ENGLISH AND SCOTTISH BORDER PROVISIONS (Hansard, 14 June 1999)

§ The Minister of State, Department of Health (Mr. John Denham)
I beg to move, That the clause be read a Second time.

§ Madam Speaker
With this, it will be convenient to discuss Government amendments Nos. 46 and 47.

§ Mr. Denham
This is the first debate of the Report stage. We had lengthy considerations Upstairs in Committee, and I am sure that we shall cover some of the same ground today.
This new clause and the amendments consequential upon it will enable sensible provision to be made for local health care services at the border between England and Scotland. It is intended that similar provision will be made at the border between England and Wales, but that does not require primary legislation.
Several GP practices located near the England-Scotland border have patients on their lists from both sides of the border. Under the existing arrangements, that means that the general practitioners concerned are part of both the English and the Scottish national health service systems. In commissioning services, in particular, that has created additional burdens on border GPs, which take up time, energy and resources that might be better devoted to 36 patient care. For example, one practice reported having to liaise with six different teams of community staff to cover its scattered population.
The new clause will enable a GP practice and its patients to be dealt with by either an English health authority or a Scottish health board, instead of having to be dealt with by both. Provisions have been made in England at the boundaries between health authorities so that all the patients registered with a GP practice have their services commissioned by a single primary care group. That enables a more coherent approach to be taken to the planning of local health services, simplifies local administrative procedures and avoids duplication of time and effort.

§ Mr. Michael Fabricant (Lichfield)
Would the Minister be kind enough to clarify whether these provisions have been brought forward primarily because of the introduction of primary care groups, and whether, if fundholding had remained, these provisions would have been unnecessary?

§ Mr. Denham
No. I understand that the problem that we are dealing with dates back to the introduction of commissioning in the early 1990s. At the moment, it affects relatively few patients and GPs; none the less, it is a problem for them.
As the effect of an order under the new clause will be to confer on the Secretary of State or English health authorities the ability to operate in relation to Scottish patients, and for Scottish Ministers and Scottish health boards to operate in relation to English patients, both Westminster and the Scottish Parliament will be able to scrutinise, debate and approve the order. Amendment No. 47 provides that the Order in Council must be laid before, and approved by resolution of, both Houses of Parliament and the Scottish Parliament.
Although relatively few patients will be affected by these provisions—about 3,500 on current estimates—they are important in ensuring that sensible, practical arrangements can be made for the provision of health care in border areas. We have consulted those who will be most affected by the provisions—health authorities, health boards and GPs in cross-border areas—and everyone who responded was in favour of the approach that we propose to take.
I commend the new clause to the House.

§ Mr. Philip Hammond (Runnymede and Weybridge)
The Minister outlined this rather late Government new clause and presented it merely as a tidying-up exercise that would extend to the border between England and Scotland the arrangements already in place for dealing with primary care groups whose populations straddle borders between health authorities in England.
I accept the Minister's underlying premise that practical and administrative difficulties arise for general practitioners whose practices deal with populations in different health authority areas, and that as a consequence they may have to deal with a multiplicity of commissioning arrangements. It is right in principle that we should seek to address GPs practical concerns in a 37 way that ensures that the service delivered to their patients is effective, meets their patients' expectations and is seamless in its presentation.

§ Mr. Fabricant
Does my hon. Friend agree that one of the problems that arises from the border areas is the disparity between the amounts of money paid per capita for patients in Scotland, as against those in England?

§ Mr. Hammond
I thank my hon. Friend for that comment. He anticipates an issue that I shall come to in a moment.
Let me set the matter in the context of the considerable pressure on general practice throughout the country—by that, I mean the United Kingdom. The position is no different in Scotland from that in England. Indeed, there is evidence that GPs in Scotland particularly have been feeling the strain over the past few months.
Over the past year, since the Government made widely known their plans for the reorganisation of primary care in the United Kingdom, general practitioners have been alarmed and disconcerted about the prospects for their future. They have been concerned about the sanctity of their status as independent contractors to the national health service, and they have been alarmed on behalf of their patients about their continuing ability to supply the range of services that those of them who were fundholders were privileged to be able to provide under the fundholding regime.
The Government have gone a considerable distance to reassure GPs about their intentions for the future of general practice services. Hon. Members who were privileged to be members of the Standing Committee that considered the Bill will by now be familiar almost verbatim with the terms of a letter written on 17 June 1998 by the Minister of State's predecessor to the chairman of the general practice committee of the British Medical Association. That letter was written in response to the widespread concerns of GPs that the move to primary care groups would impinge upon their freedom to prescribe and refer as they thought fit.
The reason that I raise the matter now is that, despite probing at some length in Committee, we were unable to ascertain whether the commitments made by the Minister of State's predecessor in that letter to GPs in England and Wales were binding in respect of GPs in Scotland. The new clause deals with the situation in which GPs in Scotland may be treating English patients, and GPs in England may be treating Scottish patients.
The tone of the letter of 17 June was reassuring. The Minister's predecessor wrote: The ability to offer patients the individual care they require has been and remains the cornerstone of general practice. The new system allows individual GPs to decide what is best for the patient, whether for example to prescribe drugs or refer patients to hospitals, in the light of their clinical judgement. Patients will continue to be guaranteed the drugs, investigations and the treatments they need. The Minister went on to state: There is no question of anyone being denied the drugs they need because a GP runs out of cash. 38 That comment is made in the context of the new unified budgets for primary care trusts, which will succeed primary care groups in due course. The Minister concluded that paragraph by stating: I can guarantee that the freedom to refer and prescribe remains unchanged. 4.30 pm
The difficulty that I and my colleagues who were members of the Standing Committee faced was that although the Minister was able to give assurances that the commitments made in the letter, which referred explicitly and specifically to primary care groups—the precursors to the primary care trusts that will eventually succeed them—would apply also to the trusts when they came into being and would be equally valid, it was not possible for him to give the Committee any such satisfactory assurance with regard to Scotland. As is clear under the arrangements in the Scotland Act 1998, and given the Bill's provisions relating to devolution, it will be for Ministers in the Scottish Executive to make such commitments and to give such binding undertakings.
There are concerns in the GP community on both sides of the border; there are also considerable morale and recruitment problems. We have additional concerns about the position of general practitioners in Scotland. The new clause clearly highlights the potential divergence between the delivery of health services in England and in Scotland. The Minister is creating a population of people who will live and belong in one country but be treated under the rules of the other country.
When the Minister replies to this short debate, perhaps he will confirm that what I have just said is correct and that when an English person is the patient of a Scottish general practitioner and crosses the border into Scotland for treatment, he will be treated under the rules and regulations pertaining in Scotland, not those pertaining in England. In that sense, that patient would be in a distinctly different position from a national health service patient who is treated at NHS expense in a private hospital, where, notwithstanding the fact that he is not in an NHS hospital, the NHS regime for ensuring quality that is in place in the NHS extends to and covers that patient during the period that he spends in a private hospital. It would be useful if the Minister could confirm my understanding that the rules and regulations and the regime of the country where the GP is located will govern the treatment.
That is not an empty question. At present, in many respects the systems and the services are similar on both sides of the border. However, it is possible—in my view and in the view of my right hon. and hon. Friends, it is quite likely—that over time differences will evolve in the regimes that operate north and south of the border. Those differences will be possible because of the responsibility that Scottish Executive Ministers will have in relation to non-reserved health matters and because of the serious discrepancy to which my hon. Friend the Member for Lichfield (Mr. Fabricant) has already drawn attention in the per capita spending on health services north and south of the border.

§ Mr. Fabricant
My hon. Friend the Member for Altrincham and Sale, West (Mr. Brady) has reminded me that there are fund-raising or tax-raising powers in the Scottish Parliament. Discrepancies between the amounts 39 of money being spent per patient in Scotland as opposed to those in the rest of the United Kingdom could be increased if the Scottish Parliament were to charge 3p extra on income tax.

§ Mr. Hammond
My hon. Friend is right to observe that, even under the existing block grant system, per capita spending in Scotland is significantly higher than in England, but, as he says, it would be possible for the Scottish Parliament to raise health spending in Scotland still further. If it were minded to do that, given that health is a devolved matter and its responsibility, that would be a legitimate political decision for it to make in the light of the expressed views of the Scottish people. I do not think that we in this place would question its right to do that.
We are considering a situation in which the evolution of divergent services between the two countries, north and south of the border, could accelerate and could become an issue. I shall give the House an example of one of the areas that we explored recently in Committee, about which I had the privilege of asking the Minister some questions.
It is clear that professions supplementary to medicine which are not already regulated under the present system, but fall to be regulated under the Bill, will be subject to regulatory regimes which can be different north and south of the border. It will be perfectly possible for such professions to have different regulatory regimes, under which someone who is entitled to practise north of the border might not be entitled to practise south of the border. It is important that we recognise those possibilities and the fact that discrepancies could occur over time.
One of the most important changes that the Government will introduce to the national health service through the Bill relates to the duty of quality, which is imposed on all health service bodies, and to the duty of co-operation, which is imposed as a statutory duty between health service bodies and between health service bodies and local authorities. We do not disagree in principle with the imposition of a duty of co-operation—it sounds sensible and we have had an opportunity to explore how well it will work in practice—but the duty of quality will be enforced in England and Wales primarily by the activities of the Commission for Health Improvement, which will have a wide-ranging remit to examine NHS bodies' implementation of their quality programme and the way in which they are interpreting the guidelines of the National Institute for Clinical Excellence.
The remit of NICE does not extend to Scotland, however, so once again there will be a discrepancy between the regimes operating in England and in Scotland. Conservative Members will be greatly interested to know what arrangements the Minister intends to put in place to ensure that people who cross the border for treatment or for diagnosis are not in any way caught in the gap between two different regimes.
The remit of NICE will include looking at the clinical and cost efficiency of various drugs and treatments that are, or will perhaps become, available in the NHS. Subject to not anticipating later debates, let us assume that the Bill will remain unchanged, and that the remit of NICE will 40 thus remain unchanged. Yet another problem will arise in respect of the English-Scottish border: once NICE has deliberated, reported and made its recommendations on the appropriateness of a making a drug or a treatment available with regard to its clinical and cost effectiveness, reality will bring us sharply up against the wide discrepancy between per capita funding of the NHS in England and in Scotland.
NICE cannot operate in a vacuum. It is not realistic to assume that the judgments that it may sensibly make in relation to England can be equally applicable in Scotland, where the NHS is differently funded. In case anyone thinks that the differences are minor or insignificant, I shall give the figures, which are interesting. In 1999–2000, expected per capita NHS expenditure in England is £802, whereas in Scotland it is £964.

§ Mr. Malcolm Chisholm (Edinburgh, North and Leith)
That point has been made several times already, and may be made many more times before the night is out. Does the hon. Gentleman recognise that public expenditure should be related to need? If so, does he accept that all the major health indicators show that Scotland is a more unhealthy nation than England?

§ Mr. Hammond
I would accept the need element, but if one looks around the English regions, it quickly becomes apparent that the regional distribution of NHS expenditure does not directly reflect need, as the hon. Gentleman suggests it should. I am trying to identify the implications of the different funding per capita in the national health service north and south of the border for the effective functioning of these apparently innocuous cross-border arrangements.

§ Mr. Fabricant
I should not like my hon. Friend to be misled into thinking that areas of deprivation exist only in Scotland. Last Friday, I attended a meeting of the primary health care group in Salters Meadow centre, Rugeley road, Chase Terrace, which became part of my constituency after the boundary change. My hon. Friend may be surprised to know that the standard mortality rate for Chasetown men suffering from heart disease is 207, which is more than twice the national average. The saddest thing of all is that the local Hammerwich hospital, which serves people from Burntwood, faces the possibility of closure as a direct consequence of the abolition of fundholding practices and the introduction of primary care groups. Is not that a disgrace?

§ Mr. Hammond
I agree with my hon. Friend: it is, indeed, a disgrace. Hon. Members will know of many local pockets of deprivation and health need around England and Wales that are not being dealt with consistently. We are faced with a discrepancy between per capita spending in England and Scotland of a fraction under 20 per cent. On the Government's own estimates, that figure is not intended to go down: it will stay approximately stable. Those planning the delivery of health care in Scotland will have significantly greater latitude than those charged with the task of planning health care in England and Wales. That cannot but have an impact on the systems, and on the availability of treatments and drugs.
The Minister may have a different view, but I cannot see any way in which the proposed cross-border arrangements could be anything other than one-way 41 traffic. I do not imagine that many Scottish patients will want to be under the regime that will operate in England, given the much tighter financial constraints that it will face. The 20 per cent. difference—£160 per capita—extrapolated across the country would have a huge effect on waiting lists in a typical English parliamentary constituency. It is a significant factor relating to the delays experienced by constituents of hon. Members with English and Welsh seats who are waiting for treatment, and those being told that treatment is not available to them.
I should be interested to hear from the Minister what additional arrangements to deal with the differences in the regulatory structure will be needed to protect patients who are involved in cross-border arrangements.

§ Mr. Graham Brady (Altrincham and Sale, West)
Before my hon. Friend finishes, I wonder whether he could shed some light on a potential problem with the new clause. Is it not possible for someone to opt to enjoy the Scottish arrangement at one time and the English arrangement at another? Would the clause not institutionalise a situation that the health authorities in the border regions could exploit by offering some services to a lower standard in the knowledge that the people in their areas could just as easily go over the border and benefit from different provision?

§ Mr. Hammond
My hon. Friend raises an interesting point to which the Minister should reply. I suspect that the Government's intention is that the arrangements should deal with patients who live in a different country from the practice where they are registered.
My hon. Friend's point brings us to initiatives such as walk-in consultation centres, which the Government favour. A variety of other cross-border issues will arise in decisions on where a person belongs and what that entitles them to. If figures are available, will the Minister tell us how many people will be affected? A finite number of people will be involved in GP practices that already have a cross-border element. Has the Minister made an estimate of what the number might rise to as a result of the incentives that the new clause, which I am confident will be incorporated in the Bill, will give patients on the English side of the border to manipulate the arrangements?
Finally, subsection (2) says: This subsection applies to any functions under the 1977 Act". The Minister was kind enough to write to my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) during the closing stages of the Standing Committee. He said that he intended to make provision for the exercise of health service functions across the England-Scotland and England-Wales borders; that the new clause would be designed to put existing practice on a firmer legal footing; and that provision would be made for the exercise of functions under part I of the National Health Service Act 1977 in relation to GP practices that straddle such borders. What is the significance, if any, of the decision to exclude from the new clause the reference that the Minister was expecting to make to part I?

§ Mr. Fabricant
As my hon. Friend has already said, doctors are alarmed and concerned about the outrageous fact that fundholding practices have been abolished before the Bill is enacted. I shall not on this occasion read at length—there might be opportunities later, in the early hours of tomorrow morning—from an e-mail that I have received from a local doctor. The hon. Member for Tyne Bridge (Mr. Clelland) smiles, because he knows that a number of doctors in Lichfield have access to e-mail and they e-mail me frequently on the issue. I shall simply quote the first line: All right, primary care groups do now exist, but there are still more questions than answers. That also applies to new clause 18.
When I asked the Minister whether the new clause would have been necessary under fundholding, he answered yes. He said that it was a simple tidying-up mechanism, but, if so, why has it been introduced at such a late stage? Are the parliamentary draftsmen at fault? Is the Department of Health at fault? Why has it been introduced at the final stage?
New clause 18 will amend the National Health Service Act 1977. In Committee, my hon. Friend the Member for Runnymede and Weybridge (Mr. Hammond) pointed out the strange architecture of the Bill. It is so peculiar and difficult to see through that the Department had to produce a consolidated Bill to incorporate the 1977 Act, of which they printed only two or three copies, so that we could attempt to follow how the Bill and previous Acts will be amended. I cannot but be suspicious that the reason for the Bill's strange architecture is to confuse the Members of Parliament who have to scrutinise the legislation and the doctors.
It is also typical that new clause 18 states in the first line: Her Majesty may by Order in Council provide for any functions to which subsection (2) applies". In other words, yet again a blank chequebook is being given by a Bill that contains no detail. Issues will be determined Upstairs in the privacy of a Standing Committee on Delegated Legislation by only a few Members of Parliament and under a time limit.
The Bill is confused, both in its structure and in what it is trying to achieve. The Bill mentions English border areas and Scottish border areas, but it gives no clear definition of those areas. Does it mean five miles either side of the border, or 10?

§ Mr. Denham
It might be helpful if I point out that subsection (5) of new clause 18 defines English and Scottish border areas in terms of the health authorities and boards adjacent to the border.

§ Mr. Fabricant
That is helpful. The Minister is, as ever, well informed, but will patients in the area feel that their position has been clarified? As my hon. Friend the Member for Altrincham and Sale, West (Mr. Brady) said, patients might find it beneficial to cross the border into Scotland. My hon. Friend the Member for Runnymede and Weybridge gave some figures that suggest that they might. He pointed out that £802 per capita is spent on health care in England and Wales, whereas £964 is spent in Scotland. That shows the differential.
The hon. Member for Edinburgh, North and Leith (Mr. Chisholm) said that there is greater deprivation in Scotland than in England, and perhaps that is so in 43 general, but there are pockets of deprivation in England and Wales, just as there are pockets of great wealth in Scotland. During the war, my mother was posted to Morningside in Edinburgh, which I believe is quite a wealthy area.
In Chasetown in my constituency, the standard mortality rate generally is 160 for men, which is 1.6 times the national average, and 142 for women. The SMR for heart disease in Chasetown is 192, almost double the national average. The figure for men is 207, and for women 196. The main causes of death are congenital factors, accidents and cancers. To say that such conditions exist only in Scotland would be a huge travesty of the truth.
Why are the moneys being spent in Scotland not also being spent at the same rate in deprived areas of England and Wales?

§ Mr. Chisholm
The hon. Gentleman has not completely understood what I said. I made a simple point about headline health indicators for Scotland as a whole compared with England as a whole, whereas he is making an entirely different point.

§ Mr. Fabricant
I am grateful for that clarification. I thought that the hon. Gentleman's point was that Scotland deserves extra money because it is deprived in comparison with England and Wales, with more disease and higher mortality rates. I think that he is now nodding in assent. I am making the same point: deprivation should be taken into account, not only in Scotland but in England and Wales.
Do not we have a national health service? Instead of the service being truly national, serving Scotland, England, Wales and Northern Ireland, it is becoming fragmented and unfair. If an individual is suffering from a complaint, he may be more likely to receive better treatment in Scotland, where more money is available, than in the rest of the United Kingdom. Is not that wrong? Should not money follow the patient, not the nationality?

§ Dr. Howard Stoate (Dartford)
Have not we always had differential spending on health care, depending on circumstances? The resource allocation working party in the 1980s made it clear that money should be allocated in different areas according to need. We currently use Jarman indices to make deprivation payments available to general practitioners. It is wrong to be hung up on the idea that Scotland gets all the money, because different regions have always had different amounts available, dependent largely on need.

§ Mr. Deputy Speaker (Mr. Michael Lord)
Order. Let us not go too far down the road of regional differences. I remind the House that we are talking specifically about arrangements at the border.

§ Mr. Fabricant
I am grateful for that guidance, Mr. Deputy Speaker.
I agree with the hon. Member for Dartford (Dr. Stoate), who is a GP. However, he reinforces my argument, which is that money should follow need. It should not be allocated according to deals that favour other countries in 44 the United Kingdom over English regions. Why should 20 per cent. more money be available, per capita, in Scotland than in England and Wales? It is not because of need or deprivation, but because of Scottish Office deals with the Treasury.
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Patients and doctors will have an incentive to use new clause 18 to move from one part of the borders region to another simply to get extra money and care. Who could blame them? Should not parents expect the best care for their children? If that means crossing the border, they will do so. However, as the hon. Member for Dartford said, money should be allocated according to need. It was a shame that the hon. Gentleman—in whose constituency, incidentally, there was a Tory gain in last Thursday's elections—chose not to be a member of the Committee considering the Bill. He is a GP, and his input would have been valuable, but perhaps the Whips decided that he should not be on that Committee—

§ Mr. Deputy Speaker
Order. The hon. Gentleman must return to the new clause.

§ Mr. Fabricant
The new clause is confused. As I said, it is not explicit, and the detail will have to be dealt with by an Order in Council. Much is left to the imagination, and the fear is that the Government will take advantage of that lack of detail when they want to make financial cuts.
We have been led to believe that Scotland will enjoy better health care because of devolution, yet a clause in the part of the Bill that deals with Scotland, to which I shall return later, provides that, under the terms of devolution, the Bill can override legislation passed in the Scottish Parliament. It is clear, therefore, that the Government are merely paying lip service to devolution. They are interested in the soundbite and the general principle, but the Bill allows them to overrule the Scottish Parliament in this matter.
Finally, in our deliberations in Committee, a number of acid tests of the Bill emerged, and one is relevant to the new clause. The Government said that they would abolish fundholding. All the GPs in my constituency were fundholders, and so were able to send patients where they could get the best treatment locally. That secured the future of the two local hospitals in my area, the Hammerwich hospital in Walsall and the Victoria hospital in Lichfield.
We asked the Government to include an acid test in the Bill. The Government had said that primary care groups would not mean a reduction in service, so we asked them to include a clause requiring the publication each year of the details of any service that would be withdrawn or added as a result of the replacement of fundholding with PCGs. That would have tested whether PCGs were improving the health service, and new clause 18 would be less relevant. The Government tacitly admit that the abolition of fundholding and the introduction of PCGs will mean a reduction in service, which is why they are introducing new clause 18.
Patients in border areas may have to cross borders, which would not have been necessary under fundholding. The position became clear in Committee. The Minister chanted the mantra—we have heard it from the Secretary of State—that fundholding was unfair and a two-tier 45 system. We suggested that every doctor should be made a fundholder, but we were told that that would be too expensive. That is an admission that fundholding was about excellence, just as grammar schools were. We cannot afford to make all doctors fundholders, so the 60 per cent. of patients who were treated by fundholding practices—practices abolished even before the Bill has been enacted—will instead receive a second-class service.
The hon. Member for Dartford is scribbling hard and may wish to take part in the debate. On the other hand, he may be told by his Whips to keep quiet. Why was the hon. Gentleman never a fundholder? The answer is ideology, not his patients' needs. He should come to Lichfield to meet my doctors.

§ Miss Ann Widdecombe (Maidstone and The Weald)
Do not ask him to do that.

§ Mr. Fabricant
I should invite the hon. Gentleman to come while he is still a Member. After the next election, if last night's European results are anything to go by, he will not still sit for Dartford.

§ Dr. Stoate
My practice never became a fundholding practice because it realised that that system was bad value for money and it did not give patients a good deal. On a point of information, the hon. Gentleman may wish to know that general practitioners in Dartford formed one of the first pilot groups for the switch to primary care groups. About 50 per cent. of those GPs were fundholders, but they voluntarily relinquished fundholding because they realised that PCGs offered far better services for patients in Dartford and Gravesham. By doing so, they provided an extremely effective PCG a year ahead of anyone else. It is providing far better services at far better value for money than any fundholding practice did. That is why the Government are not keen on fundholding.

§ Mr. Fabricant
GPs know one thing: Labour's huge majority allows the Government to jackboot any legislation through the House. They knew that fundholding would be abolished—

§ Mr. Deputy Speaker
Order. This debate is not about the merits of fundholding. Would the hon. Gentleman please return to the new clause?

§ Mr. Fabricant
The introduction of new clause 18 at such a late stage is typical of the way in which the Bill was drafted. Clauses were added at the last minute in Committee, and the new clause—the Government call it simple tidying up—is also being added at the last minute. It is impenetrable, referring to the Bill and to preceding legislation. Yet again, we find a lack of detail. Instead, huge powers are given to the Secretary of State to make decisions Upstairs. Who can wonder that GPs are disturbed? Who can wonder that they doubt the Government's motives? Most important of all, who can be surprised that a MORI poll has shown that 30 per cent. of the population now know that the national health service is not safe in the Government's hands?

§ Mr. Brady
Such was the rousing reception with which the speech by my hon. Friend the Member for Lichfield (Mr. Fabricant) was greeted, Mr. Deputy Speaker, that I could hardly hear that I was being called to speak. 46 However, the reception was highly deserved as my hon. Friend made an important contribution to the debate. My contribution will be more technical and I will deal with some of the detail of the new clause.
It would be unwise to suggest that I disagree with your suggestion that the debate should be concerned with the border, Mr. Deputy Speaker, but in my view it is not merely about the border areas but about changing the location of the border for certain purposes. The new clause gives rise to grave concern because of the provision for an Order in Council with all that that implies. When the Minister responds, I would welcome some real detail about what the Government intend to put in the order, and therefore, about the implications for people who live in the border area, whether on the Scottish or the English side.
My concern is that for the purpose of primary health care in particular a different border will be applicable. It is not the border that divides England and Scotland, which is obviously one to which people who live near it have grown used and which has a historical basis. People are comfortable with that border. However, the new clause would change the border. For health purposes, the real border will be that of the health authority area adjacent to the border with Scotland.
The new clause would not simply make arrangements relevant to what happens on one or other side of the border, but would in some ways blur the border between Scotland and England. The critical difference in the treatment that a patient receives will no longer depend on whether he lives on the side of the border that benefits from the Barnett formula and the increased health expenditure to which the broad mass of people in the United Kingdom have been happy to consent for a long time. It will depend on whether people live within the boundaries of the health authority or health board that abuts the border on the Scottish side. That provision has grave constitutional implications and it also has implications for the treatment and funding of health care for the people concerned.
As my hon. Friend the Member for Lichfield sought to suggest, expenditure on health care for the citizens of the United Kingdom differs. It depends on where they live and on the GP with whom they are registered. Due to accidents of geography, there is a question mark over the treatments that people can receive in certain areas. I do not want to stray too far away from the border, but I recently dealt with a constituent who was being denied a treatment that his consultant had told him was essential for his future health. Had he lived on the Manchester rather than the Salford and Trafford side of the health authority boundary, he would have been allowed that treatment.
In the new clause, the difference is writ large—it is between those health authority areas that are English and have roughly 20 per cent. less funding to spend on their residents and those that are Scottish.
We now also have a new distinction between health authorities that have the benefit of abutting the border and those that do not. If the health authority area is at one remove from the border, it will have less flexibility in the planning of its arrangements for the provision of treatment for its residents than if it is directly adjacent to the border. In the planning of treatments that might be discretionary and might contain some element of choice—whether 47 handed down by the national institute that will be created, or lying within the discretionary decisions currently taken by health authorities—there will be instances in which a health authority could decide that a form of treatment is too expensive to constitute good value. However, that would not be a problem for residents of that area who could cross the border to Scotland where such treatment might be available, at taxpayers' expense. That treatment would be denied to people living on the English side of the boundary.

§ Mr. John Bercow (Buckingham)
I am grateful to my hon. Friend for giving way because he is making a powerful speech. Does he agree that the phenomenon of differential treatment by postcode that he describes has no basis either in logic or in equity? Does he experience in his constituency of Altrincham and Sale, West the same backlash against that injustice that I experience in my Buckingham constituency?

§ Mr. Brady
I think that I am probably experiencing the same kind of response as my hon. Friend. More often than not, it comes down to the fact that, if there appears to be a danger that adverse publicity will arise from treatment being denied, then treatment is provided, whereas if a person is prepared to suffer in silence, treatment may never be provided. That is a real concern. It is also a concern that relates to waiting list figures, which, of course, are being massaged throughout the whole country. Many health authorities have a miraculous ability to find it in their powers to treat a patient who makes a bit of a fuss about a long delay in receiving treatment. That is nothing short of a scandal; we are beginning to see a different standard of treatment and certainly a different length of waiting time for treatment, depending on the area in which one lives or on whether one is prepared to make a fuss.

§ Mr. Hammond
Has my hon. Friend observed—as I have—that the most effective way to move oneself up the waiting list is to get one's name mentioned in the Chamber?

§ Mr. Brady
I am reluctant to be drawn on that point.

§ Mr. Deputy Speaker
Order. We are again straying a long way from arrangements on the border. Will the hon. Gentleman return to them?

§ Mr. Brady
That is why I was reluctant to be drawn by the question of my hon. Friend, Mr. Deputy Speaker.
In relation to the specifics of the new clause, we are exacerbating the situation. We are enshrining in law that it will be not merely a matter for health authorities—depending on where they are in the country—to provide different levels and types of treatment at different costs, but that there will also, in effect, be a statutory system allowing individual patients to make choices that exploit the inevitable anomalies in the treatment systems available. A patient might have the choice of registering with one GP practice or another, or might be able to register with an English GP or a Scottish one. A patient 48 might register with an English GP, but will be aware that Scottish health care facilities may, none the less, be available to him. That is one of the serious question marks over the way in which the new clause was drafted.
The point made by the Minister when he replied to the question put by my hon. Friend the Member for Lichfield relates precisely to the question of which areas the measure applies to. The Minister is right to point out that subsection (5) states: 'English border area' means the area of any Health Authority adjacent to Scotland, 'Scottish border area' means the area of any Health Board adjacent to England. However, will he tell us why? What makes that a logical assumption for the purposes of the measure?
In my view, the truly relevant distinctions would be geographically defined far more tightly than simply according to the administrative boundaries of health authorities. The Minister must accept that there might be people living in parts of Northumbria, Cumbria and the Scottish border areas who have no need of the provisions set out in the new clause but who may, none the less, derive benefit from them.

§ Mr. Denham
The reason that those health authorities and health boards are covered is that they encompass practices in which people are registered on both sides of the border. Therefore, those are the sensible health authorities and boards to draw into the legislation.

§ Mr. Brady
The Minister says that that is the reason for the inclusion of those health authority and boards, but the new clause does not limit the application of the procedures and situations set out in it to those people who are registered with practices which have patients on both sides of the border. In short, the Government are creating a potentially serious anomaly.
I am not familiar with the health authority boundaries, but as one who knows that part of the country reasonably well, I would hazard a guess that they encompass large geographical areas. Therefore, the Government are attempting to define in legislation extremely large areas to which the provisions will be applicable, even where there is no real need for those provisions or where the real need could be far more tightly defined, for example, by restricting the application of the provisions to those people who are registered with practices which have patients on both sides of the border. The new clause is badly drafted and it gives the legislation extremely wide scope.

§ Mr. Bercow
The Minister's intervention was interesting. Does my hon. Friend agree that, if the Minister is to offer a convincing rebuttal of my hon. Friend's case, it is necessary for him to show that, in the areas concerned, every practice, without exception, has patients registered on both sides of the border? If the Minister does not take this opportunity to rise and say that, my hon. Friend's case will rest.

§ Mr. Brady
I do not expect the Minister to leap to his feet, because he knows full well that he cannot demonstrate that that is so, and that is precisely what makes my point.
49 For the vast majority—probably 99 per cent.—of the residents in the health authority areas which will be affected by the new clause, the provisions are not a necessity. However, the new clause will change the nature of the health care provision that is available to them, and it will do so in a way that distorts the planning and provision of health care in a stretch of land along either side of the border between England and Scotland that is remarkably broad. That part of the country is, in the main, rural, so the health authority and health board areas are relatively large.
The new clause, in effect, blurs the border between England and Scotland for certain purposes. For the administrative basis of health care provision, the border could, in principle, be blurred away from the geographical border to the administrative border of the health authority or health board adjacent to the geographical border. As for the reason why the Government are trying to do that, I can only suggest that it is a conscious attempt to fudge some of the difficult problems raised by the progress toward devolved government in Scotland, for example, the inequities between England and Scotland in tax and spending arrangements that might arise from devolution. It is a cause of great concern. Many people in England and Wales are beginning to question the constitutional balance created by devolution. English voters are becoming increasingly concerned about the Barnett formula and the fact that their taxes will be used disproportionately to fund services in Scotland. The new clause will add to that effect.
For example, the Scottish Parliament might vote to increase taxation—by introducing the tartan tax that was debated at length during consideration of the devolution legislation—in order to provide better health services. However, that tax increase would cease to be acceptable to the Scottish people in the context of the new clause, which would cause those who are not the sole beneficiaries of that expenditure to provide the additional revenue.
The relationship between taxation and the democratic accountability for raising and spending it is ludicrously complicated. The Barnett formula and the existing anomalies in expenditure levels in England and in Scotland have been accepted—if only as a result of the passage of time. However, an additional complication could arise. Scottish electors could be asked to support the decision of the Scottish Parliament to raise taxation for the express purpose of augmenting health provisions on the northern side of the border. However, new clause 18 could lead to Scottish electors being taxed in order to spend more money not just on people south of the border, but on a relatively small and arbitrarily fixed group of them.
It is not appropriate to legislate to create an absurd anomaly. A small number of people may derive a disproportionate benefit for which others have paid and for which their elected politicians are not accountable. That could cause grave concern and a good deal of controversy. Our concerns would be lessened if the Minister would respond to the suggestion by my hon. Friend the Member for Buckingham (Mr. Bercow) and define the areas precisely. If he would come to the Dispatch Box and tell us that the new clause will affect only 50 or 100 people living in the most remote rural 50 areas of Cumbria, Northumbria and the Scottish Borders, we might be prepared to say that its constitutional abhorrence pales into insignificance.

§ Mr. Hammond
Does my hon. Friend agree that, in order to provide such an assurance, the Minister would have to contemplate freezing the lists of GPs in those border areas? Given the relative paucity of choice available to people living in those sparsely populated areas, would my hon. Friend not find that an unacceptable restriction?

§ Mr. Brady
I think I probably would—I certainly think that those affected would. Difficulties may arise if the lists are not frozen and this legislation is passed. Rather than registering with local practitioners, people who live outside the areas directly affected that would normally be served by border practices—they could live 20, 30 or 40 miles from the border—might find it advantageous to register with GPs close to the border in order to benefit from higher levels of expenditure. In very rural areas, people's local practice may conceivably be 10 miles south of them.

§ Mr. Hammond
My hon. Friend is absolutely right, but the issue is not simply the higher level of expenditure in general, but the availability in one area of a drug or treatment that is not available in another area. We have all heard stories of people selling up and moving house to get into a local health authority area where, for example, beta interferon is available. That could well happen across the border.

§ Mr. Brady
I absolutely agree with my hon. Friend. I would go further and say that not only is a clear incentive created for people to move house or register with a different GP—they might go to considerable lengths to benefit from treatment that they would otherwise be denied—but, giving due credit to health authorities and boards for their wit and intelligence in seeking to serve the interests of their population, it may be entirely appropriate for them to take into account their privileged status under new clause 18.
As designated health boards or authorities, part of their planning process may be to accept that they are part of a jigsaw that fits with the board or authority on the other side of the border. It would be perfectly possible under new clause 18 for a health authority or board deliberately to refuse a particular treatment in the knowledge that the corresponding board or authority on the other side of the English-Scottish border provided that treatment and that its own residents would not be disadvantaged by the decision.
Indeed, in aggregate, residents may benefit from such decisions because the Bill allows residents to have an à la carte health service in which they can pick a treatment that is available in their local health authority area and turn across the border to Scotland for a treatment that is not available where they live. Treatments such as beta interferon or erythropoetin, which was the treatment in question for the constituent to whom I referred earlier, may be available in one health authority area but not in another. That may become a permanent state of affairs 51 and may encourage co-ordination, whether formal or informal, in the provision of health services across the English-Scottish border.

§ Mr. Hammond
Managed from Brussels.

§ Mr. Brady
I am not sure whether my hon. Friend wants me to repeat his remark, but he said that it will be managed from Brussels, which is doubtless in the mind of the Government, although they may now think twice about their headlong rush towards integration, following yesterday's election results.
The result of new clause 18, however, for people who live in the border regions may be beneficial in that their health authority can co-ordinate treatment with the health board on the opposite side of the border. That would increase the number of treatments available to residents in that area, without any increase in total expenditure.
The disadvantage is to those people who live on the Scottish side of the border in the next tier of health board areas, but far more so to those people living in the next tier of health authority areas on the English side of the border because they are multiply disadvantaged by the Bill. They are already disadvantaged by having to pay taxes that disproportionately fund health services in Scotland under the Barnett formula.
Health authorities, with which we all deal, must make choices and decisions in conducting their daily business. They must make difficult decisions on how to divide the resources made available to them—whether the prescription of beta interferon is the best way in which to improve overall health in the area or whether money could be better spent on other treatment. Health authorities adjacent to the border would make fewer such choices under new clause 18.

§ Mr. Bercow
I am sorry to agitate and interrupt the eloquence of my hon. Friend's flow, but the scope for the form of administrative table tennis which he has described is perverse in the extreme. On the strength of his listening to Ministers' statements, does he judge that they are guilty of knavery or of folly? In other words, is this a Machiavellian plot or has the Minister, whom we know to be capable of this, stumbled into the mess inadvertently?

§ Mr. Brady
I thank my hon. Friend for that elegant intervention. I do not know whether the Minister has stumbled into this or whether his right hon. Friend the Secretary of State, who is perhaps even more capable of stumbling into problems, is responsible for it. My suspicion is that the proposed legislation is simply ill thought out.
The reason why the new clause has been tabled at this point is far from that in the picture painted earlier for my hon. Friend the Member for Lichfield: that there has been a crying need for such a provision for a long time and that it was absolutely necessary that the Government should now deal with something that has been causing difficulty. In fact, there had been no previous difficulty of any significance. Somebody suddenly realised that there might be one and thought that something ought to be drafted that might deal with it, subject to the approval of a suitable Order in Council by not only both Houses of 52 the Westminster Parliament but the Scottish Parliament. Perhaps I am more generous of nature than my hon. Friend the Member for Buckingham; I hesitate to attribute unkind motives to the Minister or suggest that he is making a foolish mistake.
The new clause appears to have been given minimal thought or consideration. It has been tabled on Report, instead of in Committee, where we might have had a much better opportunity to debate its implications. Had it appeared in the Bill in the first place, perhaps some of the very serious complications surrounding it could have been addressed earlier.
I suspect that there is no deliberate intention to deceive, although it may be convenient for the Government—if possible—to blur the inequities that arise from devolution, which are most obvious to those who live adjacent to the border. Those living nearer the border can see such inequities and problems in sharp contrast, whether in taxation, health care provision or other public services. Although I am far from convinced that the Government have made a deliberate attempt to blur such distinctions, my hon. Friend the Member for Buckingham was right to suggest that there is a possibility of knavery—and we should consider that.
Regardless of Ministers' motivation in tabling the new clause, this is an ill-judged piece of legislation. As has happened so many times in the relatively brief time that we have suffered the new Government's control of policy, legislation is being introduced which, as my hon. Friend the Member for Lichfield said, gives the Secretary of State very broad powers to introduce more detailed provisions without the facility for debate and amendment that there would have been, had they been included in the Bill.
That is unfortunate for Members of the House who, rightly, wish to debate these matters properly and in detail. Moreover, if the Labour Government are going to start paying attention to the concerns that the public plainly have about them, as demonstrated in the recent European election, they should address people's concern that the Government still behave in a way that sometimes consciously stifles debate. They are also concerned that, at other times, as in this instance, an over-reliance on delegated powers denies the Government the opportunity—they should start to understand that it is an opportunity—to enjoy the benefit of scrutiny in the House before they embody detailed matters in law.
If a tenth of the concerns that I and my hon. Friends have expressed about the new clause were to prove well-founded, the clause would constitute a bad piece of legislation. Those concerns will come back to haunt the Government, and Ministers will regret not acting on them. If they had had the good sense to put the detail of such material in the Bill, they would have benefited from hearing it debated, and from having the pitfalls highlighted.

§ Mr. Hammond
My hon. Friend is making an extremely powerful point. He was not privileged to serve on the Standing Committee that considered the Bill, but he might like to know that the Government tabled a new clause at the end of that Committee's consideration and have been forced to come back today with a substantial number of amendments to it. That demonstrates the truth of my hon. Friend's case.

§ Mr. Brady
I thank my hon. Friend. It is ludicrous to table the new clause in its current form yet still to fail 53 to address the concerns that are being expressed today. These matters should be the stuff of the primary legislation before us. It is not enough for a slice of the United Kingdom—I suspect, merely 100 miles wide at one point—on either side of the border between England and Scotland to be covered by a catch-all provision in the Bill, which can be defined only by subsequent delegated legislation.
The Minister, in his brief opening remarks, gave no information regarding the numbers of people who are resident in the areas of the health authorities and health boards that we are discussing. He gave us no idea of the geographical size of those areas. He gave us no idea of how many GP practices would be affected, either by the new clause or by the order that he presumably has in mind, but to which the House is not yet privy. He gave us no idea of the current disparity in terms of health expenditure on one side of the border or the other, or, in terms of weighted capitation, of the effect of that on different health authorities on either side of the border. He gave no indication of the kind of treatments that may currently be available in a health authority on one side of the border but which are not available in a health board area on the other side or, more likely, vice versa.
The Minister has given the House none of that information. I live in hope that he may put that right later, when he responds to this short debate. He flicks casually through his notes, but I am not certain that he has that volume of information in his possession as he sits in the House this evening.

§ Mr. Bercow
My hon. Friend's patience is renowned throughout the House, but I must trouble him once more. Does he agree that it is not necessary to gaze into the crystal ball when we can read the book? Does he accept that his point has not only intellectual merit, but practical validity? It is not just a theoretical concept that by fleshing out Government proposals in the Bill, we maximise the chance of better legislation and better service to the public. That is manifestly proven in the context of legislation that the Government have introduced in other areas of public policy. Does my hon. Friend agree that it is precisely because of the tendency to legislate by Order in Council and regulation that is not subject to the scrutiny of the House that the right hon. Member for Hartlepool (Mr. Mandelson), for example, got into such an unholy mess in relation to the working time regulations? Can we not learn from that experience?

§ Mr. Brady
I endorse everything that my hon. Friend said, but I am aware, Mr. Deputy Speaker, that you may not wish me to venture into other areas of policy. Assuming that having sold one house, the right hon. Member for Hartlepool (Mr. Mandelson) does not take advantage of the provisions of the new clause to buy another property in a health authority area where he may benefit from treatment on the other side of the Scottish border, I am not sure that I would be permitted to stray into that area.
The point is sound. Not only should the Government, as a matter of principle, bring these issues in detail to the House of Commons, but their own ends would ultimately be served better if they did so.
I suspect that the Minister does not have the basic, essential information that ought to be available to hon. Members now to enable them to reach a proper conclusion 54 about the impact of new clause 18. We have heard nothing about the number of people likely to be affected, the sums of money available, the sums spent and the treatments available in different areas. None of that information has been given to us, so the House is left in the dark.
Once again, we must agree a new clause that has wide parameters and about which we have virtually no information. That is profoundly wrong as a way of legislating and it will cause the Government considerable regret later.
The hon. Gentleman whose constituency I do not know and who was earlier described as the hon. Gentleman on the fourth Bench, but whom I know to be an hon. Member of great distinction, spoke about different levels of social deprivation in different parts of the United Kingdom. That is relevant. I expect that few hon. Members, if any, would disagree with the notion that there should be some degree of weighting in public expenditure on the basis of need, as the hon. Gentleman said.
However, new clause 18 provides a mechanism for the weighting of provision not on the basis of need, but purely on the basis of geography. It must surely be wrong that someone who lives in a wealthy part of Northumberland, close to the Scottish border, may derive much greater benefit from the measure than someone who lives in the most impoverished part of Newcastle upon Tyne would gain. My knowledge of geography is not quite so good on the Scottish side of the border. However, someone who lives in one of the remote border areas—for example, the Cheviots or wherever—may gain benefits regardless of economic status, the level of need and health indicators, putting him in a preferential position relative to those living in the most deprived parts of Glasgow or of other Scottish cities.
This is not about the provision of health care on the basis of need. It is not justifiable on any rational or moral ground. It is an attempt to gloss over an administrative problem that the Government created, but without giving proper thought and attention to the implications that it could have. The Minister's opening remarks gave me no confidence that the Government have thought things through to a position where they will be able to answer the difficulties when they bring forward their Order in Council.
I raise the question, in conclusion—

§ Mr. Bercow
Surely not.

§ Mr. Brady
I am saving myself.
Is it appropriate for the House to agree to accept a new clause that has massively broad parameters when we have been given no detail about the implications and about the people who will be affected by it? We have been given the assurance that these matters will be dealt with when the Government see fit to bring forward delegated legislation. Of course, there will be no opportunity to amend it. As it will have to be approved by both Houses of Parliament as well as the Scottish Parliament, that must leave open the possibility that the supposedly pressing need, according to the Minister, to tidy up administrative problems that have existed for some time, might be rejected and that the Order in Council might be thrown out not by this place, not by the other place, but by the Scottish Parliament.
55 If the Members of the Scottish Parliament are to do their jobs properly and are to consider the impact of legislation that carries the potential effect of requiring their constituents to pay for health provision for people living outside their constituencies and outside the boundaries of Scotland, they may see that there will be no benefit for the Scots and that health care resources may be diverted from Scottish people to English people. As an English Member, I may think that that is a reasonable state of affairs and may even up the current discrepancies in health expenditure on either side of the border. However, Members of the Scottish Parliament may see the matter in a different light.
Surely the questions that are being raised by myself and others must weigh heavily on the minds of Members of the Scottish Parliament. They will be dealing with proposals that can carry a huge disbenefit to some residents in Scotland. None of these matters has been dealt with by the Minister. I hope that he will attend to some of them when he replies. I hope that in my brief remarks I have highlighted that the Government have brought forward ill-considered and ill-thought-out legislation with potentially serious consequences, and have not bothered to bring the information to the House on which we can make a reasoned judgment.

§ Mr. Desmond Swayne (New Forest, West)
I propose to be brief. I did not intend to speak on the new clause, but I was tempted to do so by my hon. Friends the Members for Altrincham and Sale, West (Mr. Brady) and for Lichfield (Mr. Fabricant). A possibility has occurred to me that is rather different in scope from the possibilities that my hon. Friends have outlined. I should preface my remarks by saying that I have had some difficulty in understanding the clause although I have read it several times. It is not exactly transparent, perhaps because so little of its substance is present on the amendment paper. It seems that that will be manufactured in the form of an Order in Council somewhat later.
The thrust of the remarks of my hon. Friend the Member for Lichfield was that there would be a movement of patients from the English side of the border, seeking treatments on the Scottish side, because of the 20 per cent. better funding arrangements that are available to Scottish health authorities. I am indebted to my hon. Friend the Member for Altrincham and Sale, West for dwelling on the fact that the border becomes confused—he used the word "blurred"—as a result of the new clause.
My view is that the border will become a much more critical divide than hitherto in health affairs. That is because the Scottish Parliament will have absolute discretion when it comes to the treatments that it funds or does not fund. I shall put a specific possibility to the Minister and ask him to address it when he replies.
There is little doubt that the Scottish Parliament will develop its own identity both with respect to its attitude to health care and its attitude to moral issues. It strikes me that there is a distinct possibility of the flow of patients being entirely the other way round—people who are in the care of health authorities north of the border in the border areas seeking treatments south of the border. There is a real possibility that patients might legitimately 56 expect treatment under, for example, the provisions of the Human Fertilisation and Embryology Act 1990, which remains a reserved matter, while the Scottish Parliament decides as a matter of principle that it will not fund that treatment. There is the possibility that patients who are unable to secure treatment in Scotland will seek to use the provisions of the clause to secure that treatment in England. I have chosen the Human Fertilisation and Embryology Act, but I could have referred instead to the provisions of the Abortion Act 1967.
As I have said, the Scottish Parliament will have absolute discretion as to what procedures it is prepared to fund north of the border. It will be entirely operationally possible for that Parliament to deny a series of treatments in its funding decisions which, in terms of reserved legislation, the British people as a whole have been led to expect they may legitimately receive. There is a strong possibility in the years ahead of health refugees, as it were, coming to the border areas and seeking to use the provisions of the clause to obtain treatments which are not available in Scotland from English health authorities. I ask the Minister to address that possibility.

§ Mr. David Amess (Southend, West)
I apologise to the Minister for not being here at the start of the debate; I was in my room, because I had anticipated that the statement on Kosovo would last an hour, although I think that it finished after only 40 minutes. However, I was watching his performance carefully on the monitor and I have to say to him that the start of proceedings on Report has been, in every sense, a hangover from his style in Committee. He came to the Dispatch Box and gently introduced new clause 18 as though it were harmless, but it certainly is not an innocuous measure.
6 pm
Today, a member of Her Majesty's Cabinet has talked about a low turnout and, according to that right hon. Member, a low turnout indicates that the majority of people are happy. There is a relatively low turnout in the Chamber at the moment, so I assume that the majority of Members are happy with the Bill and the new clause—but I am not at all happy with new clause 18 and I would not trust the Government an inch.

§ Mr. Hammond
Does my hon. Friend agree that the other possible interpretation of low turnout is bewilderment and the impenetrability of what one is dealing with? That would apply equally to the European elections and to the Bill.

§ Mr. Amess
My hon. Friend is entirely right and what he has said will perhaps seem even more true when I have developed my arguments about border arrangements.
I say to the Minister that accepting the new clause without query is not what the House is about. The Health Bill is on Report, which is an important stage of our consideration, and I congratulate my hon. Friend the Member for Altrincham and Sale, West (Mr. Brady), who taught the House how to be succinct and got a point over so that we understood it extremely well. Of course his constituents are angry about these border 57 arrangements. I understand, although he will correct me if I am wrong, that the general hospital in his constituency has closed two wards and moved 100 nurses to other—

§ Mr. Deputy Speaker
Order. Will the hon. Gentleman please return to discussing the border arrangements?

§ Mr. Amess
Of course, Mr. Deputy Speaker, but I congratulate my hon. Friend the Member for Altrincham and Sale, West on feeling so moved as to talk about the new clause in the way that he did.

§ Mr. Brady
Staying entirely in order, I should say that the planned closure of two wards at Altrincham general hospital—

§ Mr. Deputy Speaker
Order. That is not in order.

§ Mr. Amess
New clause 18 has five subsections, and I want to deal first with subsection (5), which says: 'English border area' means the area of any Health Authority adjacent to Scotland, 'Scottish border area' means the area of any Health Board adjacent to England. I apologise if I missed the Minister giving the details of those health authorities in my rush to get to the Chamber from No. 1 Parliament street, but for goodness' sake, the Bill is a shambles. That was what we found all along in Committee and we have been provided with no proper detail.
The Bill was introduced in the House of Lords and has been in Committee, but still the Government have not got their act together. I do not know how many health authorities are involved, but would it not have been sensible for the Minister to tell us precisely which ones we are talking about?

§ Mr. Fabricant
I apologise for having had to leave the Chamber for a few minutes. My hon. Friend might like to know that when I asked the Minister for a definition, he simply referred me to another provision. He could not—perhaps he was unable to—name the health authorities concerned, and I find that shocking.

§ Mr. Amess
My hon. Friend is right. I recall forecasting in Committee that the Government would collapse, and I have been proved right—it happened yesterday, when their incompetence was well and truly shown up in those shocking results. I do not know why we are rushing through proceedings—we are here to scrutinise Bills properly—and I challenge the Minister to describe in detail when he responds to this brief debate which health authorities he is talking about.
This is an important matter because my constituents in Southend, West want it to be dealt with properly and want the Government to deal with it evenhandedly. If I knew the details of the individual health authorities, I might be in a strong position to bring out particular points in respect of the border arrangements. I speak only for myself, but I find the whole concept of borders offensive. By using such a style in the Bill and in the new clause, the Government are setting people against people. What is going on is outrageous.

§ Mr. Bercow
Does my hon. Friend agree that we need to know a number of things from the Minister? First, does 58 he yet know exactly which authorities he has in mind? Secondly, has he informed the Members whose constituencies fall within the areas of those authorities? Thirdly—my hon. Friend will agree that this point is manifestly related to the matter we are discussing—should we not be told whether those Members are in the Chamber, as they are interested parties? If not, why not?

§ Mr. Amess
My hon. Friend is on to the precise point, but if he had been privileged to serve on the Standing Committee he would have witnessed at first hand what a shambles the Bill is. Although I hope that I will be corrected, I suspect that we will not find out which health authorities will be affected. That will happen when the Bill goes to the other place, because the Government hope that it will not want to scrutinise the Bill properly; but I know that the other place will certainly scrutinise the Bill properly.
One of the Labour Members who has spoken—I am determined to tease out which constituency he represents—was an outstanding Minister who had the guts to resign over child benefit, I believe, or a similar measure. As he responded to a point made by one of my colleagues, he said that Scotland needs more money to be spent on health care and then talked about areas of deprivation. Since this rotten Government came to office on 1 May 1997, there have been areas of deprivation across the length and breadth of the country. Southend, West is now an area of deprivation.
I am delighted that the Conservatives got half the votes cast in my constituency in the European election.

§ Mr. Bercow
I am interested in what my hon. Friend has to say, but I simply cannot abide any longer the House sitting on the border, languishing between knowledge and ignorance. I therefore hope that he is grateful to me for pointing out that, unless I am much mistaken, the hon. Gentleman in question represents Edinburgh, North and Leith. He has been extremely modest in refusing to take a bow, but I do not want him skulking in the shadows unnamed.

§ Mr. Amess
My hon. Friend will have helped other people, who report on these matters, and I thank him for his advice.

§ Mr. Fabricant
On that point about skulking, has my hon. Friend noticed that only at this late stage has the Scottish Health Minister arrived for the debate? We have been discussing the border areas of Scotland and England; while England has been represented, Scotland, as ever, has been unrepresented.

§ Mr. Amess
My hon. Friend is on to an excellent point.

§ Miss Widdecombe
Where is the Secretary of State?

§ Mr. Amess
Indeed, where is the Secretary of State?

§ Miss Widdecombe
My hon. Friend will be pleased to know that we have had a response to that question—the Minister assures me that the Secretary of State has much better things to do with his time.

§ Mr. Amess
Well, there we are. Obviously, Her Majesty's Government have learned nothing from what happened on Thursday and the count that took place on Sunday. Their arrogance is beyond belief.
59 I shall gently chide my right hon. Friend. Earlier, I referred to turnouts. The turnout in the Chamber is beginning to improve, so it seems that more and more hon. Members, certainly on the Conservative Benches, think that the border arrangements in new clause 18 are important.

§ Miss Widdecombe
Can my hon. Friend judge the importance attributed to border arrangements in the eyes of the Government by the number of Labour Members who have spoken?

§ Mr. Deputy Speaker
Order. Perhaps we could now turn specifically to the border arrangements.

§ Mr. Amess
I was referring to social deprivation. The NHS figures show that in 1998–99, £36,860 million was spent in England compared with £4,642 million in Scotland. For 2001–02, the figures are £45,370 million in England and £5,549 million in Scotland. In 1998–99, the figure per head was £746 in England compared with £907 in Scotland, and for 2001–02 it is £910 in England and £1,087 in Scotland. The Minister owes it to the House to give a thorough answer to the question about the real reason for the disparity in spending.
The Minister's hon. Friend, the hon. Member for Edinburgh, North and Leith (Mr. Chisholm), referred to these matters. I remember serving on a Standing Committee of a health Bill some years ago, when we debated the amount of money being spent in Scotland. Before hon. Members shout me down, I should like to refer to a debate on Scottish teeth. It was clear that in spite of the huge amount of money being spent on dental care in Scotland, Scottish teeth needed a great many more fillings than English teeth. During the Committee stage of that Bill, Labour Members, who were in opposition at that time—it is a pity they are not now—argued that that was due to diet and social deprivation. That is utter nonsense. My constituents' teeth are every bit as important as the teeth of the people affected by these border arrangements.

§ Mr. Deputy Speaker
Order. I remind the hon. Gentleman, I hope for the last time, that this debate is not about relative spending on health north and south of the border. It is specifically about technical arrangements on the border.

§ Mr. Amess
I want to draw the Minister's attention to the heart of new clause 18. He told us that subsection (4) applies to any functions under the National Health Service (Scotland) Act 1978 or part I of the National Health Service (Primary Care) Act 1997, which are exercisable by the Scottish Ministers or any health board or NHS trust established under the 1978 Act. I may have missed the Minister giving any detail about the 1978 Act and the matters that would be affected, but I would ask him to spell out in precise detail, when he replies to the debate, what he was referring to.

§ Mr. Fabricant
Does my hon. Friend agree with me that the questions he asks are a consequence of the fact that the new clause has been introduced so late? If it had not been tabled late, he would have been able to use the excellent explanatory notes, which have been prepared by able officials in the Department of Health.

§ Mr. Amess
I have not had time to read the explanatory notes. They may be excellent, but I suspect that they do not explain the 1978 Act in detail. Perhaps the Minister will tell us whether they deal with the 1978 Act.

§ Mr. Brady
Before my hon. Friend departs from subsection (4), will he tell us whether it is his understanding—as it is mine—that the phrase "Scottish Ministers" applies to Scottish Ministers in the House rather than to members of the Scottish Executive? Should any of the health matters dealt with by the Scottish Executive also be covered by subsection (4)?

§ Mr. Amess
My hon. Friend leads me on to another subject: the powers of the Scottish Parliament in relation to the Bill. In Committee, members of Her Majesty's loyal Opposition were somewhat confused about why on earth the Bill was being introduced when it was clear that the Scottish Parliament would take over the matters that we were dealing with. I have tried to follow the Bill carefully, but I am still not convinced about the relationship between the powers and duties under the Bill and the powers of the Scottish Parliament. If the Minister is saying that the border arrangements in new clause 18 override anything discussed in the Scottish Parliament, what on earth is the good of the Scottish Parliament? The Scottish people have been sold a pig in a poke.

§ Miss Widdecombe
A pup.

§ Mr. Amess
A pup, or whatever it is. They have been led up the garden path. I am pretty sure that the good citizens of Scotland will be interested to know that the Parliament they voted for in the referendum will not be as important as they believed it would be at the time, because subsection (4) will reduce the power that they thought it would have.

§ Mr. Fabricant
Does my hon. Friend recall that the part of the Bill beginning with clause 45, where new clause 18, if it is passed, will be inserted, provides that powers of the Scottish Parliament can be overridden by the Bill? Does that not make a mockery of devolution? Is that not one in the eye for Scottish electors who thought they were electing a Labour Government to get Scottish devolution only to discover that—rightly in my opinion—the Westminster Parliament can overrule the Scottish Parliament?

§ Mr. Amess
My hon. Friend's remarks are valid in relation to border arrangements.
Subsection (2) states: This subsection applies to any functions under the 1977 Act, or Part I of the National Health Service (Primary Care) Act 1997". As a courtesy to the House, the Minister should have given us a little explanation of the 1977 Act. He may want to intervene or to deal with the matter when he winds up the debate.
I was sent here as a Member of Parliament, supporting my party's beliefs, to represent the interests of my constituents. I genuinely believe that when we complete the Report stage of the Bill tomorrow—[Interruption.]—sorry, next week. When we eventually complete the 61 Report stage, my constituents will be very angry about new clause 18. They will not be happy about the cross-border arrangements.
The Bill will be a charter for private medicine. My hon. Friends the Members for Altrincham and Sale, West and for Runnymede and Weybridge (Mr. Hammond) talked about people moving across the border. The situation is a little like the council tax. We all have a road in our constituency where people on one side pay one charge and those on the other side pay a different charge. Usually the charge is lower for a Conservative council and higher for a Lib-Lab council. The disparities caused by the new clause will be similar.
The Minister fought the general election on a manifesto that said "Vote Labour on 1 May and you will save the national health service." Bearing in mind the new clause, the manifesto should have said, "Vote Labour on 1 May and you will end up needing to save the national health service." The Bill is a shambles. Why did the Minister not mention in Committee that he was going to introduce cross-border arrangements? The Government were talking about the Bill last year, but still, on 14 June 1999, they have not got their act together.

§ Mr. Bercow
The Minister is an agreeable fellow, but I know from experience that he is adept at avoiding questions. He dances round the issue, rather like Muhammad Ali used to dance like a butterfly round the boxing ring. Will my hon. Friend take this opportunity to request that the Minister answer the specific points that were raised earlier? Which authorities does the Minister have in mind? Has he spoken to hon. Members who are directly affected? On what day did he decide to introduce the new clause? We must have specific answers to those specific questions tonight.

§ Mr. Amess
I hope that we get answers to those points. We kept putting points in Committee, but we were short-changed. We may well be short-changed on Report as well.

§ Mr. Hammond
I remind my hon. Friend that I said earlier that the Minister wrote to our right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) during the Committee stage about his intention to introduce a new clause along these lines. A more fruitful line of inquiry might be why the issue was so complicated that the Government were not able to include provisions for due consideration in Committee and why we had sight of the new clause only last week.

§ Mr. Amess
My hon. Friend tempts me to get involved in a very long discussion that may be ruled out of order.
The Government will regret the day they introduced this disgraceful Bill, which has been delivered incompetently. I do not know who is to blame, but I think that it might be the person in charge of the Government. My hon. Friend the Member for Runnymede and Weybridge was right to say that the new clause could have been introduced earlier. He said that he saw the details last week. I had a busy week campaigning, which was my main priority. I did not have time to study the new clause in detail. I have had to mug up in the brief time that 62 I have had today, and I am not best pleased about that. I have had to dump all my other important arrangements to try to understand the new clause.

§ Mr. Deputy Speaker
Order. The timing of the tabling of the new clause has been more than adequately dealt with. Perhaps the hon. Gentleman will deal with its content.

§ Mr. Amess
The fifth point about the cross-border arrangements on which I want a direct answer from the Minister relates to an article that I saw in The Independent entitled "Pupils to Train as Mini-Paramedics", which said that Scottish schoolchildren were being trained in resuscitation techniques as part of a campaign to reduce the number of deaths caused by heart attacks. I applaud that. I went to a St. John Ambulance reception at which we were shown how to resuscitate people, although I would not willingly and enthusiastically jump to give resuscitation to—no, on second thoughts I would of course want to revive anyone. The article says that the campaign, funded by the British Heart Foundation, will train children in how to keep a heart attack victim alive while they wait for an ambulance to arrive. I understand that similar projects have been undertaken in America.
Will the programme be affected by the cross-border arrangements? That may be covered in subsection (1), but if it is I did not understand it and I heard nothing about it in the Minister's speech. I suspect that it might be affected. A great deal of trouble has been taken over the scheme—possibly unnecessarily.
Surely to goodness the new clause is an admission that the Government were wrong about fundholding and that it is after all a good idea. The new clause will encourage people to cross borders. I assume that the hon. Member for Dartford (Dr. Stoate) has been told to leave the Chamber. He was not welcome in Committee, either. Having tried to intervene here and have a decent debate, he has gone off. He wanted to say something about fundholding. The new clause and the Government's policy of setting citizen against citizen are an admission that they got it wrong about fundholding. Under fundholding, doctors could ring round and find out who was available to perform an operation more quickly. That was a good thing.

§ Mr. Bercow
I am listening intently to my hon. Friend. Will he entertain the possibility that the hon. Member for Dartford (Dr. Stoate) was excluded from membership of the Standing Committee not because of his views on fundholding arrangements or cross-border provisions—

§ Mr. Deputy Speaker
Order. That has nothing to do with the new clause.

§ Mr. Amess
It was kind of my hon. Friend to intervene, but I must concentrate on cross-border arrangements. I have heard a sedentary comment from a Labour Member about queue-jumping. My goodness, given the Government's policy it is appalling for any Labour Member to talk about queue-jumping. However, we will not get to that debate for some time.
63 6.30 pm
When the Minister replies, I hope that he will give the House a little more detail about subsection (3) of new clause 18. [Interruption.] My right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) suggests that the Minister has not looked at new clause 18. I hope that that is not the case, because we are on Report and Ministers should be so familiar with the detail of their legislation by this time that the answers should pour forth from them. Therefore, it is not unkind to expect the Minister to give the House more detail about subsection (3). It puzzled me. It states: Her Majesty may by Order in Council provide for any functions to which subsection (4) applies which are specified in the Order, so far as exercisable in respect of the provision of services to persons in Scottish border areas". I do not understand that and I want to know whether the Minister understands it. As the Member of Parliament for Southend, West I need to understand it because after this debate my constituents will want to know what it means.

§ Mr. Fabricant
Is it not apparent what the provision means in the sense that yet again it is an example of the Government not knowing what they intend so they give powers to the Secretary of State to make any decision he likes about doctors, patients, border areas, non-border areas, Scotland and England?

§ Mr. Amess
My hon. Friend may be right, but the new clause is defective. The Minister will claim that it is not and we will be asked to accept it, but when it goes to the House of Lords an amendment will be tabled to it. Subsection (3) continues: to be exercisable (instead of any corresponding function to which subsection (2) applies)". I do not know what subsection (2) is and I wonder whether the Minister knows what it is. It continues: in respect of the provision of the services in question to persons in English border areas who are specified in the Order.

§ Mr. Bercow
Does my hon. Friend agree that the litmus test of whether the Minister understands the new clause is that when he replies to this short debate he is able to explain its rationale and content without reference to a crib sheet provided by those whom we are not supposed to name?

§ Mr. Amess
I do not know how I should comment on that, although I believe that the Minister was a barrister or a solicitor before he became a Member of Parliament. We will have to see whether he stands at the Dispatch Box without notes and can answer my point about subsection (3).
The Minister, when he worked on new clause 18, could have made it more easily understandable. The arrangements for borders will become a big issue. In fact, I shall suggest to the Chairman of the Health Committee that we ask the Minister to come and give evidence to the Committee to justify the border arrangements. The more I listen to myself talk, the more I believe that the new clause is unfair.

§ Mr. Fabricant
It is capricious and unfair, but is not it also worrying? Subsection (3) specifically states that the 64 Secretary of State may by Order in Council provide for any functions". Has my hon. Friend discovered any other clause in the Bill that is so open that the Secretary of State can provide for any function? Is not it outrageous that he will be given a blank cheque?

§ Mr. Amess
The whole flavour of proceedings in Committee was that the Opposition were unhappy with the wide-ranging powers given to the Secretary of State for Health. I do not wish to imply that we thought that the Secretary of State for Health was incompetent, but we thought that he was too busy to do justice to all those functions.

§ Mr. Fabricant
We are in no position to judge whether the Secretary of State is competent or incompetent because he did not do the Committee the courtesy of turning up for even five minutes.

§ Mr. Amess
My hon. Friend is right. As my right hon. Friend the Member for Maidstone and The Weald was present throughout in Committee, the Secretary of State's absence was unfortunate.

§ Mr. Hammond
To return to the point that my hon. Friend was making about the wide order-making powers that the Secretary of State will have, does he agree that the Minister could have saved much debate and given us much reassurance if he had made draft orders and regulations available to us? Does my hon. Friend recall that we pressed the Minister on whether they would be made available in time for the debate today? Sadly, we have not seen any.

§ Mr. Amess
My hon. Friend is right and I congratulate him on his diligence in Committee and today. As he knows, we were not afforded that courtesy. Indeed, we tried to make constructive, sensible changes to the Bill, but we did not have one amendment accepted.

§ Mr. Deputy Speaker (Mr. Michael J. Martin)
Order. We are not considering what was accepted in Committee. We are dealing with the new clauses and amendments before us.

§ Mr. Amess
We would not be in the mess that we are now in—grappling with new clause 18—if the matter had been handled differently. The Minister is charming and persuasive and he thought that new clause 18 would be accepted without any debate. However, I do not trust the Government's motives in the border arrangements.
I wish to go into more detail about the health authorities adjacent to Scotland.

§ Mr. Swayne
Is it appropriate to call them authorities, given the huge and sweeping powers that the new clause will give the Minister over every aspect of their function? Are they authorities in any sense?

§ Mr. Amess
My hon. Friend makes a good point. I pointed out earlier that the Bill is defective and we will probably find that that description of authority is removed when the Bill is discussed in the House of Lords. The Minister has so far failed to give us any details of the 65 health authorities adjacent to Scotland. Many people are waiting to hear which health authorities have been affected. As my hon. Friend the Member for Runnymede and Weybridge pointed out earlier, people will wish to move to those areas because they think that they will get better health care. I thought that the Labour party was supposed to be about equality, but the new clause is all about inequality. It is divisive in every sense.

§ Mr. Bercow
I am still puzzled by the way in which the new clause was tabled at such short notice and without explanation. Having consulted the reference sources, I have discovered that among the Minister's interests are cooking and walking. We welcome the fact of that hinterland, but perhaps he imagines that tabling the new clause at this late stage, without explanation or apology, is like producing a new recipe. Is not it important that, wherever else he walks, he does not walk away from his responsibility to answer the serious challenges that we have posed to him?

§ Mr. Amess
That is a telling point. The Minister knows that if he gives us a precise list of the authorities concerned, Her Majesty's loyal Opposition may accept the argument. My constituents want to know which health authorities are to get special treatment.
The Labour Government talk about equality and the Minister disarmingly suggests that the new clause is merely a tidying-up measure. I believe that we have not been given the details because there is an argument going on behind the scenes. There is uproar in health authorities throughout the country, for all manner of reasons that we will discuss later. There is a row about which authorities are to be included, because inclusion will bring favourable treatment. My constituents think that that is unfair.
As the hon. Member for Edinburgh, North and Leith (Mr. Chisholm) said, there are areas of great social deprivation, not only in Scotland but throughout the country. The areas on the other side of the border will be very upset about the favourable treatment given to the authorities on the list.

§ Mr. Bercow
If the authorities due to benefit from the special arrangements have not yet been determined, is not it possible that, in the argument that is raging behind the scenes, Ministers are planning to work on the basis of a conformists' charter, and that Labour Members who are prepared to suck up to the Government will benefit from the arrangements, while those who are not, such as the hon. Member for Edinburgh, North and Leith (Mr. Chisholm), who is a faithful servant of his constituents, will not? Must not these matters be disclosed to the House without delay? It is not acceptable for this hole-in-corner practice to be allowed to continue.

§ Mr. Amess
My hon. Friend is entirely right. The Government talk about being transparent. My goodness, they were found to be transparent on Thursday and when the votes were counted on Sunday.
Let me inform my hon. Friend that there is a row going on between the Scottish Parliament and the Government about which health authorities should get preferential 66 treatment. I suspect that the Lib-Lab alliance running the Scottish Parliament is falling out with the Government. If there were nothing underhand—

§ Mr. Deputy Speaker
Order. The hon. Gentleman should not be addressing the hon. Member for Buckingham (Mr. Bercow); he should be addressing the Chair.

§ Mr. Amess
I apologise, Mr. Deputy Speaker.
6.45 pm
There is something underhand going on. The Minister must surely realise that the listing of the health authorities is crucial to our accepting the new clause; we could not countenance accepting it otherwise.
All Members of Parliament and of the Scottish Parliament are batting for resources for their own areas, so they all want favourable treatment for their health authorities. My hon. Friend the Member for New Forest, West (Mr. Swayne) said that perhaps the word "authority" was no longer appropriate. He could be right. If the legislation had not been introduced in so shambolic a fashion, we would know what responsibility Health Ministers in the Scottish Parliament have for health authorities and the relationship between that responsibility and legislation going through our Parliament.
The second part of subsection (5) is of equal importance and is perhaps a point on which all Scottish Members should seek to speak. If they do not speak, their constituents will want to know about it.

§ Mr. Brady
Is not that especially true given that this is one of the few areas of debate in which Scottish Members can rightly participate?

§ Mr. Amess
My hon. Friend has grasped the precise point. Here is an opportunity for the 72 Scottish Members—

§ Sir Robert Smith (West Aberdeenshire and Kincardine)
On a point of order, Mr. Deputy Speaker. Will you clarify that it is in order for all Members of Parliament to speak on any matter that the House is discussing?

§ Mr. Deputy Speaker
Every hon. Member would know that. Hon. Members are making a debating point.

§ Mr. Amess
Thank you, Mr. Deputy Speaker. I could comment on that point of order, but I had better not.
Every Scottish Member should note the second part of subsection (5). Sadly, we have no Conservative Members of Parliament in Scotland at the moment. [Interruption.] My hon. Friends remind me that we have two Members of the European Parliament there; or perhaps more. We have Scottish Euro-Members but no Scottish Members of Parliament. Labour, Liberal and Scottish National Members should surely to goodness want to know about the health boards adjacent to England.
If the point made by the hon. Member for Edinburgh, North and Leith about areas of social deprivation is valid, surely many Scottish Members should want the Minister to tell us which health boards are affected.

§ Mr. Chisholm
I want to put it on the record that I never mentioned areas of deprivation, but I have been 67 slightly shy of intervening because, after five weeks in the Scottish Parliament, I am in a state of culture shock: up there we are trying to have genuine debate and scrutiny rather than the time-wasting self-indulgence that we are witnessing today.

§ Mr. Deputy Speaker
Order. The hon. Member for Southend, West (Mr. Amess) is not time wasting. I would not allow that. However, he has made his case about the cross-border authorities, and must move on.

§ Mr. Amess
Thank you, Mr. Deputy Speaker, for not allowing me to respond to the point. In fact, I had not realised that the hon. Member for Edinburgh, North and Leith was also in the Scottish Parliament.

§ Mr. Bercow
I do not want to tempt my hon. Friend away from his normal path of rectitude, as he always adheres to the traditions of the House. However, the hon. Member for Edinburgh, North and Leith is the only Scottish Labour Back Bencher in the Chamber. Does not my hon. Friend agree that it is important that the Minister, when he winds up, says whether those hon. Members affected by the new clause have been briefed in advance? Are Labour Members absent because, as the relevant information has been vouchsafed to them already, they think that they need not contribute, or because they are incompetent and have simply forgotten that the Bill has come back on Report today?

§ Mr. Amess
The reason is arrogance: Labour Members think it a bore to scrutinise legislation. They accept without question everything that the Government propose. That is outrageous. This is the mother of Parliaments, and hon. Members should understand that they are not irrelevant to the scrutiny of legislation. I would not have spoken if the Minister had intervened to list the authorities and health boards affected, but he has not done so.
It is frustrating that Opposition Members get no answers to their questions. I find that I am able to challenge the Executive only in Select Committee. New clause 18 deals with important matters. It is all about money spent in the health service, but the disparity that it introduces is unacceptable. It is also unacceptable—and arrogant—of the Government to table a new clause and expect no one to question the detail. The National Health Service Act 1977 and the National Health Service (Primary Care) Act 1997 matter.

§ Mr. John Hayes (South Holland and The Deepings)
My hon. Friend makes a profound point, but this is not the first example of such behaviour by the Government. Introducing new clauses in this way has become the hallmark of this Administration. It is impossible to examine important measures in sufficient detail, and I am surprised that Labour Back Benchers—who are also entitled to hold the Executive to account—do not feel the same way. Although my hon. Friend is too generous and liberal with the Government, I support him and hope Labour Back Benchers will do the same.

§ Mr. Deputy Speaker
Order. I have no argument with the point being made by the hon. Member for Southend, 68 West, but he has made it several times. Once a point has been made, it cannot be repeated. The hon. Gentleman must move on.

§ Mr. Amess
The Minister owes it to the House to convince us that the new clause is in the best interests of all United Kingdom citizens. For myself, I found it profoundly unsatisfactory that the Minister moved the new clause without giving any detail of its affect on the rest of our constituents. The detailed arguments about people moving house and changing doctors are relevant, because the Government's health strategy reveals a profound misunderstanding of how health care should be delivered.
This is bad legislation. As I said earlier, I am suspicious of the Government's motives with the new clause, which will affect health care delivery in every part of the country.

§ Mr. Swayne
On the national question, I refer my hon. Friend to the brief intervention from the hon. Member for West Aberdeenshire and Kincardine (Sir R. Smith). My hon. Friend was very courteous in giving way, so short was the hon. Gentleman's appearance in the Chamber. Does my hon. Friend agree that some legislation, such as that covering human fertilisation, remains the prerogative of this House, but that determination of the provision in Scotland of treatment under that legislation is the sole preserve of the Scottish Parliament? That may place a differential burden on health authorities—

§ Mr. Deputy Speaker
Order. I invite the hon. Gentleman not to get into such matters.

§ Mr. Amess
I shall say to my hon. Friend only that it is a discourtesy when an hon. Member intervenes in a debate and then scuttles out of the Chamber.

§ Dr. Evan Harris (Oxford, West and Abingdon)
My hon. Friend the Member for West Aberdeenshire and Kincardine (Sir R. Smith) made a point of order, not an intervention.

§ Mr. Deputy Speaker
Order. I am not concerned about who enters and leaves the Chamber, as that has nothing to do with new clause 18. I am concerned with the debate, which is about the amendments before us.

§ Mr. Amess
I am worried that new clause 18 will have an adverse effect on health care throughout the country. It will be discriminatory, and will introduce a great disparity in health care provision between areas. People will find it very confusing.
I think that the Minister's heart has never been in the Bill. I do not doubt that he is doing his duty for the Government, but I doubt that he would table new clause 18 were he in overall charge of the Bill. I think that he agrees that it will cause great dissatisfaction among our constituents, and believe that he will regret the day that he came to be associated with the Bill and the new clause.
Although some hon. Members believe that a low attendance in the Chamber indicates satisfaction with a proposal, I feel so passionately about the Bill that it is important that we scrutinise it properly on Report. I shall not desist until I get some straight answers. I have asked 69 five specific questions of the Minister. If the Minister would, at the very least, provide a list of the health authorities and boards affected on either side of the border, he would restore my faith in his good will.
7 pm
I am dissatisfied with the way in which this legislation is being handled. People look to this Chamber to legislate in the best interests of everyone, and I hope that the Minister will realise that the disparity in treatment that will be caused by new clause 18 is not in the best interests of his own constituents, of my constituents or of the constituents of my hon. Friends the Members for Altrincham and Sale, West, for Buckingham (Mr. Bercow), for Uxbridge (Mr. Randall), for New Forest, West, for South Holland and The Deepings (Mr. Hayes), for Runnymede and Weybridge, for Rutland and Melton (Mr. Duncan), and for my right hon. Friend the Member for Maidstone and The Weald. The Minister should withdraw new clause 18 because he should admit that it has been defectively drafted. If he thinks that we will accept it without question or that it will not be properly scrutinised when it returns to the other place, he will be disappointed.
I appeal to the Government to give the House detail on the five points that I have raised and the other points made—so succinctly—by my hon. Friends.

§ Mr. Denham
I shall try to answer as many points as possible, but the hon. Gentleman will understand if I have sometimes missed his meaning during the past hour.
It is worth remembering what I said earlier. We estimate that about 3,500 patients will be affected by the Bill, which is the number of patients in England and Scotland who are registered with a GP practice on the other side of their border. I would not be introducing the new clause if I had not been assured that it had been fully explained to health authorities and boards and the other groups involved and that they had been fully consulted. Everyone who has responded has been in favour of our approach. The new clause addresses practical problems that have faced GPs who provide primary care in what are often scattered rural communities.

§ Mr. Brady
What about the health authorities or boards not immediately adjacent to the border? Were the next ones up consulted too?

§ Mr. Denham
I am fairly certain that they were not; I see no reason why they should have been. The health authorities and boards concerned are responsible for areas rather larger than those covered by the practices involved. I could see no point in extending consultation further south or north of the border. I had to be sure that the measure was supported. In fact, the idea was initially suggested not by the Government, but by general practitioners who have complained about the current position for several years.

§ Mr. Swayne
In what detail were the health authorities consulted? How the Government intend to proceed is not clear from the new clause. Presumably, the health authorities were given detail that we have been denied.

§ Mr. Denham
As I have already said, they were told that we intended to use the new clause to enable health 70 authorities, primary care groups, primary care trusts and the Scottish equivalents to commission services for all their patients, irrespective of on which side of any border they lived.
The hon. Member for Runnymede and Weybridge (Mr. Hammond) asked about part II services.

§ Mr. Bercow
Was the estimate that 3,500 people are likely to be affected based on current figures, which could increase or decrease? Alternatively, was it predicated on the assumption, to which my hon. Friend the Member for Altrincham and Sale, West (Mr. Brady) has referred, that lists would be frozen?

§ Mr. Denham
For 1998–99, the exact estimate was that 2,313 English residents were on lists of GPs in Scotland, while 1,125 Scottish residents had GPs in England.
Several hon. Members have asked about how orders would be made and which patients would be affected by them. Although it is highly unlikely that people will sign up for a practice many miles from their homes to gain some perceived benefit, I can assure the House that any order would be specific about the category of people to whom it would apply, which gives us the ability to tackle that unlikely scenario. I was asked whether orders could fix the number of patients at the time of their introduction. Order-making powers might enable us to prevent people from signing up for practices many miles from their homes where it would be unnecessary or perverse. However, we see no need to fix lists and have taken no such decision. New patients are always moving in and out of areas and registering with a GP practice.

§ Mr. Brady
Surely there must be many cases—beta interferon, for example, or any other expensive drug or treatment—in which it would be entirely rational for someone to move house into an area covered by an order. However an order is drafted, it cannot possibly preclude people who do that from being allowed to register with a GP.

§ Mr. Denham
The position has been misunderstood. If people felt now that it would be better to move either north or south of the border, they could do so. We must focus on the need to sort out the practical problems faced by GP practices and patients when it comes to the delivery of health care in border areas. The new clause is a sensible means of dealing with those problems.

§ Mr. Bercow
Will the Minister give way?

§ Mr. Denham
I have given way several times and would like to get on. We have had a lengthy debate and I want to move on to some of the other reasonable questions that were posed.

§ Mr. Hammond
I have listened carefully to the Minister. Without going to the extreme solution of moving house, will the hon. Gentleman clarify one matter? Where a health authority area includes a number of people who are patients of a GP over the border, would anything prevent any other persons residing in that authority area from signing on with that GP if they wished to do so, or can only certain people in the area access that privilege?

§ Mr. Denham
I may have missed the hon. Gentleman's point, but at the moment if a Scottish patient, for example, 71 registers with an English GP, that GP has to make provision under the Scottish health service and vice versa. New clause 18 seeks to deal with the problems that arise from that situation.
At present, if one crosses the border to register with a GP one none the less remains treated by one's own, English or Scottish, health service. That decision was taken during the early 1990s, I presume. That causes GPs or primary care groups practical problems, such as being able sensibly to commission treatment on behalf of their patients. That is why it is more sensible for treatment for all patients of the practice to be commissioned because they are attached to that practice rather than according to the health authority in whose geographical area they live.

§ Mr. Hammond
I thank the Minister for that explanation, which was extremely useful. However, he did not deal with my question. Is he telling the House that only people who live in a tightly defined sub-region of the health authority or health board area can access a GP on the other side of the border, or would I be right in thinking that any patient who lives in the area has the right to transfer? Would he not anticipate an exodus of patients to those border GPs, if there were sufficient incentive—for example, if there were significant differences in treatment and service availability on either side of the border?

§ Mr. Denham
I do not anticipate that trend developing in practice. One can construct such a theoretical argument—the hon. Member for Altrincham and Sale, West (Mr. Brady) did so—but in practice, most people, sensibly, want their GP to be within a reasonable distance. We are talking about vast rural areas. GPs can be a long way away and it is unlikely that people will want to go even further. Also, it is unlikely in practice that such a disparity in services will arise. Indeed, had real concern that that would happen existed, I am sure that it would have been mentioned by the people we directly consulted—the GPs themselves, who are concerned about their patients, and the health board in the area.
There are two further protections. The hon. Member for Runnymede and Weybridge asked whether anyone could theoretically sign up to a GP over the border. The order can specify the persons to whom it applies and the functions affected. Also, as I said—this answers the question about overruling the Scottish Parliament—each order will be subject to affirmative resolution both here and in the Scottish Parliament. Therefore, the provisions being made under the new clause could be scrutinised.

§ Mr. Bercow
Will the Minister give way?

§ Mr. Denham
One more time.

§ Mr. Bercow
I am grateful to the Minister, whose patience and charity are well established throughout the House. Will he explain whether the order could not only specify categories of people to whom the arrangements would apply, but limit the number to whom they would 72 apply? Does he accept that in either case a problem would arise? If there is a limit on numbers, it is arbitrary; if there is not, the flood gates have been opened.

§ Mr. Deputy Speaker
Order. That was not a very brief intervention.

§ Mr. Denham
I had quite settled back into my seat, Mr. Deputy Speaker.
The order could specify the number of people. I am not sure that that is likely to be the way in which one would approach the problem, but the hon. Gentleman asked a reasonable question about the breadth of the legal provision, and the answer is yes.
I must deal with two specific points. First, the hon. Member for Runnymede and Weybridge asked about the fact that part II arrangements are included in the drafting of the clause and about our intentions in that regard. That has been done to allow the scope, if it were decided that we should do so, for streamlining part II arrangements for cross-border GPs who—this is analogous to the commissioning of care for patients—work to two different Red Books for two different sets of patients. The drafting of the Bill would enable that to be streamlined, but I must stress for the record that we have not decided to go down that road and we have not even begun any consultation with the GPs, health authorities or health boards affected. We would certainly want to do so before moving in that direction. The extension to part II would allow that change to take place.

§ Mr. Hammond
I thank the Minister for that clarification. If he has made no moves in that direction and has not begun any consultation, what changed between the date of his letter to my right hon. Friend the Member for Maidstone and The Weald (Miss Widdecombe) the week before last and his tabling of the new clause last week?

§ Mr. Denham
The answer to that question is that the clause was tabled after further examination of the issue and the provision that we should make.
I have always regretted the introduction of new clauses at a late stage in a Bill, as I did when we were in opposition. During the passage of the National Health Service (Primary Care) Bill, which was considerably less lengthy and complex than this Bill, three times as many new clauses were introduced on Report than have been introduced for this Bill, which I thought regrettable. I recall Conservative Members making speeches from the Government Benches that deprecated the fact that so many new clauses were introduced—well, I would like to think that I can recall that, but I think that they overlooked the matter at the time.
The final and most important question concerns the funding arrangements. I do not intend to debate the entire Barnett formula, save to note again that hon. Members who have suddenly discovered its existence seemed to be silent about its dire consequences throughout most of the 18 years of the previous Administration.
We intend that the allocations of the health authorities and boards concerned will be adjusted to reflect the new arrangements and through that the different level of funding. It is intended that the adjustment should affect the actual level of spending on the patients concerned as is reflected in current commissioning arrangements. 73 For example, the allocation of an English health authority or primary care trust would be increased to reflect the current levels of spending on any Scots on the GP list. There is no question of money being lost to Scots patients because of the arrangements.
However, that is not to push the concept of capitation funding too far. It is not as though each individual is entitled to a fixed amount, which flows—ultimately—from the Barnett formula. Even under the previous Conservative Administration, the health service was not divided up with a fixed sum per head. A health authority, a health board or a primary care trust will use its funds to respond flexibly to the needs of its local population—whatever level of capitation each individual may, notionally, have attracted. That applies on both sides of the border.
It is worth bearing in mind that the existing arrangements have their drawbacks, which is why we want to take this action. Those arrangements take up time, energy and resources that might better be devoted to patient care. For example, at present, practices have to provide different arrangements for their English and Scottish patients. As I pointed out earlier, one practice reported having to liaise with six different teams of community staff to cover its scattered population.
A question was put about the letter from my predecessor to Dr. John Chisholm of the GPC—part of the British Medical Association. When my predecessor wrote that letter, the then Minister at the Scottish Office with responsibility for health wrote to the BMA in Scotland and gave similar guarantees. I am advised that those were repeated in guidance issued to local health care committees in Scotland on 8 February this year.

§ Mr. Hammond
Does the Minister know whether the assurances given by Scottish Ministers in this Parliament have been repeated by Ministers in the Scottish Executive since that body came into being?

§ Mr. Denham
I have no knowledge of that, although I shall look to the Under-Secretary of State for Scotland, my hon. Friend the Member for Western Isles (Mr. Macdonald), for information on that point. That matter is clearly not my responsibility.
I confirm that, fortunately for geography teachers and students throughout the country, there is no debate on which areas of England and Scotland lie adjacent to the border. There is no option in that matter. The English health authorities defined in the Bill will be North Cumbria and Northumberland and the Scottish health boards will be Borders and Dumfries and Galloway.