain some 100 different medicines, compared with 30 on the provisional list. Most of the medicines will be generic, or unbranded, products; but a number of proprietary medicines will be retained where the group concluded that they were necessary and where no generic preparation currently exists. I should emphasise that the quality of all the selected drugs is assured. They all conform to the very high standards we require of all medicines under the Medicines Act 1971.

For the purposes of the regulations that my right hon. Friend the Secretary of State for Scotland and I will introduce, it is necessary to list all the products that will no longer be prescribable on the National Health Service. The regulations will also cover those products which the advisory committee on borderline substances has advised are not medicines and should not be prescribed by general practicioners. I am today publishing both the selected list of drugs and those no longer to be prescribable. Copies are available in the Vote Office.

I shall also today be giving the representatives of the medical and pharmaceutical professions the opportunity to comment on these regulations as they affect the terms of their contracts with the Health Service.

I shall mention three specific issues concerning the operation of the limited list that have been raised during the period of consultation. The first is the question of the arrangements for reviewing the list itself. This was raised by, among others, the Royal College of Physicians. We fully accept that it is essential for independent professional advice to be available after 1 April on the need for changes to the list. I do not believe that complex machinery is required but I shall be very ready to discuss with the professional bodies concerned how the arrangements that have been used to formulate the extended list should be developed for the future.

Secondly, questions have been raised about the implications of the new arrangements for dispensing doctors—that is, doctors, predominantly in rural areas, who themselves dispense drugs to their patients. For these doctors the regulations will in effect retain the status quo. Dispensing doctors will still be able to supply any medicine to those of their patients for whom they already dispense although they will have to issue private prescriptions for medicines that are no longer available on the National Health Service. Concern has also been expressed about the position of retail pharmacists who now hold stocks of drugs that will no longer be available on the National Health Service. I am quite prepared to examine any relevant evidence that pharmacists may present on their stockholding of drugs.

Thirdly, the question has been raised whether there should be some form of appeal mechanism for individual cases in which a doctor believes it is necessary to prescribe on the National Health Service a medicine that will no longer be available. Most concern was expressed by doctors who felt that there were serious omissions in the provisional list. My unanimous medical advice is that the selected list is now comprehensive and will make it unnecessary on clinical grounds for patients to use medicines not on the list. Nevertheless, let me say this: if, after examining the complete list and in the light of experience, the medical representative organisations still wish to propose that such a mechanism should be provided, my right hon. Friend and I will be ready to discuss it with them. I should make it clear, however, that any mechanism would need to be very carefully controlled to ensure that it could be used only in genuinely exceptional circumstances.

During the period of consultation a number of alternative proposals have been advanced. None of these offered the same prospect of achieving sensible savings in the Health Service drugs bill without either harming the interests of patients or threatening the fundamental and legitimate interests of the pharmaceutical industry. The selected list, which I am publishing today, is likely to produce savings in the drugs bill of some £75 million now, rising to a higher figure in due course. It is by making sensible savings of this kind that we are able to provide health authorities with the increased resources which I announced recently. I am therefore convinced that the approach that we have adopted remains the right one in principle. I also believe that the selected list, which I am publishing today, will demonstrate that in practice the Health Service will continue to provide all medicines required to meet the clinical needs of patients.

Mr. Michael Meacher (Oldham, West)

Is the Secretary of State aware that the fact that his final list is no less than three and a half times as long as his first attempt shows what a hash he made of his original statement? For three months he has unnecessarily caused enormous upset and anxiety because of his total failure to consult doctors and the other professions involved. Since the Government included only 31 drugs in the original list yet have always claimed that the list will meet all clinical needs, what guarantee can there be, since the Government got it so wildly wrong the first time, that even this much extended list is completely proof against further error or misjudgment?

Why, after three months, are the arrangements for reviewing the list not yet finally determined? Does it not show continuing divisions in the Government's thinking when the Secretary of State comes to the House today and says that most medicines in his limited list will be generic products yet the Minister of State said in the House only three weeks ago: There is no, and never was any, element of generic substitution in the limited list proposals".—[Official Report, 28 January 1985; Vol. 72, c. 59.] Is the Secretary of State aware that these proposals will still produce a two-tier system, which may well suit Tory interests since privatisation within general practice is more likely if some medicines are obtainable only on a full-cost basis, but will certainly deprive many poorer patients of drugs that they need but cannot afford? Is he also aware that operating a so-called white list of 108 items and a black list of some 1,500 items will produce a bureaucratic nightmare, which will also substantially whittle down any potential net savings?

I have two more technical questions. Why are these provisions being introduced by way of amendments to the terms of service of doctors? On the hospital side, what precise arrangements are being made to override, which is in effect what he is doing, local drug and therapeutic communities where hospital formularies do not coincide with his final list? More fundamentally, his havering on both the review machinery and the appeal mechanism which is needed is not good enough. Will he give an assurance that both will be firmly in place when the scheme starts on 1 April?

On the financial side, since the savings on this list will now fall well short of the £100 million that he promised originally, will he give a commitment, which will be needed if he is to make up the savings total that he spoke of, that the rate of return to the drug manufacturers under the pharmaceutical price regulation scheme will be reduced from the current excessive 21 per cent. at least to the 16.9 per cent. limit that is now accepted as the maximum for risk contractors under Government contract?

If this limited list is so good for Health Service patients, why is the Secretary of State not extending it to private patients?

Mr. Fowler

I think that is one of the silliest responses—

Mr. John Evans (St. Helens, North)

That is not original.

Mr. Fowler

Regrettably, it is not original. That is just the point I was about to make. I have seldom heard such a silly response to a statement.

A few weeks ago the hon. Gentleman was pressing me to consult. I have now consulted and I have brought forward—

Mr. Meacher

Why did the Secretary of State not consult before his earlier list was presented?

Mr. Fowler

The hon. Gentleman knows perfectly well that when I announced the proposal, I did so on the Floor of the House of Commons. That, I would have thought, he would support.

Mr. Meacher

No.

Mr. Fowler

The hon. Gentleman had better make up his mind what the devil he does want, because everyone else is confused.

If I may try to explain to the hon. Gentleman what is happening, we made it clear from the beginning that we would consult on this and that the list was provisional. We have benefited from the advice of about 2,000 general practitioners and also from the advice of the chief medical officer and an independent team. The result is that we have a list of over 100 different medicines compared with the list that we originally proposed. That seems a sensible outcome to the consultation.

To pick up the hon. Gentleman's second major point, it is the unanimous view of the independent committee that the selected list of drugs will meet all clinical requirements. It is for that reason that we set up the independent committee.

In regard to savings, we expect the final list to cut the drugs bill by about £75 million straight away and by more later. I think that the original rough figure was about £100 million. I think that we will come to that in the not too distant future. As for the pharmaceutical price regulation scheme and the negotiations on it, the hon. Gentleman must know—otherwise, he has not been listening to any of the debate on drugs — that those negotiations are taking place at this moment.

As for the hon. Gentleman's last major point on generic substitution, I do not believe in indiscriminate generic substitution. It would not be right to apply that to all categories of medicine. It would undermine the pharmaceutical industry and make research into worth-while and life-saving drugs difficult, if not impossible. I do not believe that is in the interests of the industry, the country, employment or all the things that the pharmaceutical industry has created.

We have consulted on this. We have brought forward an extended list which, I believe, meets all legitimate concerns. I have made it clear that I am prepared to consult further on some crucial issues. At the very least I think the hon. Gentleman's response is entirely churlish.

Several Hon. Members

rose—

Mr. Speaker

Order. I understand the concern of the House about this matter, but there is a very important debate on the Royal Air Force in front of us. I shall allow questions on this matter to continue until 5.5 pm, so there will have been a full half hour for the whole statement.

Mr. Michael Meadowcroft (Leeds, West)

Does the Secretary of State accept that his statement is a considerable improvement on what he said before and that, given that he means what he says about the possibility of an override facility, it should have a fair wind from members of my party? I am glad that the right hon. Gentleman has resolved the problem that he had with his Scottish colleagues over dispensing doctors. However, does he accept that the problem now is that most of the "me too" proprietary drugs, which are the most expensive varieties, are outside the seven categories that the right hon. Gentleman is now listing for us? What proposals does he have to consult on including them in future? Will the right hon. Gentleman confirm that the generics that are on the list, which are available only in proprietary form, are out of licence, so that other people can manufacture them? Otherwise, presumably they are still available only in proprietary form. Can the right hon. Gentleman tell us whether the policing—[HON. MEMBERS: "Too long."]—will be costly? Finally, can the right hon. Gentleman tell the House why, in altering the general practitioners' contract, he has not also looked at the pharmacists' contract, because, financially they will be hit seriously by the proposal?

Mr. Fowler

We are in the middle of negotiations with the pharmacists and, as I have already made clear, we shall make the draft regulations available to the medical profession. I am grateful for what the hon. Gentleman said at the beginning of his question because he has recognised—the hon. Member for Oldham, West (Mr. Meacher) singularly failed to do so—the considerable steps that have been taken to meet all legitimate concern on the matter. The review was the basic matter that the hon. Gentleman asked about. It was suggested by the Royal College of Physicians that there should be a review of the list. I am accepting that in principle. I should like to talk to the Royal College of Physicians and the other organisations about that, and I am willing to come to any reasonable arrangement with them. However, one or two of the things that I have announced mean that the BMA and organisations like it now have to be prepared to talk. In the light of what I have announced, it would be quite wrong if they were still to refuse to come round the discussion table.

Mr. Mark Carlisle (Warrington, South)

Does not my right hon. Friend's statement show that he has consulted and, indeed, taken account of what was said? Does it not show how irresponsible the BMA's attitude has been? Did my right hon. Friend hear the remarks attributed today to Dr. John Marks, the chairman of the BMA, and were they not another example of utter irresponsibility?

Mr. Fowler

I think that Dr. Marks has got it slightly wrong. I do not want to raise the temperature on this matter again, but frankly I think that he got it wrong on the list and he certainly got it wrong with regard to our aims and intentions to extend the list. I say to Dr. Marks and the BMA that we have made it clear by the action we have taken that we are prepared to listen, change the plans and meet all reasonable requests that have been put to us. I very much hope that the BMA will now understand that and come and talk sensibly about the whole thing.

Rev. Martin Smyth (Belfast, South)

I welcome the statement as it shows some change in pattern. On the other hand, while the Secretary of State said that six independent members advised the chief medical officer, were they like-minded, or were they completely independent in the sense that they had different opinions? Will the right hon. Gentleman specifically tell us whether the Secretary of State for Northern Ireland will issue an identical list and, if so, why he was not mentioned along with the Secretary of State for Scotland in today's statement?

Mr. Fowler

The Secretary of State for Scotland will make his own announcement following this one. There is no question about either the independence or expertise of the advisers. The advice that was given to me was unanimous, and has been accepted entirely and in full by me.

Mrs. Jill Knight (Birmingham, Edgbaston)

May I assure my right hon. Friend that he has the support of the overwhelming majority of his right hon. and hon. Friends for the step that he has taken, as we recognise that money in the Health Service must be spent wisely and without waste, if it is to serve the Health Service? Has my right hon. Friend considered, in the flexible approach that he is taking to the matter, the patient who has a psychological tie to one particular drug? Will that rather special case be considered and weighed up in the procedure that my right hon. Friend described?

Mr. Fowler

I am grateful to my hon. Friend for her support, and I think that she speaks for a great many people. With regard to an appeal mechanism for doctors to deal with the situation that my hon. Friend set out, let me repeat that it was the unanimous view of the committee that the selected list of drugs will meet all clinical requirements. Much of the concern was about possible gaps in the original list. Nevertheless, let me make it clear —this is in direct response to my hon. Friend—that if the profession wished to propose an appeal mechanism that would cover a case similar to the one that my hon. Friend raised, I should be ready to discuss that. It must be carefully controlled and concentrated on the exceptional case. Organisations such as the BMA will have to come to talk about that. I cannot do it by proxy.

Mr. Robert Hughes (Aberdeen, North)

Does not the Secretary of State accept that the fact that the new list, which I have not yet seen, is now three and a half time larger than his list, represents a resounding vote of no confidence in his initial judgment? Secondly, I should like to make a specific point about clinical assessment. Is it not the case that some elderly people taking more than one drug rely on colour in choosing the drug to take? Perhaps it is a comparatively minor problem in some areas, but it is extremely important. Will the right hon. Gentleman therefore operate the exceptions system for at least the first 12 months? Will he operate an appeal system to allow doctors greater flexibility during the trial period, with the appeal being made by the health authorities instead of the other way round, because individuals can suffer severely if the appeal procedure is too long?

Mr. Fowler

I cannot do that, but as I have just made clear to my hon. Friend the Member for Birmingham, Edgbaston (Mrs. Knight) I am prepared to talk to the profession on an appeal mechanism. However, I must underline the view that I have from the expert committee, which is that the selected list of drugs will meet all clinical needs. However, I am prepared to try and meet points such as the one that the hon. Gentleman is making, but in the way that I have set out rather than the way that he set out. He referred to consultation. The fact is that if I had come to the House and produced the same list, I would have been accused by the hon. Gentleman and the hon. Member for Oldham, West (Mr. Meacher) of not having had any meaningful consultation. I have gone through consultation. I think that we now have a good list. I hope that that will remove much of the controversy and some of the misrepresentation that have dogged the past few months.

Dr. Brian Mawhinney (Peterborough)

Does not the substantial extension of the list that my right hon. Friend has just announced fully vindicate his insistence, sometimes in the face of hostile and organised opposition, that he was willing to listen to the views of doctors and others? Does my right hon. Friend accept that his announced willingness to contemplate an appeals procedure will be greatly welcomed both on Conservative Benches and in the country, and further vindicates the Government's reasonable attitude on the issue?

Mr. Fowler

I am grateful to my hon. Friend. I think that the appeals procedure will be welcomed in the medical profession and generally by the public. With regard to consultation, it must be said that, although the BMA has not put detailed points to us, we have had the advice of just under 2,000 general practitioners who have written to us. Therefore, there is no question but that the basis of the advice that we have had has been extensive and sound.

Mr. Jack Ashley (Stoke-on-Trent, South)

Will the Secretary of State move forward from considering the appeals system to considering brand new drugs? What happens to the brand new drugs that are flooding the market? Who will decide which of those drugs is to be accepted on the NHS list? Will the Secretary of State assure us that the new machinery to evaluate those drugs will be open to public scrutiny so that we know that safety, efficacy and need are the overriding considerations? Cost should not be the overriding consideration. If it were, the right hon. Gentleman would be economising at the expense of the National Health patient.

Mr. Fowler

We are not, in any way, relaxing the licensing system. I entirely accept that any advice upon which we act must be independent and must be seen to be independent. I am certainly prepared to have talks about that type of mechanism. The review mechanism that I want would consider new drugs and whether there was a new suitable generic alternative to replace a branded drug. Obviously, this would occur within the seven categories that I have set out.

Sir Dudley Smith (Warwick and Leamington)

Is my right hon. Friend aware that, as one who has been connected for nearly 20 years with the pharmaceutical industry, I am deeply apprehensive that these new measures will inevitably lead to further restrictions on prescribing by doctors? Is my right hon. Friend aware that that cannot be in the interests of the pharmaceutical industry, of doctors and, above all, of patients?

Mr. Fowler

The Government support a prosperous pharmaceutical industry. My Department is the sponsoring Department. I understand that the industry does not want a change in those arrangements. Ninety-five per cent. of drugs on the NHS list that will not now be prescribed do not require a prescription in any event. When my hon. Friend has the opportunity to read the list, he will note that all kinds of drugs, which I think the public would find extraordinary, cannot now be prescribed. The list includes Barker's Liquid of Life, Dr. Williams Pink Pills, Mrs. Cullen's Powders and Rock Salmon Cough Mixture. I have no objection to people using Rock Salmon Cough Mixture, but I have the strongest objection to the taxpayer picking up the bill for it.

Mr. Gregor MacKenzie (Glasgow, Rutherglen)

If the Secretary of State looks at the first item under "Analgesics" he will see that doctors are now to be permitted to prescribe aspirin tablets. Will people be asked to pay £1.80 for a bottle of aspirin tablets?

Mr. Fowler

If the right hon. Gentleman looks at the list he will see that a much wider range of analgesics will be available. The advice of my medical experts on the independent committee is that that range of drugs will be adequate to meet all clinical needs.

Mr. David Crouch (Canterbury)

Does my right hon. Friend agree that our principal concern should be for the patient rather than about telling the doctor what he may or may not do? Would it not be wiser to leave the doctor with his freedom rather than restrain an innovative and successful industry? Would it not be better to use education rather than edict to achieve the economies that are sought by my right hon. Friend?

Mr. Fowler

My hon. Friend must recognise that I am trying to seek value for money throughout the whole of the NHS. That means that I am trying to ensure that money is directed towards patient care. I do not think that it would be defensible for me or the Government to leave any aspect of the NHS—the drugs bill or any other item—out of that scrutiny. That is what we have done. That is why I believe that this policy is right. I emphasise again for my hon. Friend's benefit that 95 per cent. of the drugs that will not now be prescribed do not require a prescription in any event. That is a fairly conclusive answer to my hon. Friend's fears.

Mr. Laurie Pavitt (Brent, South)

I remind the Secretary of State that he is the first Minister of any political persuasion since the inception of the Health Service to interfere with a doctor's clinical freedom. Is this not a precedent? When a professional politician can order a doctor as to the treatment he will give, it goes beyond pharmaceutical services. It is really a red light showing throughout the NHS. Does a doctor—not a rural doctor—prescribing privately to a patient on his list have to charge the patients a fee? Does the doctor have to remove the patient from his list? Does the right hon. Gentleman accept that clinical needs cover more than just the ingredients of a pill or medicine that is delivered? A range of aspects is covered. A doctor is the only person able to decide the best treatment for his patient. A doctor can take a million different approaches because of his knowledge of his patient.

Mr. Fowler

The hon. Gentleman will know that a doctor cannot charge a fee for a prescription. On the hon. Gentleman's first point about my being the first Minister to interfere with the freedom of prescription, I would put it another way: this Government are the first Government to tackle the problem of the drugs bill inside the NHS.

Mr. Pavitt

The right hon. Member for South Down (Mr. Powell) did.

Mr. Fowler

I thank the hon. Gentleman. That was another Conservative Government. This Government act when the Opposition have just wind and hot air.

Several Hon. Members

rose—

Mr. Speaker

Order. In view of the great interest in this statement, I shall allow questions to continue until 5.10 pm.

Mr. Robert McCrindle (Brentwood and Ongar)

On the issue of clinical freedom to which the hon. Member for Brent, South (Mr. Pavitt) referred, does my right hon. Friend agree that this same freedom is extended in no other country that has a publicly financed national health service? Why, therefore, is it considered that complete clinical freedom should prevail only in this country?

Mr. Fowler

My hon. Friend is right. There are restrictions of one kind or another in virtually every other country in western Europe. This is a sensible policy, which other Governments have accepted. I ask the House to accept that the vast majority of the drugs that will not be prescribable under the NHS do not require a prescription in any event. This means that people can buy those drugs over the counter and do not require a doctor's prescription.

Mrs. Renée Short (Wolverhampton, North-East)

Not long ago the Minister of State told me in answer to a parliamentary question that the estimated savings from the limited list will enable the Government to maintain the level of expenditure announced in the autumn statement. The Secretary of State has clearly retreated from that position. How will he know what savings have been made? Will the right hon. Gentleman explain to the House the mechanism for checking that amount?

Mr. Fowler

We have not retreated from that position. The result of the consultation is that our original estimate of up to £100 million, which was a rough estimate at that time, has been reduced to £75 million. We always recognised that the consultation would mean reduced savings. Our aim now is to look for additional ways of obtaining better value from the drugs bill. One of the encouraging aspects of this debate has been the fact that more attention than ever before has been given to this issue. I hope that we shall achieve further savings through better prescribing and more competition in the generic manufacturing of the drugs on the limited list.

Sir David Price (Eastleigh)

I ask my right hon. Friend, in his capacity as the sponsoring Minister of the pharmaceutical industry, what effect his new list will have on employment. My right hon. Friend will be aware that both sides of the House have received vigorous representations from the pharmaceutical industry telling us that his original list was destructive of jobs.

Mr. Fowler

It would be sensible for the pharmaceutical industry to look at the new extended list before rushing into any kind of estimate. I want to emphasise two points. The Government entirely support a prosperous pharmaceutical industry, and the industry recognises that. It also recognises that it does not want a change of sponsorship from the Department of which I am Secretary of State. The research into some of the most important drugs in the most crucial areas would be affected by a policy of generic substitution—it will not be affected by the policies that I propose.

Mr. Charles Kennedy (Ross, Cromarty and Skye)

Does the Secretary of State agree that the lack of initial consultation with the medical profession gave rise to the legitimate fears about the list being expressed by many people? Had he consulted initially with the medical profession on the basis of the Greenfield report, he could have presented the House not with indiscriminate generic substitution but with generic substitution involving medical consent, which would have led to greater savings than those that he has predicted this afternoon.

Mr. Fowler

The hon. Gentleman's last point is entirely wrong. If he believes it, he should do a little more homework on the subject. It is bizarre to suggest that we need more consultation and more talks about how we should try to reduce the drugs bill. Ever since I have been in my Department—three and a half years—and for years before that we have talked about this subject and debated it in the House. What is required are decisions, and what I am putting forward is the basis of a reasonable decision for this House to reach.

Mrs. Virginia Bottomley (Surrey, South-West)

Will my right hon. Friend comment on the recent advertising campaign by the pharmaceutical industry? Does he regard it as a shameful example of exploiting people's fears and putting self-interest before public interest?

Mr. Fowler

The Association of the British Pharmaceutical Industry—and in some ways it does not speak for all the excellent companies—has gone entirely over the top in its advertising campaign and has sought to raise fears unnecessarily. When the only solution to the problem that the association puts forward is that of taking away exemptions from old people, I find it extraordinary and hypocritical that it should mount an advertising campaign in which it claims to be defending NHS patients.

Mr. Harry Ewing (Falkirk, East)

Is the right hon. Gentleman aware that any Secretary of State with responsibility for the NHS who begins with a restricted list of 30 items and then returns to the House with 100 items has shown himself wholly unfit to have the care of the Health Service in his hands? Does the right hon. Gentleman admit that, although he is leaving 100 items on the list, he is taking 1,800 items off the list? Of those, the vast majority are prescribed for old-age pensioners. Is not the Secretary of State condemning old-age pensioners to having to buy their medicines across the counter?

I congratulate the 54 general practitioners in the constituency of the Under-Secretary of State for Scotland, the hon. Member for Argyll and Bute (Mr. MacKay), who inspired the Under-Secretary to fight a little harder than he usually fights to ensure that the position of the prescribing doctors would be preserved. Will the Secretary of State tell the House whether it is the Government's intention to buy back from the pharmacists the drugs that they hold in stock and that will now be removed from the list?

Mr. Fowler

I do not think that the hon. Gentleman has done any better than his hon. Friend the Member for Oldham, West (Mr. Meacher) who began the questions. We always said that we would consult, and that consultation has provided a list that is more extensive and which meets all the clinical needs of patients. That is what the consultation was about. I share the sentiments of the hon. Gentleman—I am glad to agree with him on one point—in his admiration for the views put by my hon. Friend the Under-Secretary of State for Scotland on dispensing doctors. They have been invaluable in helping the Government to come to a decision.

Rev. Martin Smyth

On a point of order, Mr. Speaker. I think that I may have had a response, from a sedentary position, to my question to the Secretary of State on whether the Secretary of State for Northern Ireland—

Mr. Speaker

Order. That is not a point of order for me. The hon. Gentleman is seeking to raise a question with the Secretary of State, which is not a matter for me. It is unfair on hon. Members who wish to contribute to the following debate to extend questions on the statement, which have already continued for much longer than I originally suggested.

Rev. Martin Smyth

How can Northern Ireland Members raise issues affecting the NHS when we have been told that they have been turned over to the Northern Ireland desk, especially as this is a national debate? Ministers from the Welsh and Scottish Offices were present on the Treasury Bench but Northern Ireland was not represented. I asked the Secretary of State a specific question, which I think he answered from a sedentary position—

Mr. Speaker

Order. I suggest that the hon. Gentleman should table a question on this matter or write to the Secretary of State.

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