Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 299 - 319)



  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 BDA.

  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 of Optometrists.

  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 David.

  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 on—because dental disease is progressive—then 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 a year.

  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 it up?

  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 benefit.

  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.

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