ADVISORY COMMITTEE WITH RESPECT TO STANDARDS

HC Deb 14 March 1990 vol 169 cc597-617

'( ).—(1) The Secretary of State shall establish and maintain a committee for advising him with respect to the maintenance and improvement of the quality of goods or services provided by any health service body under an NHS contract.

(2) The committee established and maintained under this section—

1. (a) shall consist of a chairman and not more than nine other members, appointed by the Secretary of State;
2. (b) shall include such representatives of the medical and nursing professions and organisations representing consumers as seem appropriate to the Secretary of State; and
3. (c) shall meet at least twice a year.

(3) It shall be the duty of the Secretary of State—

1. (a) to consult the advisory committee, and
2. (b) to consider any representation made to him by the advisory committee, on any matter pertaining to the quality of any goods or services provided by any health service body under an NHS contract.

(4) It shall be the duty of the Advisory Committee to make recommendations to the Secretary of State with respect to measures which it considers best calculated to maintain and improve standards of goods or services provided by health service bodies.

(5) The Secretary of State may by regulation, approve any recommendations of the advisory committee for the purpose of—

1. (a) giving practical guidance to health service bodies with respect to maintaining and improving standards of goods or services supplied or received; and
2. (b) promoting what appear to him to be desirable practices in the provision of goods or services under NHS contracts.

(6) In this section "health service body" and "NHS contract" have the same meanings as in section 4 of this Act.'.—[Mr. Tom Clarke.]

Brought up, and read the First time.

Madam Deputy Speaker

With this it will be convenient to take the following: New Clause 16—Advisory Committee: supplementary powers—

'( ).—(1) For the purpose of ensuring compliance with any regulation issued under subsection (Advisory Committee with respect to standards) (5) above, the chairman of the advisory committee may, at any time, cause an assessment to be made of the working practices of any hospital, establishment or other facility involved in the provision of goods or services under section 4 of this Act.

(2) The results of any assessment carried out under subsection (1) above shall be reported to the Secretary of State by the chairman of the advisory committee.

(3) The chairman of the advisory committee may, with the approval of the Secretary of State as to the numbers and terms and conditions of service, appoint such staff as he may determine to fulfil the duties of the advisory committee under this Act.

(4) There shall be paid out of monies provided by Parliament the remuneration of, and any travelling or other allowances payable to the members of staff of the advisory committee in consequence of the provisions of this Act.'.

New clause 35—Standards and inspection of community care services—

"(1) The Secretary of State shall establish a minimum standard for community care services which every individual may expect to receive.

(2) The Secretary of State shall ensure that there is an inspectorate that is sufficiently staffed to ensure that the minimum standards are adhered to by local authorities.

(3) In setting minimum standards under subsection I the Secretary of State shall consult those bodies he considers are representative of those who have the experience and knowledge of the provision and need for community care services.'.

New clause 38—Standards and inspection of community care services (Scotland)—

"(1) The Secretary of State shall establish a minimum standard for community care services which every individual may expect to receive.

(2) The Secretary of State shall ensure the establishment of a Social Services Inspectorate sufficiently staffed to ensure that the minimum standards are adhered to by local authorities.

(3) In setting minimum standards under subsection 1 the Secretary of State shall consult those bodies he considers are representative of those who have the experience and knowledge of the provision and need for community care services.'.

New Clause 45—NHS Contracts—

(1) The acquirer of an NHS contract shall take into account not just price but a broad range of factors when considering which provider should be awarded the contract. This will include the quality of service provided taking into account both patient satisfaction and clinical effectiveness.

(2) The acquirer shall institute a thorough and ongoing monitoring of the contract as it progresses which shall be open to public inspection.

(3) A complaints procedure shall be instituted for both staff and patients with respect to the operation of the contract.'.

New Clause 47—Clinical Effectiveness—

'The Secretary of State shall in pursuit of satisfactory systems of measuring clinical effectiveness and quality of treatments:—

1. (1) create an applied research agency for the NHS;
2. (2) develop a clinical database to support the epidemiological research it will do;
3. (3) with the data and methodoligies developed, introduce an ongoing monitoring and audit of clinical practice both to discover and disseminate best practice throughout the system.'.

We will also consider the following amendments: No. 228, in clause 3, page 3, line 11, at end insert— '1A. In carrying out its primary functions including those provided under Section 4 below, a Regional, District or Special Health Authority or a Family Health Services Authority must ensure that the quality of such goods or services that it may provide, attains such standards of quality as may be determined by the Secretary of State for those particular goods and services and must publish annually a report giving details of its attainments in monitoring and improving quality standards.'.

No. 15, in clause 4, page 4, line 36, at end insert—

'(3) No National Health Service contract shall be valid unless it specifies the quality of service to be provided under the contract and how the quality is to be measured and monitored.'.

No. 21, in page 4, line 36, at end add—

'(3A) The acquirer will—

1. (a) publish the terms and conditions of any contract agreed with the provider;
2. (b) institute a thorough and ongoing monitoring and quality assurance programme keeping the local CHC aware of developments;
3. (c) create a complaints procedure for staff and patients with respect to the contract.'.

No. 33, in page 4, line 36, at end insert—

'(()) The Secretary of State may by regulations, require any health service body acting as a provider to have regard to:

1. (a) any relevant national codes of practice pertaining to any goods or services provided;
2. (b) any specific outcome requirements established by him, both applicable generally and in relation to specific clinical conditions, or
3. (c) any minimum standards of performance on any matter of concern, determined by him, in respect of any NIIS contract to which the provider is a part.'.

No. 4, in page 4, line 42, at end insert—

'(3A) Where any health service body proposes to enter into an arrangement which will be an NHS contract in which it will be the acquirer within the meaning of subsection (1) above, it shall publish a document setting out the standards of goods and services which are proposed to be acquired under that arrangement.

(3B) Prior to making a decision about the standards of goods and services which are proposed to be acquired, a health service body shall seek the views of Community Health Councils within their district on the standards of goods and services, and shall also seek the views of such other persons as seem to them to have an interest in the matter or to be representative of the interest of patients in their district on the matter, and shall, in determining the standards of goods and services, take account of any views or representations received on the matter.'.

No. 5, in page 4, line 42, at end insert— '(3A) The Secretary of State shall by regulations specify, for each category of services, the standards of goods and services which shall be the minimum standards for goods and services which may be specified by any health service body which is an acquirer in the terms and conditions of any arrangements which is a National Health Service contract.'.

No. 57, in page 4, line 42, at end insert— '(3A) Any contract made under subsection (1) above shall provide that services supplied by NHS consultants shall he subject to the professional standards of care then in force under the regulations of the Royal College having jurisdiction for the place in which the contract is made.'.

No. 6, in page 5, line 33, at end insert— '(7A) The terms and conditions of any arrangement which is an NHS contract shall include a statement of the means by which the acquirer will satisfy himself, throughout the term of the arrangement, that the standards of goods and services provided under that arrangement are sufficient to meet the standards specified in the terms and conditions of the arrangement.

(7B) Where the terms and conditions of any arrangement which is an NHS contract include a statement referred to in subsection (7A), it shall be the duty of the provider under that arrangement to make available any facilities, information or services necessary to permit the acquirer to satisfy himself as subsection (7A) requires.'.

No. 135, in clause 28, page 26, line 33, at end insert— '(2A) No National Health Service contract shall be valid unless it specifies the quality of service to be provided under the contract and how the quality is to be measured and monitored.'.

No. 136, in page 26, line 38, at end insert—

'(3A) The acquirer will—

1. (a) publish the terms and conditions of any contract agreed with the provider;
600
2. (b) institute a thorough and ongoing monitoring and quality assurance programme keeping the local CHC aware of developments;
3. (c) create a complaints procedure for staff and patients with respect to the contract.'.

No. 37, in page 27, line 22, at end insert— '( ) Where a reference is made to the Secretary of State under subsections (4) and (5), he or the person appointed by him, shall take into account the distance a patient would otherwise have to travel when determining what is "practicable" under subsection (5).'

No. 45, in clause 5, page 6, line 42, at end insert—

'( ) In exercising his powers under this Section, the Secretary of State shall have particular regard to ensuring ).hat there exists a sufficient range and quality of services both in a local area and nationally to ensure that the functions of the National Health Service contained in the principal Act are carried out.'.

Mr. Tom Clarke (Monklands, West)

I beg to move, That the clause be read a Second time.

I shall refer to new clauses 15 and 16, and I hope that the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy) will not mind if I say a few words about new clause 38. Hopefully, I shall not anticipate his speech too much.

Hon. Members who served on the Standing Committee will recall that in Committee my hon. Friend the Member for Leicester, East (Mr. Vaz) moved a similar amendment to establish a national inspectorate under the director of patient services. In his excellent speech to the Committee he explained that he had the support of several important bodies and people, including the Royal College of Nursing. At this time in the evening I do not wish to be provocative, so I hope that the Secretary of State will not mind if I mention one last opinion poll. The RCN conducted an opinion poll among Conservative Members. It discovered that 80 per cent. of Conservative Members support the setting of national standards and 70 per cent. support the establishment of a national inspectorate to monitor health care provision. Most people would welcome those views.

We are trying to find ways of ensuring that those views are recognised in the Bill, particularly in view of the clear support for them within the House and elsewhere. When the hon. Member for Ross, Cromarty and Skye speaks to the new clause he will probably broaden the arguments to deal with proper monitoring and inspection of community care in Scotland.

I remind the House that earlier this evening the hon. Member for Great Yarmouth (Mr. Carttiss)—I hope that I spare his blushes—made a thoughtful and courageous speech. He said that many issues which had not been resolved in Committee were meant to be debated on the Floor of the House. They will not be reached because of the guillotine motion. The issue dealt with by the new clause is just such an item. I was glad that the hon. Gentleman made that point and I sincerely welcome what he said.

In Committee, under pressure from my hon. Friend the Member for Leicester, East, the Under-Secretary of State for Health said: The Government will reflect on how best to improve standards. We do not believe that it should be through a national inspectorate, or through a national accreditation scheme. However, there are ways to improve the service, for example by a national advisory committee. My right hon. and learned Friend the Secretary of State will reflect on and bring forward proposals for such improvement. The health advisory service advises on the quality of care provided to the mentally ill and the elderly. Its work with the mentally ill is under review. It could provide a useful model for advising DHAs, and hospitals with which they have contracts, about standards of care."—[Official Report, Standing Committee E, 23 January 1990; c. 347.] The Committee welcomed that in so far as it went and in anticipation of something more extensive—a bigger commitment—perhaps even a new clause or amendment on Report. So far as I can see, that has not happened. I hope that when the Secretary of State replies he will appreciate that in new clauses 15 and 16 we aim to respond to what we consider to be the Government's assurance to improve standards by enshrining the advisory committee in legislation.

11.15 pm

When the hon. Member for Ross, Cromarty and Skye dealt in his new clause with community care, many of us felt that he was absolutely right. That is why earlier this evening, in the debate on the guillotine motion, I was particularly surprised when the hon. Member for Lancashire, West (Mr. Hind), who unfortunately is not in his seat now but, in fairness, was here for most of the evening, said that the House had discussed Scotland. That comes as no surprise. Scotland is part of the United Kingdom. Scotland is dealt with in the Bill. Community care in Scotland is important. Frankly, we have not debated the matter enough. Therefore, I am pleased that community care in Scotland and the need for proper monitoring and inspections are dealt with in this group.

I hope that the importance of that is not lost on the House. Many people are convinced that community care in Scotland is not properly monitored. Moreover, it is difficult to do because of the present limited nature of joint planning, despite the legislative opportunities that the Secretary of State and the Under-Secretary of State for Scotland have not so far embraced or introduced.

The new clauses would be an ideal opportunity for the Government to show their commitment to standard setting and improving quality within the NHS. New clause 15 would establish the advisory committee and give it the power to establish minimum standards of care. That is terribly important in the light of the evidence of the accident of geography, where in some areas standards are high, yet in others they are not only far too low, but entirely unacceptable for community care.

New clause 16 gives the committee supplementary powers to assess local working conditions to ensure minimum standards. The case for that is self-evident. It is self-evident that we are attempting, particularly in the absence of real advocacy, to ensure that basic standards are met and that there is accountability and proper monitoring. We have a great deal of support for that.

I referred earlier to the Royal College of Nursing. In its evidence to the Select Committee on Social Services, it said: Therefore, in order to ensure a high quality of standards of care, the College wishes to see an independent, nationally trained inspectorate working at local level to monitor the care that is delivered by the private, the voluntary and the public sectors. This would be an independent body which would maintain quality and which is neither purchaser nor provider. Precedents for this include the HMI in education and, more recently, the directors of consumer services established in the privatised water, gas, telecommunications and electricity industries to safeguard consumer interests and uphold standards. The very important point which emerges from that evidence is that we are dealing with consumers. The frail, the vulnerable, the elderly, the physically disabled, the mentally ill and the mentally handicapped are consumers. Unfortunately, because of the restrictions on our debate, we have not had many opportunities—we have had far too few—to discuss those groups in the context of community care. None the less, if there is a commitment to consumers, these new clauses give the Government an opportunity to go beyond mere words, to go beyond a mere oral assertion that they will issue circulars, and so on. We are offering them a statutory opportunity to do the minimum necessary to ensure that the standards of care that are insisted upon are proper and reasonable standards that can be monitored and for which there can be proper accountability.

The amount of money involved is considerable. There is much talk of value for money. We are entitled to an assurance that taxpayers' money is being spent in a way that is consistent with the principle of value for money as well as with the rights of the consumer. For all those reasons, I thought that the excellent case that my hon. Friend the Member for Leicester, East and others made in Committee would have persuaded Ministers to accept some reasonable proposals.

Unfortunately, Ministers did not at that stage accept any of our amendments. I recall only one promise from the Parliamentary Under-Secretary of State for Scotland—the hon. Member for Stirling (Mr. Forsyth). That is a matter that we shall follow closely, but it is not particularly relevant to these new clauses. Beyond that promise we were offered not just very little but nothing at all, except, as in respect of so many other matters, the promise that, by the time of the Report stage, the Government would have taken advice, would have involved themselves in consultations, and might even surprise us by saying that they agreed to our modest proposals.

In presenting these new clauses, we are giving the Secretary of State an opportunity—not just at the 11th hour but almost at the 12th—to show just a little generosity. Generosity is something that was absent from his dealings with the Committee and the House.

In that spirit I commend the new clauses to the House. I look forward to hearing from the Secretary of State a response that is as positive as I am sure the House would want.

Mr. Tim Devlin (Stockton, South)

Amendment No. 57, which stands in my name, deals with two essential points—one is a general point and the other clears up an existing anomaly. Perhaps I should first declare an indirect interest in that my father is a member of the council of the Royal College of Surgeons and joint author of the "National Confidential Enquiry into Perioperative Deaths". I wish to refer to the monitoring role of the royal colleges of surgeons, anaesthetists, obstetricians, gynaecologists and others. It is right to ensure in any Bill of this kind that the services delivered to the public meet certain minimum quality criteria. That is the aim of my amendment.

I shall be interested in the response of my right hon. and learned Friend the Secretary of State to my point about the anomalous positions of the royal colleges of England and those of Scotland. The standard maintenance role of the royal colleges of England is being upset by that of the colleges of Edinburgh and Glasgow. This is a particular difficulty. A member of the Royal College of Surgeons of England who practises in Scotland is not subject to the authority of the Royal College of Surgeons of Edinburgh or Glasgow. Because he is beyond the territorial jurisdiction of the English college, he cannot be monitored from there either.

Similarly, a small number of Scottish practitioners who practise south of the border are beyond the geographical jurisdiction of the Scottish colleges, yet when they are monitored by the English colleges they say that they are members of the Scottish college and therefore do not wish to submit to the jurisdiction of an English college.

This is a small, but important, point. If we want a system in which there is professional peer group pressure to improve standards of health care, that pressure must be exercised through the appropriate royal college. That does not happen with those two minority groups.

Sir George Young (Ealing, Acton)

The new clauses and the amendments have the same objective, but they would achieve it in different ways. Amendments. Nos. 4, 5 and 6, which stand in my name, are slightly less bureaucratic than new clause 15 in that they avoid setting up an advisory committee, but their objectives are the same—to use the new regime to drive up standards, to improve the quality of services and to increase confidence in the NHS.

Amendment No. 4 provides the machinery for delivering those objectives—machinery which is not explicit in the Bill. It would require that, for any NHS contract, the acquiring body should consult on the standards of service to be provided under the contract. There needs to be a mechanism for ensuring in each case that the quality of service that patients can expect is understood publicly and that there is a quality yardstick by which a contractor can be assessed. Patients and the organisations which represent their interests have the right to know what they can expect from a contractor in the Health Service. The amendment provides such a mechanism. It would require that the quality standards are consulted upon and made public.

Amendment No. 5 clarifies the regulatory responsibility of the Secretary of State in relation to standards of health care. Where resources are limited, as they always will be, there may be a temptation for a hard-pressed Health Service body to cut corners on standards. Some health authorities and budget-holding general practitioners may therefore be tempted, when entering into contracts for the provision of care, not to specify adequate standards from their contractors. The amendment would limit this temptation by giving to the Secretary of State the role of setting for each category of service minima below which the quality of health care should not fall. At the moment, the Department provides a substantial amount of material regulating the standards of provision, and the amendment simply makes that explicit.

Amendment No. 6 deals with monitoring. The working of contracts for health care should be closely monitored to ensure that contractors meet the standards expected of them and that the terms of the contract are met. The amendment would require that the means by which monitoring and evaluation of quality of care provided under contracts should be set out in the contracts and would require contractors, by statutory duty, to co-operate with monitoring and evaluation procedures. That would help patients to feel secure, in that a system of monitoring and enforcement would guarantee that high standards are maintained and ensure the full co-operation of contractors.

The three amendments are fully consistent with the objectives in the White Paper. They simply seek to write into the Bill a procedure for guaranteeing the high quality of service that we all want to see.

11.30 pm

Mr. Kennedy

New clauses 35 and 38, to which the hon. Member for Monklands, West (Mr. Clarke) was kind enough to refer in his opening remarks, are partly based on the learning curve of the hon. Member for Glasgow, Cathcart (Mr. Maxton) in Committee. They refer to standards of inspection of community care services in Scotland, England and Wales, and take account of the slight differences in the role or existence of the inspectorates in each.

Despite earlier exchanges in Committee, there remains considerable doubt that the Bill's objectives in respect of community care will be fully realised. The Secretary of State might have acknowledged in our earlier debate on the timetable motion that it is regrettable that the House cannot devote more time to important aspects of the Bill. However, I suspect that new clause 15 and other parts of the Bill will have much more of an uphill struggle when they reach the other place, and I shall be watching its progress—and, hopefully, the alterations that are made to it—very closely.

The Bill makes welcome provision for local authorities to publish plans for community care, but there is no proper agreement on a mechanism to ensure that minimum standards are met, and therefore there is nothing positive or indicative for which inspectors can look.

If one considers the education system, it should not be so great a problem as is feared in the minds of Ministers or civil servants at the Department of Health. The education system proves that it is possible to set minimum standards and to operate an inspectorate without necessarily imposing too much centralisation or inhibiting scope for personal initiative and development.

One must question how community care plans will be properly assessed in the absence of minimum standards—particularly as it is more than likely under present budgetary constraints that there will be disagreements between the health authority or health board and the local authority.

The Secretary of State repeated earlier today that heavy reliance is being placed on contract setting to ensure quality of service. The right hon. and learned Gentleman spoke of competition in the hospital sector being based on quality. The same applies to the care in the community approach. The quality control aspects of a contract, whether it concerns health or community care, are currently minimal and are unlikely to provide an adequate safeguard, at least in the short term.

The guidance issued since the Committee stage is encouraging. The word "quality" is used in the very first sentence and recurs throughout. Ministers appear to have become more sensitive to that aspect than they were earlier. Nevertheless, there remains genuine anxiety that minimum standards will be fastened upon by the providers and contractors of care rather than serve as a starting point.

My final point concerns the social services inspectorate. Exchanges between the Minister for Health and me in Committee revealed that in the past few years the number of inspectors in England and Wales has doubled. That is welcome, and it will probably increase further if the Minister is successful in realising her ambition to extend the scope and the role of the inspectorate. However, such a major and fundamental change as the community care aspect of the Bill surely contains scope for a further inspectorate. In Scotland, the need for minimum standards still exist, but the establishment of a proper inspectorate is crucial.

I am indebted to the Royal College of Nursing for its assistance with amendment No. 33. The amendment aims to give the Secretary of State a reserve power to establish a series of minimum standards of care which health care providers would have to observe. In effect, it would establish a safety net for quality in future. There is no time to go into the details of the argument behind the amendment, but perhaps in the short time available I should commend back to the Secretary of State his own words on 10 October 1989 at that marvellous occasion, the Conservative party conference. The Secretary of State referred to the two prime problems which arise if all decisions about acceptable standards are left to individual contracts: first, will the purchaser be in a strong enough position to face a monopoly provider and, secondly, will minimum standards vary significantly throughout the country from Plymouth to Inverness? In his speech at the conference, the Secretary of State listed a catalogue of inexplicable anomalies between districts and regions and concluded: These failings are not fair to the patients when the treatment you receive (and the delay you experience) depends entirely on the luck of the draw. Above all, on where in the country you live and whether you have an illness which is well-treated locally or not. Amendment No. 33 aims to provide a permissive regulatory framework for the Secretary of State to be able to exercise the power to address precisely the problem that he highlighted on that occasion.

Amendment No. 37 expresses the concern that hospitals, particularly in rural areas, will be in a monopoly position under contracts because they are the only providers of a service in that region. What effects will there be on people having to travel, as that clearly will be a logical component of the internal market, and on the fact that the Secretary of State will view a local monopoly in an entirely different way from patients because many patients in rural areas have to travel significant distances to receive treatment? [Interruption.] If the hon. Member for Wirral, South (Mr. Porter) finds this boring, I am sure that he can find entertainment elsewhere. Perhaps these are rough and ready arguments because those of us who served on the Committee did not pursue many of the points as we had hoped for a proper debate.

Amendment No. 45 embodies the plea that the Secretary of State shall have particular regard to ensuring that there exists a sufficient range and quality of services both in a local area and nationally to ensure that the functions of the National Health Service contained in the principal Act are carried out. There is genuine anxiety about the future of the service because of the step into the unknown that the Bill represents. Even at this late stage the Secretary of State has a chance to offer some reassurance.

Mr. Michael Morris

I am happy to associate myself with amendments Nos. 5 and 6, in the name of my hon. Friend the Member for Ealing, Acton (Sir G. Young), and I hope that they will appeal to my right hon. and learned Friend the Secretary of State. If we are not talking about medical audit, we are talking about performance review. There is a great deal of experience of performance review among professional organisations across the Atlantic and I had hoped that we might learn from that experience.

Certain questions need to be asked. Was the operation necessary in the first place? Was it correctly undertaken? What is the rate of readmission and cross-infection? What was the cost of performing the operation, and was the patient satisfied? Certain initiatives can be taken to guard against inappropriate surgery, unnecessary blood transfusions and the unco-ordinated treatment of intensive care patients. The amendments address the question of who is to check the quality of care. Every other industry in the country has quality control, and I cannot believe that it is right that the NHS should not. That is why I support the amendments.

Mrs. Maria Fyfe (Glasgow, Maryhill)

I support the proposals of the hon. Member for Ross, Cromarty and Skye (Mr. Kennedy). I am sure that we can all agree that it ought to be perfectly possible to set minimum standards and to have inspectorates to ensure that they are achieved. The hon. Gentleman cited the example of schools, for which we have minimum standards, and inspectors to ensure that they are met. An even more useful example, perhaps, is the example of the factory inspectorate, which ensures that the conditions in which people work are adequate.

Similarly, we should want to ensure that a large number of criteria are satisfied in relation to the suitability of the conditions in which old people are looked after in small premises. I have been shocked by some of the cases of which I have heard in the course of my constituency work and by the conditions in which some old people have been made to live.

There is also the question of the charge made for services. I heard of one old lady who was persuaded to leave the home in which she was living to go into a private house where her rent was doubled after two months. That old person felt vulnerable and unable to do much about her plight. The attitude seems to be that the Department of Social Services will pick up the tab, and that it does not matter if the public purse is robbed to pay people to provide the services.

There is also a danger to old people's privacy. Some people seem to view old people as having lost all right to be treated as thinking and sentient human beings. They open their mail, listen to their telephone conversations and generally engage in a lot of unwarranted interference that would not be tolerated by someone who was capable of defending himself. But many old people are powerless unless they have a relative to stand up for them.

What about the items that are provided for old people? In one case, for example, a person who was virtually immobile was given only a commode and felt extremely embarrassed and ill at ease. That person could no longer 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 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 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 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 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	Fields, Terry (L'pool B G'n)
Adams, Allen (Paisley N)	Fisher, Mark
Allen, Graham	Flannery, Martin
Alton, David	Flynn, Paul
Anderson, Donald	Foot, Rt Hon Michael
Archer, Rt Hon Peter	Foster, Derek
Armstrong, Hilary	Fraser, John
Ashton, Joe	Fyfe, Maria
Banks, Tony (Newham NW)	Galloway, George
Barnes, Harry (Derbyshire NE)	Garrett, John (Norwich South)
Barnes, Mrs Rosie (Greenwich)	Garrett, Ted (Wallsend)
Barron, Kevin	George, Bruce
Battle, John	Gilbert, Rt Hon Dr John
Beggs, Roy	Godman, Dr Norman A.
Beith, A. J.	Gordon, Mildred
Benn, Rt Hon Tony	Gould, Bryan
Bennett, A. F. (D'nt'n & R'dish)	Graham, Thomas
Bermingham, Gerald	Grant, Bernie (Tottenham)
Blair, Tony	Griffiths, Nigel (Edinburgh S)
Blunkett, David	Griffiths, Win (Bridgend)
Boateng, Paul	Hardy, Peter
Boyes, Roland	Harman, Ms Harriet
Bradley, Keith	Hattersley, Rt Hon Roy
Brown, Gordon (D'mline E)	Henderson, Doug
Brown, Nicholas (Newcastle E)	Hinchliffe, David
Brown, Ron (Edinburgh Leith)	Hoey, Ms Kate (Vauxhall)
Buchan, Norman	Hogg, N. (C'nauld & Kilsyth)
Buckley, George J.	Home Robertson, John
Caborn, Richard	Hood, Jimmy
Campbell, Menzies (Fife NE)	Howarth, George (Knowsley N)
Campbell, Ron (Blyth Valley)	Howells, Geraint
Campbell-Savours, D. N.	Howells, Dr. Kim (Pontypridd)
Carlile, Alex (Mont'g)	Hoyle, Doug
Cartwright, John	Hughes, John (Coventry NE)
Clark, Dr David (S Shields)	Hughes, Robert (Aberdeen N)
Clarke, Tom (Monklands W)	Hughes, Roy (Newport E)
Clay, Bob	Hughes, Simon (Southwark)
Clelland, David	Illsley, Eric
Clwyd, Mrs Ann	Ingram, Adam
Cohen, Harry	Jones, Barry (Alyn & Deeside)
Coleman, Donald	Jones, Ieuan (Ynys Môn)
Cook, Robin (Livingston)	Jones, Martyn (Clwyd S W)
Cousins, Jim	Kennedy, Charles
Cox, Tom	Kilfedder, James
Crowther, Stan	Lamond, James
Cryer, Bob	Leadbitter, Ted
Cummings, John	Lestor, Joan (Eccles)
Dalyell, Tam	Lewis, Terry
Darling, Alistair	Livingstone, Ken
Davies, Rt Hon Denzil (Llanelli)	Livsey, Richard
Davies, Ron (Caerphilly)	Lloyd, Tony (Stretford)
Davis, Terry (B'ham Hodge H'l)	Lofthouse, Geoffrey
Dixon, Don	Loyden, Eddie
Dobson, Frank	McAllion, John
Doran, Frank	McAvoy, Thomas
Duffy, A. E. P.	McCartney, Ian
Dunnachie, Jimmy	Macdonald, Calum A.
Eadie, Alexander	McFall, John
Eastham, Ken	McKay, Allen (Barnsley West)
Ewing, Harry (Falkirk E)	McKelvey, William
Ewing, Mrs Margaret (Moray)	Maclennan, Robert
Faulds, Andrew	McNamara, Kevin
Fearn, Ronald	Madden, Max
Field, Frank (Birkenhead)	Maginnis, Ken

Mahon, Mrs Alice	Salmond, Alex
Marek, Dr John	Sedgemore, Brian
Marshall, Jim (Leicester S)	Sheerman, Barry
Martin, Michael J. (Springburn)	Sheldon, Rt Hon Robert
Martlew, Eric	Shore, Rt Hon Peter
Meacher, Michael	Short, Clare
Meale, Alan	Sillars, Jim
Michael, Alun	Skinner, Dennis
Michie, Bill (Sheffield Heeley)	Smith, C. (Isl'ton & F'bury)
Michie, Mrs Ray (Arg'l & Bute)	Smith, Rt Hon J. (Monk'ds E)
Moonie, Dr Lewis	Smith, J. P. (Vale of Glam)
Morgan, Rhodri	Smyth, Rev Martin (Belfast S)
Morris, Rt Hon A. (W'shawe)	Soley, Clive
Mowlam, Marjorie	Spearing, Nigel
Mullin, Chris	Steel, Rt Hon Sir David
Murphy, Paul	Steinberg, Gerry
Nellist, Dave	Stott, Roger
Oakes, Rt Hon Gordon	Taylor, Mrs Ann (Dewsbury)
Orme, Rt Hon Stanley	Taylor, Rt Hon J. D. (S'ford)
Owen, Rt Hon Dr David	Taylor, Matthew (Truro)
Paisley, Rev Ian	Thompson, Jack (Wansbeck)
Patchett, Terry	Turner, Dennis
Pendry, Tom	Wallace, James
Pike, Peter L.	Walley, Joan
Powell, Ray (Ogmore)	Wardell, Gareth (Gower)
Prescott, John	Wareing, Robert N.
Primarolo, Dawn	Welsh, Andrew (Angus E)
Quin, Ms Joyce	Welsh, Michael (Doncaster N)
Radice, Giles	Wigley, Dafydd
Randall, Stuart	Williams, Rt Hon Alan
Redmond, Martin	Williams, Alan W. (Carm'then)
Rees, Rt Hon Merlyn	Winnick, David
Richardson, Jo	Wise, Mrs Audrey
Robertson, George	Worthington, Tony
Robinson, Geoffrey	Young, David (Bolton SE)
Rogers, Allan
Rooker, Jeff	Tellers for the Ayes:
Ross, Ernie (Dundee W)	Mrs. Llin Golding and Mr. Frank Haynes.
Ross, William (Londonderry E)
Ruddock, Joan

NOES
Adley, Robert	Burns, Simon
Alexander, Richard	Butcher, John
Alison, Rt Hon Michael	Butler, Chris
Allason, Rupert	Butterfill, John
Amery, Rt Hon Julian	Carlisle, John, (Luton N)
Amess, David	Carlisle, Kenneth (Lincoln)
Amos, Alan	Carrington, Matthew
Arbuthnot, James	Carttiss, Michael
Arnold, Jacques (Gravesham)	Cash, William
Arnold, Tom (Hazel Grove)	Chalker, Rt Hon Mrs Lynda
Atkins, Robert	Channon, Rt Hon Paul
Baker, Rt Hon K. (Mole Valley)	Chapman, Sydney
Baker, Nicholas (Dorset N)	Churchill, Mr
Baldry, Tony	Clark, Dr Michael (Rochford)
Banks, Robert (Harrogate)	Clark, Sir W. (Croydon S)
Batiste, Spencer	Clarke, Rt Hon K. (Rushcliffe)
Bellingharn, Henry	Colvin, Michael
Bendall, Vivian	Conway, Derek
Bennett, Nicholas (Pembroke)	Coombs, Anthony (Wyre F'rest)
Benyon,W.	Coombs, Simon (Swindon)
Biffen, Rt Hon John	Cope, Rt Hon John
Blaker, Rt Hon Sir Peter	Couchman, James
Body, Sir Richard	Cran, James
Bonsor, Sir Nicholas	Currie, Mrs Edwina
Boscawen, Hon Robert	Curry, David
Boswell, Tim	Davies, Q. (Stamf'd & Spald'g)
Bottomley, Mrs Virginia	Davis, David (Boothferry)
Bowden, A (Brighton K'pto'n)	Day, Stephen
Bowden, Gerald (Dulwich)	Devlin, Tim
Bowis, John	Dorrell, Stephen
Boyson, Rt Hon Dr Sir Rhodes	Douglas-Hamilton, Lord James
Brandon-Bravo, Martin	Dover, Den
Brazier, Julian	Dunn, Bob
Bright, Graham	Durant, Tony
Brown, Michael (Brigg & Cl't's)	Eggar, Tim
Bruce, Ian (Dorset South)	Emery, Sir Peter
Buck, Sir Antony	Evans, David (Welwyn Hatf'd)
Budgen, Nicholas	Favell, Tony

Fenner, Dame Peggy	Lloyd, Peter (Fareham)
Field, Barry (Isle of Wight)	Lord, Michael
Fishburn, John Dudley	Luce, Rt Hon Richard
Forman, Nigel	Lyell, Rt Hon Sir Nicholas
Forsyth, Michael (Stirling)	Macfarlane, Sir Neil
Forth, Eric	MacGregor, Rt Hon John
Fowler, Rt Hon Sir Norman	Maclean, David
Fox, Sir Marcus	McLoughlin, Patrick
Freeman, Roger	McNair-Wilson, Sir Michael
French, Douglas	Madel, David
Gale, Roger	Malins, Humfrey
Garel-Jones, Tristan	Mans, Keith
Gill, Christopher	Maples, John
Glyn, Dr Sir Alan	Marland, Paul
Goodhart, Sir Philip	Marlow, Tony
Goodson-Wickes, Dr Charles	Marshall, John (Hendon S)
Gorman, Mrs Teresa	Marshall, Michael (Arundel)
Gorst, John	Martin, David (Portsmouth S)
Gow, Ian	Maude, Hon Francis
Grant, Sir Anthony (CambsSW)	Mawhinney, Dr Brian
Greenway, John (Ryedale)	Maxwell-Hyslop, Robin
Gregory, Conal	Mayhew, Rt Hon Sir Patrick
Griffiths, Peter (Portsmouth N)	Mellor, David
Grist, Ian	Meyer, Sir Anthony
Ground, Patrick	Mills, Iain
Grylls, Michael	Miscampbell, Norman
Hague, William	Mitchell, Andrew (Gedling)
Hamilton, Hon Archie (Epsom)	Mitchell, Sir David
Hamilton, Neil (Tatton)	Moate, Roger
Hampson, Dr Keith	Monro, Sir Hector
Hanley, Jeremy	Montgomery, Sir Fergus
Hannam, John	Morris, M (N'hampton S)
Hargreaves, Ken (Hyndburn)	Moss, Malcolm
Harris, David	Moynihan, Hon Colin
Haselhurst, Alan	Neale, Gerrard
Hayes, Jerry	Nelson, Anthony
Hayhoe, Rt Hon Sir Barney	Neubert, Michael
Hayward, Robert	Newton, Rt Hon Tony
Heathcoat-Amory, David	Nicholls, Patrick
Hicks, Mrs Maureen (Wolv' NE)	Nicholson, David (Taunton)
Hicks, Robert (Cornwall SE)	Nicholson, Emma (Devon West)
Higgins, Rt Hon Terence L.	Norris, Steve
Hill, James	Onslow, Rt Hon Cranley
Hind, Kenneth	Page, Richard
Hogg, Hon Douglas (Gr'th'm)	Paice, James
Howard, Rt Hon Michael	Parkinson, Rt Hon Cecil
Howell, Rt Hon David (G'dford)	Patnick, Irvine
Howell, Ralph (North Norfolk)	Patten, Rt Hon Chris (Bath)
Hughes, Robert G. (Harrow W)	Pawsey, James
Hunt, David (Wirral W)	Peacock, Mrs Elizabeth
Hunt, Sir John (Ravensbourne)	Porter, Barry (Wirral S)
Hurd, Rt Hon Douglas	Porter, David (Waveney)
Irvine, Michael	Portillo, Michael
Irving, Sir Charles	Price, Sir David
Jack, Michael	Raison, Rt Hon Timothy
Jackson, Robert	Rathbone, Tim
Janman, Tim	Renton, Rt Hon Tim
Jessel, Toby	Ridsdale, Sir Julian
Johnson Smith, Sir Geoffrey	Roberts, Wyn (Conwy)
Jones, Gwilym (Cardiff N)	Rossi, Sir Hugh
Jones, Robert B (Herts W)	Rost, Peter
Jopling, Rt Hon Michael	Rowe, Andrew
Key, Robert	Rumbold, Mrs Angela
King, Roger (B'ham N'thfield)	Sackville, Hon Tom
Kirkhope, Timothy	Sayeed, Jonathan
Knapman, Roger	Scott, Rt Hon Nicholas
Knight, Greg (Derby North)	Shaw, Sir Michael (Scarb')
Knight, Dame Jill (Edgbaston)	Shelton, Sir William
Knowles, Michael	Shephard, Mrs G. (Norfolk SW)
Knox, David	Shepherd, Colin (Hereford)
Lang, Ian	Sims, Roger
Latham, Michael	Skeet, Sir Trevor
Lawrence, Ivan	Smith, Sir Dudley (Warwick)
Lee, John (Pendle)	Smith, Tim (Beaconsfield)
Leigh, Edward (Gainsbor'gh)	Speller, Tony
Lennox-Boyd, Hon Mark	Spicer, Sir Jim (Dorset W)
Lester, Jim (Broxtowe)	Squire, Robin
Lightbown, David	Stanbrook, Ivor
Lilley, Peter	Stanley, Rt Hon Sir John
Lloyd, Sir Ian (Havant)	Stern, Michael

Stevens, Lewis	Waldegrave, Rt Hon William
Stewart, Allan (Eastwood)	Walden, George
Stewart, Andy (Sherwood)	Walker, Bill (T'side North)
Stewart, Rt Hon Ian (Herts N)	Waller, Gary
Stokes, Sir John	Ward, John
Stradling Thomas, Sir John	Wardle, Charles (Bexhill)
Sumberg, David	Watts, John
Summerson, Hugo	Wells, Bowen
Taylor, Ian (Esher)	Wheeler, Sir John
Taylor, John M (Solihull)	Widdecombe, Ann
Taylor, Teddy (S'end E)	Wiggin, Jerry
Tebbit, Rt Hon Norman	Wilkinson, John
Temple-Morris, Peter	Wilshire, David
Thompson, D. (Calder Valley)	Winterton, Mrs Ann
Thompson, Patrick (Norwich N)	Winterton, Nicholas
Thorne, Neil	Wolfson, Mark
Thornton, Malcolm	Wood, Timothy
Thurnham, Peter	Woodcock, Dr. Mike
Tracey, Richard	Yeo, Tim
Tredinnick, David	Young, Sir George (Acton)
Trippier, David
Trotter, Neville	Tellers for the Noes:
Twinn, Dr Ian	Alastair Goodlad and Michael Fallon.
Waddington, Rt Hon David

Question accordingly negatived.

It being after Twelve o'clock, MADAM DEPUTY SPEAKER proceeded to put forthwith the Questions which she was directed to put at that hour, pursuant to the Order [14 March.]

Question put, That amendments Nos. 39 to 141, 158, 256, 275, 286 and 341, remaining to be made, be made to the Bill:—

The House divided: Ayes 276, Noes 202.

Division No. 128]	[12.13 am
AYES
Adley, Robert	Butterfill, John
Alexander, Richard	Carlisle, John, (Luton N)
Alison, Rt Hon Michael	Carlisle, Kenneth (Lincoln)
Allason, Rupert	Carrington, Matthew
Amery, Rt Hon Julian	Carttiss, Michael
Amess, David	Cash, William
Amos, Alan	Chalker, Rt Hon Mrs Lynda
Arbuthnot, James	Channon, Rt Hon Paul
Arnold, Jacques (Gravesham)	Chapman, Sydney
Arnold, Tom (Hazel Grove)	Churchill, Mr
Atkins, Robert	Clark, Dr Michael (Rochford)
Baker, Rt Hon K. (Mole Valley)	Clark, Sir W. (Croydon S)
Baker, Nicholas (Dorset N)	Clarke, Rt Hon K. (Rushcliffe)
Baldry, Tony	Colvin, Michael
Banks, Robert (Harrogate)	Conway, Derek
Batiste, Spencer	Coombs, Anthony (Wyre F'rest)
Bellingham, Henry	Coombs, Simon (Swindon)
Bendall, Vivian	Cope, Rt Hon John
Bennett, Nicholas (Pembroke)	Couchman, James
Benyon, W.	Cran, James
Biffen, Rt Hon John	Currie, Mrs Edwina
Blaker, Rt Hon Sir Peter	Curry, David
Body, Sir Richard	Davies, Q. (Stamf'd & Spald'g)
Bonsor, Sir Nicholas	Davis, David (Boothferry)
Boscawen, Hon Robert	Day, Stephen
Boswell, Tim	Devlin, Tim
Bottomley, Mrs Virginia	Dorrell, Stephen
Bowden, A (Brighton K'pto'n)	Douglas-Hamilton, Lord James
Bowden, Gerald (Dulwich)	Dover, Den
Bowis, John	Dunn, Bob
Boyson, Rt Hon Dr Sir Rhodes	Durant, Tony
Brandon-Bravo, Martin	Eggar, Tim
Brazier, Julian	Emery, Sir Peter
Bright, Graham	Evans, David (Welwyn Hatf'd)
Brown, Michael (Brigg & Cl't's)	Fallon, Michael
Bruce, Ian (Dorset South)	Favell, Tony
Buck, Sir Antony	Fenner, Dame Peggy
Buckley, George J.	Field, Barry (Isle of Wight)
Burns, Simon	Fishburn, John Dudley
Butcher, John	Forman, Nigel
Butler, Chris	Forsyth, Michael (Stirling)

Forth, Eric	McNair-Wilson, Sir Michael
Fowler, Rt Hon Sir Norman	Madel, David
Fox, Sir Marcus	Malins, Humfrey
Freeman, Roger	Mans, Keith
French, Douglas	Maples, John
Gale, Roger	Marland, Paul
Garel-Jones, Tristan	Marlow, Tony
Gill, Christopher	Marshall, John (Hendon S)
Glyn, Dr Sir Alan	Marshall, Michael (Arundel)
Goodhart, Sir Philip	Martin, David (Portsmouth S)
Goodson-Wickes, Dr Charles	Maude, Hon Francis
Gorman, Mrs Teresa	Mawhinney, Dr Brian
Gorst, John	Maxwell-Hyslop, Robin
Gow, Ian	Mayhew, Rt Hon Sir Patrick
Grant, Sir Anthony (CambsSW)	Mellor, David
Greenway, John (Ryedale)	Meyer, Sir Anthony
Gregory, Conal	Mills, Iain
Griffiths, Peter (Portsmouth N)	Miscampbell, Norman
Grist, Ian	Mitchell, Andrew (Gedling)
Ground, Patrick	Mitchell, Sir David
Grylls, Michael	Moate, Roger
Hague, William	Monro, Sir Hector
Hamilton, Hon Archie (Epsom)	Montgomery, Sir Fergus
Hamilton, Neil (Tatton)	Morris, M (N'hampton S)
Hampson, Dr Keith	Moss, Malcolm
Hanley, Jeremy	Neale, Gerrard
Hannam, John	Nelson, Anthony
Hargreaves, Ken (Hyndburn)	Neubert, Michael
Harris, David	Newton, Rt Hon Tony
Haselhurst, Alan	Nicholls, Patrick
Hayes, Jerry	Nicholson, David (Taunton)
Hayward, Robert	Nicholson, Emma (Devon West)
Heathcoat-Amory, David	Norris, Steve
Hicks, Mrs Maureen (Wolv' NE)	Onslow, Rt Hon Cranley
Hicks, Robert (Cornwall SE)	Page, Richard
Higgins, Rt Hon Terence L.	Paice, James
Hill, James	Parkinson, Rt Hon Cecil
Hind, Kenneth	Patnick, Irvine
Hogg, Hon Douglas (Gr'th'm)	Patten, Rt Hon Chris (Bath)
Howard, Rt Hon Michael	Pawsey, James
Howell, Rt Hon David (G'dford)	Peacock, Mrs Elizabeth
Howell, Ralph (North Norfolk)	Porter, Barry (Wirral S)
Hughes, Robert G. (Harrow W)	Porter, David (Waveney)
Hunt, David (Wirral W)	Portillo, Michael
Hunt, Sir John (Ravensbourne)	Price, Sir David
Irvine, Michael	Raison, Rt Hon Timothy
Irving, Sir Charles	Rathbone, Tim
Jack, Michael	Renton, Rt Hon Tim
Jackson, Robert	Ridsdale, Sir Julian
Janman, Tim	Roberts, Wyn (Conwy)
Jessel, Toby	Rossi, Sir Hugh
Johnson Smith, Sir Geoffrey	Rost, Peter
Jones, Gwilym (Cardiff N)	Rowe, Andrew
Jones, Robert B (Herts W)	Rumbold, Mrs Angela
Jopling, Rt Hon Michael	Sackville, Hon Tom
Key, Robert	Sayeed, Jonathan
King, Roger (B'ham N'thfield)	Scott, Rt Hon Nicholas
Kirkhope, Timothy	Shaw, Sir Michael (Scarb')
Knapman, Roger	Shelton, Sir William
Knight, Dame Jill (Edgbaston)	Shephard, Mrs G. (Norfolk SW)
Knowles, Michael	Shepherd, Colin (Hereford)
Knox, David	Sims, Roger
Lang, Ian	Skeet, Sir Trevor
Latham, Michael	Smith, Sir Dudley (Warwick)
Lawrence, Ivan	Smith, Tim (Beaconsfield)
Lee, John (Pendle)	Speller, Tony
Leigh, Edward (Gainsbor'gh)	Spicer, Sir Jim (Dorset W)
Lennox-Boyd, Hon Mark	Squire, Robin
Lester, Jim (Broxtowe)	Stanbrook, Ivor
Lightbown, David	Stanley, Rt Hon Sir John
Lilley, Peter	Stern, Michael
Lloyd, Sir Ian (Havant)	Stevens, Lewis
Lloyd, Peter (Fareham)	Stewart, Allan (Eastwood)
Lord, Michael	Stewart, Andy (Sherwood)
Luce, Rt Hon Richard	Stewart, Rt Hon Ian (Herts N)
Lyell, Rt Hon Sir Nicholas	Stokes, Sir John
Macfarlane, Sir Neil	Stradling Thomas, Sir John
MacGregor, Rt Hon John	Sumberg, David
Maclean, David	Summerson, Hugo
McLoughlin, Patrick	Taylor, Ian (Esher)

Taylor, John M (Solihull)	Wardle, Charles (Bexhill)
Taylor, Teddy (S'end E)	Watts, John
Tebbit, Rt Hon Norman	Wells, Bowen
Temple-Morris, Peter	Wheeler, Sir John
Thompson, D. (Calder Valley)	Widdecombe, Ann
Thompson, Patrick (Norwich N)	Wiggin, Jerry
Thorne, Neil	Wilkinson, John
Thornton, Malcolm	Wilshire, David
Thurnham, Peter	Winterton, Mrs Ann
Tracey, Richard	Winterton, Nicholas
Trippier, David	Wolfson, Mark
Trotter, Neville	Wood, Timothy
Twinn, Dr Ian	Woodcock, Dr. Mike
Waddington, Rt Hon David	Yeo, Tim
Waldegrave, Rt Hon William	Young, Sir George (Acton)
Walden, George
Walker, Bill (T'side North)	Tellers for the Ayes:
Waller, Gary	Mr. Alastair Goodland and Mr. Greg Knight.
Ward, John

NOES
Abbott, Ms Diane	Faulds, Andrew
Adams, Allen (Paisley N)	Fearn, Ronald
Allen, Graham	Field, Frank (Birkenhead)
Alton, David	Fields, Terry (L'pool B G'n)
Anderson, Donald	Fisher, Mark
Archer, Rt Hon Peter	Flannery, Martin
Armstrong, Hilary	Flynn Paul
Ashton, Joe	Foot, Rt Hon Michael
Banks, Tony (Newham NW)	Foster, Derek
Barnes, Harry (Derbyshire NE)	Fraser, John
Barnes, Mrs Rosie (Greenwich)	Fyfe, Maria
Barron, Kevin	Galloway, George
Battle, John	Garrett, John (Norwich South)
Beggs, Roy	Garrett, Ted (Wallsend)
Beith, A. J.	George, Bruce
Benn, Rt Hon Tony	Gilbert, Rt Hon Dr John
Bennett, A. F. (D'nt'n & R'dish)	Godman, Dr Norman A.
Bermingham, Gerald	Golding, Mrs Llin
Blair, Tony	Gordon, Mildred
Boateng, Paul	Gould, Bryan
Boyes, Roland	Graham, Thomas
Bradley, Keith	Grant, Bernie (Tottenham)
Brown, Gordon (D'mline E)	Griffiths, Nigel (Edinburgh S)
Brown, Nicholas (Newcastle E)	Griffiths, Win (Bridgend)
Brown, Ron (Edinburgh Leith)	Hardy, Peter
Buchan, Norman	Harman, Ms Harriet
Buckley, George J.	Hattersley, Rt Hon Roy
Caborn, Richard	Haynes, Frank
Campbell, Menzies (Fife NE)	Henderson, Doug
Campbell, Ron (Blyth Valley)	Hinchliffe, David
Campbell-Savours, D. N.	Hoey, Ms Kate (Vauxhall)
Cartwright, John	Hogg, N. (C'nauld & Kilsyth)
Clark, Dr David (S Shields)	Home Robertson, John
Clarke, Tom (Monklands W)	Hood, Jimmy
Clay, Bob	Howarth, George (Knowsley N)
Clelland, David	Howells, Geraint
Clwyd, Mrs Ann	Howells, Dr. Kim (Pontypridd)
Cohen, Harry	Hoyle, Doug
Coleman, Donald	Hughes, John (Coventry NE)
Cook, Robin (Livingston)	Hughes, Robert (Aberdeen N)
Cousins, Jim	Hughes, Roy (Newport E)
Cox, Tom	Hughes, Simon (Southwark)
Crowther, Stan	Illsley, Eric
Cryer, Bob	Ingram, Adam
Cummings, John	Jones, Barry (Alyn & Deeside)
Dalyell, Tam	Jones, Ieuan (Ynys Môn)
Darling, Alistair	Jones, Martyn (Clwyd S W)
Davies, Rt Hon Denzil (Llanelli)	Kennedy, Charles
Davies, Ron (Caerphilly)	Kilfedder, James
Davis, Terry (B'ham Hodge H'l)	Lamond, James
Dixon, Don	Leadbitter, Ted
Dobson, Frank A	Lestor, Joan (Eccles)
Doran, Frank	Lewis, Terry
Duffy, A. E. P.	Livingstone, Ken
Dunnachie, Jimmy	Livsey, Richard
Eadie, Alexander	Lloyd, Tony (Stretford)
Eastham, Ken	Lofthouse, Geoffrey
Ewing, Harry (Falkirk E)	Loyden, Eddie
Ewing, Mrs Margaret (Moray)	McAllion, John

McAvoy, Thomas	Rogers, Allan
McCartney, Ian	Rooker, Jeff
Macdonald, Calum A.	Ross, Ernie (Dundee W)
McFall, John	Ross, William (Londonderry E)
McKay, Allen (Barnsley West)	Rowlands, Ted
McKelvey, William	Ruddock, Joan
Maclennan, Robert	Salmond, Alex
McNamara, Kevin	Sedgemore, Brian
Madden, Max	Sheerman, Barry
Maginnis, Ken	Sheldon, Rt Hon Robert
Mahon, Mrs Alice	Short, Clare
Marek, Dr John	Sillars, Jim
Marshall, Jim (Leicester S)	Skinner, Dennis
Martin, Michael J. (Springburn)	Smith, C. (Isl'ton & F'bury)
Martlew, Eric	Smith, Rt Hon J. (Monk'ds E)
Meacher, Michael	Smith, J. P. (Vale of Glam)
Meale, Alan	Smyth, Rev Martin (Belfast S)
Michael, Alun	Soley, Clive
Michie, Bill (Sheffield Heeley)	Spearing, Nigel
Michie, Mrs Ray (Arg'l & Bute)	Steel, Rt Hon Sir David
Moonie, Dr Lewis	Steinberg, Gerry
Morgan, Rhodri	Stott, Roger
Morris, Rt Hon A. (W'shawe)	Taylor, Mrs Ann (Dewsbury)
Mowlam, Marjorie	Taylor, Rt Hon J. D. (S'ford)
Mullin, Chris	Taylor, Matthew (Truro)
Murphy, Paul	Thompson, Jack (Wansbeck)
Nellist, Dave	Turner, Dennis
Orme, Rt Hon Stanley	Walley, Joan
Owen, Rt Hon Dr David	Warden, Gareth (Gower)
Paisley, Rev Ian	Wareing, Robert N.
Patchett, Terry	Welsh, Andrew (Angus E)
Pendry, Tom	Welsh, Michael (Doncaster N)
Pike, Peter L.	Wigley, Dafydd
Powell, Ray (Ogmore)	Williams, Rt Hon Alan
Prescott, John	Williams, Alan W. (Carm'then)
Primarolo, Dawn	Winnick, David
Quin, Ms Joyce	Wise, Mrs Audrey
Radice, Giles	Worthington, Tony
Randall, Stuart	Young, David (Bolton SE)
Redmond, Martin
Rees, Rt Hon Merlyn	Tellers for the Noes:
Richardson, Jo	Mr. James Wallace and Mr. Alex Carlile.
Robertson, George
Robinson, Geoffrey

Question accordingly agreed to.