Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 60 - 79)



  Q60  Charlotte Atkins: But if that was the only item, then she would be paying more.

  Dr Cockcroft: There will be instances when that happens, when you go for a fee per item to a banded system. But we have done an analysis of the case and obviously the maximum charge comes down very significantly, from nearly £400 to under £200, and we know that a large number of people in the system, if they are doing that, will pay less rather than more.

  Q61  Charlotte Atkins: Of course, the big issue as far as dentistry is concerned is the availability of NHS dentists to carry out NHS dentistry. That is obviously the big issue. One issue that has been raised with me very significantly is the situation where parents are possibly bribed to take up a Denplan arrangement so that their children can receive NHS dentistry. Will you tell me what the new contract will do for that and what impact that will have on NHS dentists who are providing NHS dentistry for both parents and children?

  Dr Cockcroft: First of all, to make acceptance of a child conditional on signing up for private treatment would be a breach of the regulations from April.

  Q62  Charlotte Atkins: But it happens widely now, does it not?

  Dr Cockcroft: It does. We are well aware of that.

  Q63  Charlotte Atkins: How many children are affected?

  Dr Cockcroft: I do not think we would have figures about that.

  Q64  Charlotte Atkins: It worries me that we are having a significant change here in the contract and you are telling me that you do not know how many children potentially might be affected by the new contract coming in and the possibility that the dentist will not be treating those children on the NHS from next April.

  Dr Cockcroft: Certainly that was a clear issue for dentists who were operating an acceptance policy, not that it is conditional but they do treat children. If a practice treats adults privately and children on the NHS, that is a decision for them to take. It is a breach of regulations to make one conditional on the other. I think that is different. We are saying, if you want to agree a contract with a dentist or a PCT wishes to agree a contract with a dentist which allows that practice at the moment to contract and provide services to children, it can do that, but it does not allow them to make acceptance of those children conditional on the adults accepting the private policy.

  Q65  Charlotte Atkins: You are saying they can treat the parents or adults under Denplan and they can also, at the same time, treat any children under the NHS.

  Dr Cockcroft: Yes. Absolutely clearly.

  Q66  Charlotte Atkins: But it would be incorrect and against the regulations for one to be conditional on the other.

  Dr Cockcroft: Yes.

  Q67  Charlotte Atkins: The idea that dentists cannot treat children on the NHS while still carrying out private practice is incorrect.

  Dr Cockcroft: Yes.

  Charlotte Atkins: Thank you.

  Mr Amess: Witnesses, you must watch yourselves on the parliamentary channel. Dr Harvey apart, up until now you really look as if you are auditioning for a part on The Glums. Do give the impression you are enjoying things a bit!

  Charlotte Atkins: They are not.

  Mr Amess: Clearly they are not.

  Charlotte Atkins: We want you to show the teeth.

  Q68  Mr Amess: Smile! Before I get to optical services, Dr Cockcroft, why are you only the Acting Chief Dental Officer?

  Dr Cockcroft: The previous Chief Dental Officer, Raman Bedi, went back to his Chair at King's in October. I was previously Deputy Duty Dental Officer and I had been leading on the modernisation of primary care. I was asked to carry on the work that I was already doing in terms of leading on the modernisation of NHS dentistry, so it did not seem a very sensible time, certainly to me and I hope the rest of the Department, to bring in somebody new to do that. I am acting because I have not been substantively appointed as the Chief Dental Officer and been through the process to do that.

  Q69  Mr Amess: But you are in the frame to get the job.

  Dr Cockcroft: Mr Amess is determined to make me smile, I can see. I think the job has not been advertised. I was substantively appointed as Deputy Chief Dental Officer.

  Q70  Mr Amess: Right. Now we turn to Mr Dyson—and you are not related to the vacuum cleaners either.

  Mr Dyson: No.

  Q71  Mr Amess: Going back in my parliamentary annals, when I was Edwina Currie's private parliamentary secretary and she was taking the committee stage of the Bill, I can remember as if it were yesterday when we introduced charges, and Jerry Hayes, who was then an MP, leaked a very embarrassing letter to the Committee. Of course nowadays it has all changed completely. Perhaps you would tell us something about total expenditure on sight tests, because it has obviously changed an awful lot over the last decade.

  Mr Dyson: The current level of expenditure on NHS-funded sight tests is about £184 million. The most significant step increase over recent years was obviously in 1999-2000, after the Government had reintroduced free sight tests for those aged over 60, and at that point expenditure grew from what had been just over £100 million in the previous year to just under £150 million. Since 1999 expenditure on sight tests has grown steadily each year. In 2004-05 there was a 6% increase over the previous year; the year before that there had been a 7% increase, and so on and so forth.

  Q72  Mr Amess: You may not have it in your brief there, because I do not know if our wonderful clerk gives you a tip off, but in real terms what would roughly be the increase in expenditure from 10 years ago?

  Mr Dyson: First of all, I should emphasise that the increase over the last 10 years will have been heavily influenced by that one year when we re-introduced free sight tests for over 60s. With that caveat, I think the increase—and I would have to check these figures—in cash terms is about 55-60%. I would need to check the real terms increase.

  Q73  Mr Amess: Perhaps you would write to us about that. The current eye sight test is well below the cost of providing the service and until recently, it was expected to cover the cost. Why has this principle, which we were told was very important, been abandoned?

  Mr Dyson: It is perhaps worth making a few comments there. First of all, just for the sake of clarity, it is important to be clear that the fee that the NHS pays to those who undertake the sight test has nothing to do with the cost to the patient. In terms of the fee paid to the optometrist or the ophthalmic medical practitioner, it is true that until about the early 1990s the approach was to have a so-called cost-plus approach to setting fees, where the Department would look with representatives of the professionals and companies who provided sight tests at the costs involved. There were two difficulties with that. First of all, it is quite difficult to pinpoint the true cost of providing a sight test, because you have to take a number of factors that are common to   running an overall business and then make judgments about how you apportion those between the different elements of the business. The second concern was that the cost-plus approach was perhaps over mechanistic. It overlooked, and in some cases maybe even discouraged, efficiency improvements, so that the view the Department took was that rather than a cost-plus approach we  should negotiate with representatives of the profession, taking into account recruitment, retention and motivation. On those criteria, the current system works very well. We have what I think almost everyone would accept is a service that provides a great degree of choice for patients, encourages a wide variety of providers, and, indeed, our minister Rosie Winterton has recently offered fresh assurances to representatives of the profession that that system will continue. Perhaps I could add that it is difficult to make comparisons but the   Federation of Ophthalmic and Dispensing Opticians, which represents a number of providers, recently did a survey amongst their members (so not entirely representative but it is an interesting comparison nonetheless) about the average charge that they levied for private sight tests, and that average sight test fee was on average slightly below the NHS sight test. So, taking 2004-05 as an example, the NHS fee was just under £18 and the private sight test fee was an average £17.68, so very, very similar.

  Q74  Mr Amess: I shall not take it any further. That is a splendidly crafted argument but it does seem to me that the principle has been abandoned. I am a little bit confused as to your justification of that, but c'est la vie. Deregulation of optical services, which has had a huge, huge impact—not even touching on laser treatment and all that—has it affected the entry of new providers or waiting times?

  Mr Dyson: I think it is important to be clear what one means by regulation or deregulation. It remains the fact that any practitioner who provides optical services has to register with the General Optical Council, so they are regulated in that sense. They have to demonstrate that they are properly qualified, that they undertake continuing education and training, that they remain fit to practice. So this is a regulated system in that sense, and of course practitioners also have to be listed with the primary care trusts where they provide services and the PCTs can undertake additional checks. They will take clinical references, they will inspect premises and equipment and so on and so forth. I assume the question is more about—

  Q75  Mr Amess: I wondered, first of all, is the Department happy with deregulation? You can practically go into a petrol station now and pick up a pair of spectacles. Is the Department happy with the way deregulation has turned out in practice?

  Mr Dyson: I think it is slightly misleading, with respect, to refer to a completely deregulated system. Whether you are an optometrist or ophthalmic medical practitioner who is undertaking a sight test or you are a dispensing optician who is dispensing spectacles or contact lenses or whatever, you have to be registered with the General Optical Council and you have to show that you are fit to practice, and both the conduct of the sight test and the dispensing of appliances is governed by national standards. In terms of the fact that there are no controls, in the sense that the NHS does not say, "We are going to dictate who provides NHS ophthalmic services in this area", we are not going to have a limit on the number of people; we are not going to place restrictions on patients as to which provider they can go to, provided that the people carrying out the clinical work are registered and appropriately qualified. The Department takes the view that that system works very well, in that it promotes patient choice, and this is an area where we receive very few complaints about the quality of the service they receive.

  Q76  Mr Amess: Fine. Fourteen years on, it has been a success, the Department is happy with it and it has made a real contribution to waiting times.

  Mr Dyson: As I have said, the minister recently had cause to offer some reassurances to representatives of the profession who were concerned that the current ophthalmic provisions in the Health Bill might lead to a degree of tighter regulation. The minister was at pains to point out that this was a misunderstanding of the clauses in the Health Bill. We are satisfied that the current system works well in terms of quality and choice for patients.

  Mr Amess: Thank you.

  Q77  Anne Milton: Mr Smith, it is your moment to cheer up, to smile at the camera! The one subject that causes a huge amount of grief in people is car parking charges. Maybe you could tell us what the principles are underlying the provision of car parking in NHS hospitals.

  Mr Smith: The principles are different from those which have been discussed so far and lie in a number of roots. One is that trusts are able to generate income from a variety of sources—and I think that was put in the note to you from the Department. The other roots are the rise of car ownership and the desire of people to drive to wherever they want to go to and the burgeoning demand on hospitals, the fact that we deal with a whole spectrum of situations from acute hospitals in very tight urban situations that have virtually no car parking, to hospitals in more rural settings that have plenty of land and plenty of availability, and overlaying that—and very importantly, because it is a directive to many trusts that operate the hospitals—is the fact that Crown immunity was lifted and local planning authorities are able, when hospital developments take place, to impose planning constraints on the hospitals that lead them to implement sustainable travel plans, to try to organise a shift of travel from cars to other means of transport, including for patients. That whole variety of circumstances has led to a situation where it has not been deemed sensible to try to impose central regulation, which could not deal with all the circumstances. Indeed, some hospitals that have undertaken major developments have had to make annual contributions to provide bus services to and from the hospitals. I have worked and been a director of estates in hospitals where, before we introduced car parking controls and charges to pay for those, we were seen as an unofficial parking site for people who worked in office blocks locally. Rather than draw on NHS funding, which was directed for patients, certainly the trust that I worked in chose to levy a charge both on visitors and staff to cover the costs that were incurred in setting that system up and running it—because it required not just materials and controllers to be bought, but staff to be employed to run that. It was a very conscious decision not to place that as a charge against the NHS.

  Q78  Anne Milton: The issue you raise about hospital car parks being seen as the town centre car park have been a real problem in the past. I think one of the problems now is that they are seen and viewed by many patients and visitors as a cash cow, in that the hospital will maximise any income they can from it, irrespective of the hardship that it causes patients or visitors. Are there any plans to offer exemptions to specific groups of patients or are you going to leave it simply down to local decision making?

  Mr Smith: At the moment it is left to local decision making. Again, in the organisations in which I have worked, consideration has been given not to particular people suffering from particular disease groups, but more to the concern: Do people have to attend for a course of treatment on a regular basis? and exemptions have been available for part of the payment. But it is a matter very much for local discussion. I am not aware that the Department has contemplated changing that view.

  Dr Harvey: Could I add that within the NHS Low Income Scheme you do get help with travel costs and indeed car parking,[8] so those people under the NHS Low Income Scheme who are exempt would get a refund from the local trust for their car parking, I think I am correct in saying.

  Mr Smith: Absolutely true.

  Dr Harvey: And indeed, for the travel costs for travel to the hospital.

  Q79  Anne Milton: The burden, if you are attending for a frequent course of treatment, is quite substantial at some hospitals, and actually those people are probably the people least able to make alternative arrangements on public transport because they are not well, obviously, by definition. What about assistance for travel to non-hospital settings which, of course, is going to become more and more relevant with the Government's drive trying not to treat people in acute hospitals?

  Dr Harvey: Certainly travel to primary care organisations where a patient is under the care of a hospital consultant, an NHS consultant, is indeed covered within the NHS low income scheme (Hospital Travel Costs Scheme); so if you are being treated under the care of a consultant, wherever that might be, then, indeed, you are covered.

8   Note by witness: Reimbursement for car park charges is available if the charge was unavoidable. Back

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