Examination of Witnesses (Questions 60
- 79)
THURSDAY 19 JANUARY 2006
DR FELICITY
HARVEY, MR
MIKE BROWNLEE,
DR BARRY
COCKCROFT, MR
BEN DYSON
AND MR
ROB SMITH
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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