Examination of Witnesses (Questions 299
THURSDAY 9 FEBRUARY 2006
Q299 Chairman: Good morning, ladies
and gentlemen. May I welcome you to what is now our third evidence
session in relation to the inquiry we are doing on NHS charges.
I wonder if I could ask you to introduce yourselves for the record
and say what organisation you represent.
Dr Baker: I am Maureen Baker.
I am the Honorary Secretary of the Royal College of GPs.
Dr Ellman: I am Lester Ellman.
I am the Chair of the General Dental Practice Committee of the
Mr Cartwright: Good morning. I
am David Cartwright, an optometrist with Boots Opticians and also
President of the College of Optometrists.
Mrs Hansford: I am Lynn Hansford.
I am an independent optometrist and I am the Chairman of the Association
Q300 Chairman: I want to ask a general
question to all of you about NHS charges. Do you think charges
deter patients from seeking the services that you provide? We
had evidence last week from the CAB saying that they believe people
do make choices on occasions about what they can and cannot afford
if they have more than one prescription to pay for. Do you think
that is the case?
Dr Baker: Yes, I do think that
is the case. We have heard, particularly from pharmacist colleagues,
of patients bringing in a prescription and saying, "I'll
have that one but I'll not have that one", or, "I'll
come back next week and get that one". I am sure that it
does happen, yes.
Dr Ellman: Certainly in dentistry
the patient's choice range is now huge and a lot of them do opt
to take choices that are not within the standard framework of
the NHS. That is because there are a lot of things out there which
are not covered by the NHS.
Mr Cartwright: I think in optical
services it is slightly different in that we do not have charges,
so a patient does not come in and pay something. What happens
is if they are eligible for an eye examination they have a voucher
which should cover the cost of spectacles. I think the issue is
that people are not deterred by the charges, but perhaps they
are not adequately aware of what is on offer.
Mrs Hansford: I would agree with
Q301 Chairman: I think in general
terms we are saying it is probably the prescription charges that
may deter people from taking them up. Is there any particular
area of concern in relation to that or do you think it is across
the board? People on low incomes are exempt from prescription
charges so why do we have this type of problem?
Dr Baker: If someone has an acute
illness and they have not been on regular prescriptions and so
they have not paid their "season ticket", so they have
to pay for each item, and they come along and they are prescribed
a number of items that relate to that particular acute illness,
then three or four prescriptions soon mount up. Yes, people on
low incomes are exempt, but if you are just over the threshold
then it can be quite a hit if you are not expecting it and so
it can have an effect.
Q302 Chairman: Has the Royal College
ever done any studies of this as opposed to the anecdotal things
we hear about of people not being able to afford four prescriptions?
Dr Baker: Not to my knowledge.
Q303 Chairman: So we have no evidence
base for this?
Dr Baker: No.
Q304 Chairman: We just think that
it happens and pharmacists say that it does.
Dr Baker: That is right.
Q305 Chairman: Dr Ellman, in your
evidence you talk about the widening gap in the dental health
of the population. Why is this?
Dr Ellman: It is very difficult
to answer directly and say we have got absolute evidence of why
it is. There is no doubt that some socio-economic groups particularly
are more at risk and that some priorities are given in different
directions by different people, and there are some cultural differences
too. If you have not grown up in a culture of looking after your
teeth and regarding that aspect of your healthcare as being particularly
important then it tends to lapse to some extent and you only seek
emergency care when there is some problem. So there is that widening
gap. A tiny bit is related to the people who are not in the supported
group but who are on the threshold of being who may find charges
inhibitive to them. I have no evidence for that. I worked in inner-city
Manchester for 30 years and I ran a practice there and we have
certainly got some of that, but I cannot identify it entirely.
Q306 Chairman: Is there any conclusive
evidence that suggests that those who do not consult dentists
early on for check-ups can end up costing the NHS more in the
long run as it were?
Dr Ellman: That must be so. I
am not sure that we have done any studies on it directly. If you
take the simple evidence that if you can get to the problem that
the patient has before it becomes a major problem and moves onbecause
dental disease is progressivethen obviously it has got
to be less expensive in the long run. I am not sure it is entirely
as simple as that, but that is a fair estimate.
Q307 Chairman: Has your Association
argued with government that that is what you ought to be doing
when you have been looking at issues around a new contract and
things like that?
Dr Ellman: We have talked in terms
of prevention as being something that we would very much like
to see heavily espoused by the new contract.
Q308 Chairman: Is the same true for
patients who delay or avoid having sight tests, that in the end
it could be that there would be increased costs because of that
delay to the National Health Service?
Mr Cartwright: Yes, it is. If
you take many of the common eye conditions, if they are diagnosed
early and are treated they will not lead to visual loss in the
future. For instance, glaucoma would be a good example where the
patient is not immediately aware that their vision or the visual
field might be getting worse until it is often too late to treat.
So it is essential to diagnose that early and treat it early and
that would lead to savings later on in the ongoing care of that
patient. There is some evidence from the University of York to
say that about 10% of falls in the elderly are due to visual disability,
much of which is preventable and that costs about £250 million
Q309 Chairman: The elderly are not
charged for sight tests any longer, are they?
Mr Cartwright: That is correct.
Q310 Chairman: It is the deterrence
of the NHS charges that we would like to look at, where that shows
that because of these charges people do not go along for eye tests
and consequently it costs more money in the long run. Do you think
York may have looked at that?
Mrs Hansford: There is no evidence
that the cost of eye care does put people off going. When free
eye examinations were introduced for the over-60s there was not
a huge increase in the uptake of eye examinations; it stayed pretty
stable. That would indicate that it is not a deterrent for people
to come and have their eyes tested. What it is is they do not
understand because there is not enough publicity about the importance
of good vision and how good vision can maintain your independence
and make sure that you function properly through your life.
Q311 Anne Milton: The evidence about
elderly people falling over because they do not see well I have
heard before. Dr Ellman, could you give me an example in dentistry
of what will cost more if you do not get it treated early?
Dr Ellman: If you leave a tooth
which has decayed it may well progress into requiring more extensive
treatment like root canal therapy which is a lot more expensive
than a simple filling restoration, and that is not uncommon. If
it does not particularly hurt at the beginning and they do not
seek help, although they may know it is there, then it may well
progress and become a much larger problem and the restoration
may be much more difficult.
Q312 Anne Milton: I am no expert,
but it feels as though if dentistry does not treat you early then
you just end up having your teeth out. Do you see what I mean?
Dr Ellman: I do not, sorry.
Q313 Anne Milton: By not treating
a dental problem early there is a limit to how much it can cost
you in the long run. In your example about root canal work, if
you take the tooth out it costs money
Dr Ellman: Under the current system
there is a limit to what the patient can pay, but that does not
limit what the NHS will have to pay, it is merely a limit to the
patient charge. Similarly, even in the new system which the Government
is introducing in April, although there will be a capped ceiling
on what the patient's charge would be, in fact it will cost the
NHS more because it will take the dentist's time away from being
able to treat other patients just because it is a more expensive
and time-consuming procedure.
Q314 Dr Stoate: I think what Anne
is trying to say is that if you do not get an optical test done
you can go blind and that can have huge consequences. If you do
not get your teeth fixed the worst that can happen is you lose
your teeth. Are we saying there is more that can happen to you
than losing your teeth and, if so, what?
Dr Ellman: Obviously losing your
teeth is now a social stigma in this country to a large extent.
Q315 Dr Stoate: What is the big deal
with losing your teeth?
Dr Ellman: You have got to have
dentures replaced regularly.
Q316 Dr Stoate: Are there chronic
long-term health implications apart from losing your teeth?
Dr Ellman: Not once they have
been taken out!
Q317 Chairman: I want to ask the
optometrists about young children. When I was at school I used
to have eye tests. They may not have been that scientific, but
I do remember having an eye test at school. That has stopped now.
Do you think that is a disadvantage?
Mr Cartwright: Certainly in my
view there should be a more universal screening programme for
children before the age of eight because if you catch something
before the age of eight you have a chance of treating it, but
if it is after the age of eight you cannot. Children under-19
in full-time education are eligible for an NHS examination.
Q318 Chairman: How many of them take
Mr Cartwright: Out of 11.7 million
NHS examinations, around 25% are children so around 2.5 million
would be children.
Chairman: We do not know what the population
of under-16s is at any one time.
Q319 Mike Penning: Perhaps you could
let us now.
Mrs Hansford: In an ideal world
all children should have their eyes examined before they start
school because the formative years, as David said, are up to age
eight, so you need to detect any developmental problems before
that time and the earlier the better because the earlier you pick
it up the more easily you can deal with it and the better the
outcome at the end. You wear spectacles and so you understand
that if you cannot see properly you do not perform properly. It
really is important that all children, in order to reach their
educational potential, ought to be able to see properly at all
times. So we would really feel that that would be a major health
Chairman: A member of my family has just
found out at 14-years old that they have got a sight deficiency.
I think that may have been picked up earlier if it had happened
to me as a child.