Examination of Witnesses (Questions 320
THURSDAY 9 FEBRUARY 2006
Q320 Dr Stoate: I am surprised that
you are so benign about your age of eight because in my experience
as a GP, if you do not diagnose strabismus before the age of 18
months you are never going to get binocular vision and that in
itself is quite a handicap. Eight is far too late if you are going
to diagnose a squint.
Mrs Hansford: I would agree with
you. Eight is the cut-off time.
Q321 Dr Stoate: It is much too late
Mrs Hansford: You could pick them
up at four.
Q322 Dr Stoate: Four is too late.
Mrs Hansford: It is too late.
A child with a strabismus like you are speaking of most parents
would be aware of.
Q323 Dr Stoate: I would like to put
on the record that I am a Fellow of the Royal College of GPs and
a former College examiner. Dr Baker, we have had a lot of anecdotal
evidence that prescription charges put patients off receiving
treatment. Is there any concrete evidence that prescription charges
affect the way that GPs treat their patients?
Dr Baker: I am not aware of any
literature that would provide that evidence, but that is not to
say it is not there. I try to keep up particularly with the health
inequalities issues. We can certainly ask our Information Services
Department to see if there is anything that relates to that question.
I personally am not aware of any studies that have looked at that
Q324 Dr Stoate: If your Information
Services Department does have any evidence, I would be very grateful
if you would submit it to us because we need to have a good evidence
base if we are going to make a sensible report to Government.
Dr Baker: We did have a publication
by our health inequalities group called "Hard Lives"
which is an overall look at some health inequalities issues. I
would certainly be happy to send that on and I can make a specific
request around the literature regarding charging and deterring
people from treatment.
Q325 Dr Stoate: Obviously everyone
resents paying charges. What we need to know is how much of people's
reluctance to pay is just simply resentment at having to pay for
what ought to be a free service and how much of it is because
they are having a genuine hardship effect. We need to have some
evidence for that if possible.
Dr Baker: The evidence we will
find for you if it is there. In my own experience as a GP, I have
people say to me, "Don't prescribe me this and this because
I cannot afford it".
Q326 Dr Stoate: I am sure that happens.
What we need to try and gauge is a measure of how prevalent that
is. I want to move on to non-emergency transport. Do you think
that the cost of transport for people to get to hospitals and
to clinics can affect the way they access the service?
Dr Baker: Yes, I do. In fact,
the Royal College of GPs is currently writing a paper with colleagues
in the Royal College of Physicians and we are looking at the best
way in which generalists and specialists can work together so
that patients can get the best access to treatment. That is one
of the issues that have come up. We have been hearing of cases
where people may have a number of chronic conditions and they
attend outpatient clinics for that, but because of a number of
factors, ie they are more ill, they are poor and they either rely
on public transport or it is a question of can they drive, can
they park, do they pay parking charges, people default from ongoing
treatment for those chronic conditions and that leads to poorer
outcomes for important chronic conditions.
Q327 Dr Stoate: Do you have any evidence
you could submit on exactly how prevalent that is?
Dr Baker: Again, I am not aware
of any evidence. We are looking to see what there is in terms
of referencing this paper. If we find specific references we can
send that to you and I would be also be very happy to send the
paper to the Committee once that has been launched.
Dr Stoate: Thank you very much.
Q328 Charlotte Atkins: Dr Ellman,
what are your main criticisms of the new system of dental charges
and what do you think will be the impact on the uptake of treatment?
Dr Ellman: The impact on patient
behaviour is absolutely unknown. This is one of the biggest problems
we have. The problem that arises from that is you cannot then
model the system to make sure that it brings in the appropriate
amount of money. The remit of the Cayton committee
that looked at it was that it should bring in the same proportion
of money as the current system does. The current system brings
in about £487 million out of a total spend of £1.8 billion,
so it is about 28%. What we do not know is when you change charging
regimes as drastically and dramatically as this particular change
is happening what that will do to patient attendance and patterns
and nobody else can tell you. The bits that we do not like about
the charging are the massive steps which are difficult for patients
to get their heads round. For one simple filling they move from
a band of £15.50 to £42.40. I do not know what the patient
is going to say about that. They may opt to get additional treatment
done or they may save it for some time.
Q329 Charlotte Atkins: What you are
saying is that patients may wait until they have more than one
pain in their mouth to ensure that they fit nicely into the middle
band as opposed to just missing the first band, is it not?
Dr Ellman: It is a possibility.
I have no handle on this. I have no way of knowing what patients
will actually do. Some will progress as they have always progressed
but many will be unsure.
Q330 Charlotte Atkins: Is the new
contract going to be profitable for dentists or are a lot of dentists
going to go down the completely private route?
Dr Ellman: There is some evidence
from the plan providers particularly, because they are the people
who have people signed up, that quite a number of dentists are
moving outside the NHS because they do not see the reforms being
satisfactory for their particular practice. How workable it is
remains to be seen. I know that the Department of Health is fairly
confident that they think they have got it right, but a lot of
my colleagues are confident they have not. The one really big
item that is missing is the drive towards prevention. I think
the drive towards prevention is the one that I would really like
to have seen in place. That is there as a token more than as a
Q331 Charlotte Atkins: So by going
private they think they could do more preventative work, do they?
Dr Ellman: Most dentists who go
private do not go private just for the income. They go private
to allow them to spend time to produce the quality of dentistry
they think they want to produce and they feel patients deserve.
The two things do go together. The new system does not really
provide them with that time and it does not provide them with
a generation towards a quality of service and a quality of outcome
which we all want. The intangible factor is that of job satisfaction
and that is one that dentists do not get when they are pushed
really hard in terms of a lack of time to deal with patients.
So when you get the average dentist out there working on the NHS
seeing 40 patients a day, they do not feel that they can form
a good working relationship with those patients, they have not
got the time to encourage prevention to take place and that is
a continual reinforcement process.
Q332 Charlotte Atkins: If they want
to get off the drill-and-fill treadmill, would not the best way
of doing that be by increasing the input of fluoridation in terms
of particularly young people's health?
Dr Ellman: The scientific evidence
is that fluoridation makes a massive impact particularly on young
people's dental health, yes, but this has issues that you know
a lot more about in this House than I know about it to do with
the resistance to it. That is not in my gift but it is there.
Q333 Charlotte Atkins: What is your
view about the issue of dentists who are requiring parents to
go private while they treat their children on the NHS? I understand
under the new contract that will not be acceptable.
Dr Ellman: I have no evidence
that this actually happens. I am not denying that it does.
Q334 Charlotte Atkins: You should
see my postbag in that case because I can assure you it does.
Dr Ellman: I will take your evidence.
I think it is wrong that patients are treated in that way. It
is not something we do in our own practice. You could say we only
treat adults privately and we will happily take your children
on the NHS, but I do not think one should be a condition of the
other. I find that unacceptable.
Q335 Charlotte Atkins: Is it not
difficult to separate that? You could have a dentist saying, "I
don't make it conditional", but we know some say on a nod
and a wink, "I will not take your children unless you go
on Denplan", or some other private system and it is very
difficult to prove one way or the other, is it not?
Dr Ellman: I would imagine it
Q336 Charlotte Atkins: If you heard
that some of your members were going down this route you would
condemn them for that, would you?
Dr Ellman: I think we would want
to advise them not to do so.
Q337 Charlotte Atkins: Mr Cartwright,
based on what I hear and see from your own evidence, you are concerned
about the cross-subsidy to sight test fees from people who require
spectacles, is that right?
Mr Cartwright: That is correct,
Q338 Charlotte Atkins: Is that because
you think that the present sight fee does not cover the extensive
sight test that most optometrists embark on?
Mr Cartwright: The current sight
test paid for by the NHS, which is £18.39, does not cover
the real cost of providing that examination, which is around £37.
There is this cross-subsidy from the sale of spectacles and contact
lenses which in effect is a tax in some ways on the wearer of
spectacles who is then paying for part of that examination.
Q339 Charlotte Atkins: Just because
you have a sight test at one particular practice does not mean
you cannot take that sight test off and go and buy your spectacles
somewhere else, is that right?
Mr Cartwright: That is correct.
1 Note by witness: In 2003, Harry Cayton, the
Director for Patient Involvement at the Department of Health,
established a working group to review patient charges. He submitted
the group's report to Ministers on 31 March 2004. The report was
published on 7 July 2005. The BDA were present on the committee
as expert advisors and concentrated on two key issues for dentists
of bad debt and missed appointments. Back