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get to the bathroom because it was so far away. It seems pretty obvious that decent toilet and washing facilities should be provided within easy reach of people who cannot move far.

There is much detail to be worked out in seeking to achieve proper inspection, but it needs to be done if old people are not merely to be set aside and forgotten about as though they have stopped mattering as long as they have a roof over their head. If we do not set standards and establish an inspectorate to check them, local authority social workers may well feel that they simply have to put up with the standards set in their area.

It would depend on what happened to be available. Standards could vary widely, and we could know that some of them were unacceptable but be unable to do anything about it--except to wring our hands and try to shift people around to better accommodation. But old people should not be shunted around like parcels from one place to another. They should be able to end their days in comfort, peace and security. It does not seem too much to ask that old people who cannot look after their own affairs any more should be assured of safety, security and comfort and minimal decent standards.

I hope that the Minister will be able to accede to our request. If the Government can inspect cottages to discover whether they are liable to poll tax, they can surely inspect small homes in which old people live.

11.45 pm

Mr. Kenneth Clarke : I have always regarded the hon. Members for Monklands, West (Mr. Clarke) and for Ross, Cromarty and Skye (Mr. Kennedy) as among the more sincere hon. Members in the House. However, when they said that they were looking forward to continuing after midnight and how much they feared the imminent approach of the guillotine, I was less than usually convinced that they meant everything that they were saying--they do not look like men dying to go on after midnight.

I am delighted that we have reached the new clauses dealing with quality. As speeches from hon. Members on both sides of the House have shown, there is virtual unanimity on the idea that raising the quality of care and clinical treatment in the NHS and of the care and support that can be given to those who live in the community and require better domiciliary services is at the heart of all our ambitions. Certainly, the notion of raising the quality of the NHS and of domiciliary and residential services in the community is at the heart of the Government's reforms, and of this Bill.

Quality has been the mainstay of all our proposals, and I do not instinctively think about it along the lines of the amendments. That reveals the political division between us on method. I do not begin by thinking of great national committees and quangos to inspect everyone and ensure quality in a service that is already giant and daunting in its complexity and geographical scope. I have always thought that the idea of central Government laying down minimum standards, as suggested by the hon. Member for Ross, Cromarty and Skye, is not very useful, because there is so much variation across the country and among client groups.

Our approach to these reforms has been to build into the organisation and the systems of the NHS and care in the community methods that will stimulate those who

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work in the service at local level to strive to achieve the highest possible quality in response to the patients and clients whom they serve.

Those of us who were here between 3 am and 6 am today will recall that the Government look to contracts, above all else, to raise the quality of the services provided in the NHS. At times we held what was almost a seminar this morning ; at times our exchanges about exactly how we see quality being reflected and defended in the contract system were lively. The hon. Member for Newham, South (Mr. Spearing) laughs. From beginning to end, the hon. Gentleman has not quite understood the contract system in the NHS.

In future, services will be provided locally in pursuance of an agreement between the district health authority or general practitioner and hospitals and community units. Those who want services provided for residents will stipulate what they want--not just their quantity and cost, but most importantly their quality which they can specify and how they will measure it when the service is delivered. In exchange, those who work in the units and deliver the services will sign up to a given level of quality, explain how they propose to measure it, and deliver it in exchange for the resources that they have agreed to receive.

Every contract will stipulate the quality of service. We went over this ground in Committee when I said that I would let Committee members have the first specimen contract as quickly as possible. Those contracts vary in quantity and they have been worked out in different parts of the NHS as people with enthusiasm for the idea have got down to producing the type of contract that should be exchanged between a district health authority of a GP practice and a hospital that sets out what service is meant to be provided and what quality is to be attained.

I want the professions, doctors and nurses to look at the contract to see what they think about it for their particular service. Many doctors and nurses may not like the way in which the quality of their service is described. In that case the royal colleges must lay down how they would like their service to be judged and describe the quality to which they aspire. In that way they will help us to produce good contracts with which they can feel content because they are being asked to deliver something sensible that they should like to achieve and by which they are content to be measured in exchange for the resources that they require.

Fortunately, we are moving away from some of the rubbish that we have had for heaven knows how many hours. We are now coming down to the realities of what is being worked upon in 190 districts in England, Scotland and Wales as they prepare for the reforms. My hon. Friend the Member for Ealing, Acton (Sir G. Young) tabled amendments Nos. 4, 5 and 6, supported by my hon. Friend the Member for Northampton, South (Mr. Morris). They agree with the underlying aim to build stipulated quality into the arrangements for the work of the NHS. I do not like putting the whole thing in a straitjacket as their amendments suggest. I welcome my hon. Friends' attempts to set up, step by step, what should be done and what is required, but I do not want all the units and all the districts to grab the rulebook or the statute while saying that everything must be reduced to this, this and this. We are pursuing the underlying aims described by my hon. Friends.

I know that I frequently describe all our reforms in terms of acute services--I always talk about hip replacements or varicose veins, things for which there are

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waiting lists. I talk about the cold surgery about which most of our constituents are conscious. It is best to describe those services because they are the easiest to describe in terms of contract, quality, arranging the price and such. The contracts on which we must work, however, are those for more complicated services. We want an integrated service between the acute sector and community care. We must work on those contracts involving a mixture of disciplines--for example, doctors and nurses. In those circumstances, one may be talking not about the treatment of a disease, but the management of a condition such as diabetes.

The contractual system at the heart of our reforms will contribute far more to raising the quality of the NHS than the committees and other ideas--the only ideas--produced by the Opposition.

Sir Michael McNair-Wilson : I accept what my right hon. and learned Friend says about contracts being an obvious yardstick of the success of a particular hospital, but he is talking too clinically. Surely the real critic of the efficiency of a service is the patient. He will decide whether the contract was placed in the right hospital and whether the right service was provided. The contract can give only an indication. It cannot supply the playback from the customer that many of us want.

Mr. Clarke : We can steer through all the formalities. We can enter into contracts and alter present structures so that everyone knows what we are talking about in terms of quantity, how soon one will receive one's first outpatient treatment, how much it will cost, the quality stipulated by the GP and how that will be measured by the DHA or whoever thereafter.

What in the end will determine whether it is a success is the patient's judgment of how it works. So we are building in more consumer choice, making GPs more responsive to their patients and the DHAs more responsive to their GPs. The contracts will also be steered to those places where the patients feel most content, either because they particularly want to go to their local hospitals or because they are treated better there in every way, from the appointment arrangements to the follow-up after they have left hospital. That will help to determine what really goes on, will humanise the whole system and help to stimulate higher quality.

My hon. Friend the Member for Northampton, South said that we needed a system of quality control. I could not agree more. It is surprising that of all the health care systems throughout the world, none of them measures the quality of outputs. Indeed, most health care systems never bother to measure their outputs at all. The Labour party in the House typifies what goes on in health care systems throughout the world. They are dominated by the interests of the people who work in them to such an extent that they never bother to ask what is coming out by way of service and quality.

We are introducing a system of clinical audit, and we have the full agreement of the medical profession in doing so. When I was first at the Department of Health a few years ago, for a Minister to suggest to many in the medical profession that we would clinical audit and go in for organised quality control across the system was regarded as a blasphemous utterance. I concede that the Royal

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College of Surgeons has done valuable pioneering work. The same is true of the Royal College of Anaesthetists, the Royal College of General Practitioners and the Royal College of Nursing. The whole medical profession has swung round, and we are allowing them to organise their own system of clinical audit which will systematically measure the quality of their output.

But I appreciate that there are still concerns about quality in the NHS. Some of those concerns expressed last summer, when all the campaigning was going on, involved people raising fears about the quality of the service as an excuse for trying to stop anything being changed in the environments in which they worked. But that was never the position of the Royal College of Nursing, to which several hon. Members have referred.

As I say, concerns remain. The hon. Member for Ross, Cromarty and Skye said that all I talked about now was interesting but new, and was therefore disturbing, unsettling and worrying to those who worked in the service. We must continue to reassure all concerned that we are striving to raise quality and that they have nothing to fear--either themselves or in terms of the quality of care for their patients--if they join in with us.

Because there are still those fears, which I think are misplaced, I have invited all the medical royal colleges and the other statutory bodies to enter into talks with me about how, even at this stage of the Bill--if necessary, by statutory revision, which will have to occur in another place --we can devise new systems which will enable us to monitor and check to make sure that the higher standards of care are achieved. Those talks are going on now and I trust that they will reach a successful outcome.

Mr. Michael : What a filibuster.

Mr. Clarke : I am not taking lectures from the hon. Gentleman about filibusters. He conducted a filibuster about eight hours ago. Now he can listen to some serious content.

In respect of care in the community, which is a particular concern of the hon. Member for Monklands, West, we are strengthening greatly the social services inspectorate in England.

Mr. Tom Clarke : The Secretary of State must be aware that, although those may sound to him like fine words, they in no way match up to the promises given in Committee. If the Government are as convinced as the right hon. and learned Gentleman claims about the need for quality, let them show it by accepting what is a reasonable new clause. I hope that he will do that. But if he does not, I shall invite the House to divide on the issue.

Mr. Clarke : I am glad to hear that. As I said at the outset, the whole basis of our reforms is aimed at raising the quality of treatment and care in the Health Service and the community services. All that the Labour party can do after hours of debate and months of deliberation is to advocate the setting up of a new Committee. The bureaucratic approach to the Health Service which dominated its policy in the past will soon be swept away. If Labour Members wish to divide on this new clause, I trust that it will be rejected as wholly inadequate to the challenges facing the National Health Service which will be more properly addressed by our reforms, when they are

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implemented--on time--at the beginning of April 1991. That is when a better National Health Service will begin to be delivered. 12 midnight

Mr. Tom Clarke : That was as unsatisfactory as the rest of the Secretary of State's speech. I ask the House to divide.

Question put, That the clause be read a Second time :

The House divided : Ayes 203, Noes 279.

Division No. 127] [12 midnight

AYES

Abbott, Ms Diane

Adams, Allen (Paisley N)

Allen, Graham

Alton, David

Anderson, Donald

Archer, Rt Hon Peter

Armstrong, Hilary

Ashton, Joe

Banks, Tony (Newham NW)

Barnes, Harry (Derbyshire NE)

Barnes, Mrs Rosie (Greenwich)

Barron, Kevin

Battle, John

Beggs, Roy

Beith, A. J.

Benn, Rt Hon Tony

Bennett, A. F. (D'nt'n & R'dish)

Bermingham, Gerald

Blair, Tony

Blunkett, David

Boateng, Paul

Boyes, Roland

Bradley, Keith

Brown, Gordon (D'mline E)

Brown, Nicholas (Newcastle E)

Brown, Ron (Edinburgh Leith)

Buchan, Norman

Buckley, George J.

Caborn, Richard

Campbell, Menzies (Fife NE)

Campbell, Ron (Blyth Valley)

Campbell-Savours, D. N.

Carlile, Alex (Mont'g)

Cartwright, John

Clark, Dr David (S Shields)

Clarke, Tom (Monklands W)

Clay, Bob

Clelland, David

Clwyd, Mrs Ann

Cohen, Harry

Coleman, Donald

Cook, Robin (Livingston)

Cousins, Jim

Cox, Tom

Crowther, Stan

Cryer, Bob

Cummings, John

Dalyell, Tam

Darling, Alistair

Davies, Rt Hon Denzil (Llanelli)

Davies, Ron (Caerphilly)

Davis, Terry (B'ham Hodge H'l)

Dixon, Don

Dobson, Frank

Doran, Frank

Duffy, A. E. P.

Dunnachie, Jimmy

Eadie, Alexander

Eastham, Ken

Ewing, Harry (Falkirk E)

Ewing, Mrs Margaret (Moray)

Faulds, Andrew

Fearn, Ronald

Field, Frank (Birkenhead)

Fields, Terry (L'pool B G'n)

Fisher, Mark

Flannery, Martin

Flynn, Paul

Foot, Rt Hon Michael

Foster, Derek

Fraser, John

Fyfe, Maria

Galloway, George

Garrett, John (Norwich South)

Garrett, Ted (Wallsend)

George, Bruce

Gilbert, Rt Hon Dr John

Godman, Dr Norman A.

Gordon, Mildred

Gould, Bryan

Graham, Thomas

Grant, Bernie (Tottenham)

Griffiths, Nigel (Edinburgh S)

Griffiths, Win (Bridgend)

Hardy, Peter

Harman, Ms Harriet

Hattersley, Rt Hon Roy

Henderson, Doug

Hinchliffe, David

Hoey, Ms Kate (Vauxhall)

Hogg, N. (C'nauld & Kilsyth)

Home Robertson, John

Hood, Jimmy

Howarth, George (Knowsley N)

Howells, Geraint

Howells, Dr. Kim (Pontypridd)

Hoyle, Doug

Hughes, John (Coventry NE)

Hughes, Robert (Aberdeen N)

Hughes, Roy (Newport E)

Hughes, Simon (Southwark)

Illsley, Eric

Ingram, Adam

Jones, Barry (Alyn & Deeside)

Jones, Ieuan (Ynys Mo n)

Jones, Martyn (Clwyd S W)

Kennedy, Charles

Kilfedder, James

Lamond, James

Leadbitter, Ted

Lestor, Joan (Eccles)

Lewis, Terry

Livingstone, Ken

Livsey, Richard

Lloyd, Tony (Stretford)

Lofthouse, Geoffrey

Loyden, Eddie

McAllion, John

McAvoy, Thomas

McCartney, Ian

Macdonald, Calum A.

McFall, John

McKay, Allen (Barnsley West)

McKelvey, William

Maclennan, Robert

McNamara, Kevin

Madden, Max

Maginnis, Ken

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