Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 340 - 359)



  Q340  Charlotte Atkins: In the future you could have a basic sight test, a medium one and one that is far more expensive. Could you have a different level of sight test and follow-on care in the future?

  Mr Cartwright: Absolutely. The optical profession has published its view of what could be done in the future where there was a much wider role for optometrists in providing that essential eye examination. The role of the optometrist could be expanded within that to some extent, but then we would also have an additional service where the optometrist is effectively the first port of call for anybody who has a problem with their eyes. So if it is a red eye conjunctivitis then that would go to the optometrist and the vast majority of cases the optometrist would be able to treat. We could also have glaucoma monitoring and diabetic monitoring where the optometrist should be fully engaged as well. If optometry was doing that those services should be remunerated at a realistic level.

  Q341  Charlotte Atkins: Would it make sense to offer a differential service to different people depending on age and general health? At the moment you have a standard sight test that everybody who comes through the door has, although I have been very impressed by some of the sight tests I have been offered because they seem incredibly extensive. In fact, they normally convince you you are blind and you are so relieved by the end of it that you are not that you are willing to accept anything!

  Mr Cartwright: Over the last 10 years the diagnostic tests that are available have expanded quite markedly and optometrists are involved in that. At the moment there is this cross-subsidy and actually it would be something that the Government is missing out on in not taking advantage of that resource that is available to free up resource elsewhere.

  Q342  Charlotte Atkins: What do you think the future for the sight test should be? What would you recommend?

  Mr Cartwright: We would recommend that we should have an expanded eye examination as an essential service that is available in all areas.

  Q343  Charlotte Atkins: So that you are pulling in youngsters who at the moment are not getting that full cover?

  Mr Cartwright: Certainly there should be a much greater awareness of the importance of eye examinations and eye health and preventative eye care. There would then be optometrists being in effect the GP for eye services. So any eye condition would initially come to the optometrist for diagnosis and monitoring to decide what it is and to potentially treat and then we would also be engaged locally in glaucoma schemes, diabetic retinopathy monitoring schemes, the treatment of age related macular degeneration or the diagnosis of age related macular degeneration and advice and guidance there.

  Q344  Charlotte Atkins: The Department does not seem to think that the sight fee itself really matters because it is negotiated in a competitive framework. What is your view about that?

  Mr Cartwright: Absolutely not. The cross-subsidy is not a good example where the one who wears spectacles then has to pay for part of the eye examination for somebody who potentially has not got to wear spectacles, so there is a hidden cost to a third party.

  Q345  Charlotte Atkins: The other issue is to do with the NHS voucher and the fact that many practices do not seem to stock spectacles which are fully covered by an NHS voucher. Does that mean that a number of people either do not come for a sight test or they decide that they will not buy a pair of spectacles simply because they cannot afford the gap between the voucher and the cost of the spectacles?

  Mr Cartwright: Two-thirds of optical practices do supply spectacles like single vision or bifocals or two pairs covered by the cost of the voucher. There is not any evidence—that does not mean to say that it definitely does not happen—to say that people are deterred from an eye examination or from coming along to an optical practice because of the cost of spectacles. There needs to be greater awareness of the fact that people can come along that are eligible for an eye examination and that it is an important part of monitoring for eye conditions which if found early can be treated, but in two-thirds of practices the voucher will cover the cost of the spectacles.

  Q346  Mike Penning: Dr Ellman, I was astonished to hear you were not aware of this blackmailing which is going on within dentists about how you cannot keep your children on the NHS unless you go private yourself. Not only is that an issue for my constituents, but my dentist wrote to me (obviously he does not realise I sit on this Committee) saying that if I wanted to stay with him I had to go private and my children would get NHS services if I stayed. Are you saying you have never heard of this before?

  Dr Ellman: I said I have no evidence that that is happening. You are giving me some. Can I just correct the position that your dentist seems to have taken which says he will happily treat your children on the NHS but you must go private? He did not use that as a lever.

  Q347  Mike Penning: He did. He said he would remove me from his list as an NHS patient unless I went private.

  Dr Ellman: He did not say he would not treat your children on the NHS unless you go private.

  Q348  Mike Penning: Yes, he did.

  Dr Ellman: In that case, I am sorry, I would not agree with that.

  Q349  Mike Penning: I will supply you with that letter. Are you for the contract? Are you happy with it? Are you going to sign the contract that is being offered to you or are you going to reject it?

  Dr Ellman: I do not have powers to reject on behalf of the dentists.

  Q350  Mike Penning: But you are going to advise them on whether it is good or bad for them.

  Dr Ellman: Yes, we do advise them. We have just said that at the present time this contract is an absolute mess. That was in our press release the other day. The contract needs to be looked at in a much more serious manner than it has been looked at because there are serious flaws in it.

  Q351  Mike Penning: If they do not change the flaws you are going to advise your members not—

  Dr Ellman: They will probably have to live with it because quite a lot of our practitioners on two grounds want to remain within the NHS. One is that they are in areas where to move outside the NHS would be inappropriate and the other is that a lot of dentists are actually wedded to the concept of the NHS; that is what they want to do. Those who move away rarely do it on grounds of the economics of the situation, but rather the fact that job satisfaction of spending longer with patients, has been removed.[2]

  Q352  Mike Penning: NHS dentistry could not survive without your members being fully involved in that. If your members said "No, we're not happy with his contract" the Government would have to look again, would they not?

  Dr Ellman: They would, you are quite right. Unfortunately dentists do not work that way. They are independent contractors and the word independent comes to the fore.

  Q353  Chairman: Do dentists take a collective view through your Association on issues like new contracts? Do they have a vote?

  Dr Ellman: No. We do not do that because we did not negotiate the contract; it was imposed on us.[3] It is a Department of Health contract that has been pushed forward. All we have done is talk about it, advise them and chip away at some of the things that are wrong. Some of the things that are still wrong make it a very disadvantageous contract in some respects.

  Q354  Chairman: As an Association representing dentists you have not negotiated the new contract with the Department like the BMA negotiated with the new GP contract, have you?

  Dr Ellman: That is correct.

  Q355  Chairman: You have not done that and therefore you do not have a collective view on whether it is good or not.

  Dr Ellman: It may have been done previously but it has not been done on this occasion.

  Chairman: I hope my two colleagues will be able to send you information about this other issue and then you can respond to that.[4] I am sure we would appreciate that during the course of our inquiry. We are going to move back now to vouchers for glasses.

  Q356  Mr Campbell: Citizens Advice told us that they had evidence that a lot of people who go for an eye test cannot afford to pay the difference between the voucher and the price of the glasses. What is your take on that? Is the voucher system wrong? Do they need to increase that or take it away altogether?

  Mrs Hansford: As David said, two-thirds of optical practices in the UK offer spectacles within the voucher value. I think you will always be able to find people who fall outside that or who perhaps have not understood it. When I read that I did feel that perhaps we need to work with Age Concern and the CAB to see if we cannot resolve that. It sounds like it is small pockets of a problem. What you have to understand is there is no such thing as an NHS pair of glasses anymore. What happens is that all spectacles are provided as a private contract and the Department of Health provide a voucher to help people who are on low incomes towards the cost of a private pair of spectacles. It is up to the patient to decide what spectacles they want to buy, whether they want to buy a budget pair or a more expensive pair. Maybe there are misunderstandings about whether there are cheaper pairs available, I would not know and it is difficult to talk about specific cases. There is plenty of opportunity to buy spectacles within the voucher value.

  Q357  Mr Campbell: There must be a big difference between the worth of the voucher and the price of the glasses.

  Mrs Hansford: There can be. If you buy a pair of spectacles like I am wearing there will be a huge difference between the voucher value and the spectacles. You would expect me to be wearing top of the range spectacles, would you not? If I had a voucher it would make a very small dent in the cost of this pair of glasses, but I did not have to choose this pair of glasses, I could have chosen a budget pair and I could have had a pair of bifocals instead of a pair of varifocals, but that is my choice. One of the strengths of the optical market is that it has complete and utter patient choice. There are no restrictions to the optical market whatsoever. You can have 10 optical practices in a row in a street. Whilst that is very uncomfortable for us sometimes as business people, it is a driver for excellence. If you have got lots of competition you have to be good to make sure that you keep your head above water and that your business is a success.

  Q358  Mr Campbell: Would it not be better to do away with the voucher system and have an income cut-off rather than a voucher system and give them a good pair of glasses?

  Mrs Hansford: I do not understand what you mean.

  Q359  Mr Campbell: So instead of having a voucher system they would have to declare if they are on Income Support or low wages. Would that not be a better system, where the Government would give them a good pair of glasses rather than the budget pair?

  Mrs Hansford: But a budget pair does not mean it is a bad pair of glasses, it just means that it is not a designer pair of glasses.

2   Note by witness: An independent survey carried out for Doctors' and Dentists' Remuneration Review Body in 2002 looked at the reasons why dentists were turning away from NHS dentistry: about 70% said they felt rushed when treating NHS patients; around 60% said that their workload did not allow them to provide the professional standard of care with which they were comfortable; while at present 60% of dentists spend at least 90% or more of their time working in the General Dental Services, only about 16% expected to be so committed in five years' time. Back

3   Note by witness: As a result of primary legislation-the Health and Social Care (Community Health and Standards) Act 2003-the new General Dental Services contract was outlined in this Act. The Act was an enabling act for the Department of Health to implement the contract. It was not designed as a negotiated contract between the Government and the profession. The BDA were privy to discussions with the dentistry Minister, Rosie Winterton MP and her departmental officials about the contract. The BDA constructively inputted into these discussions, but the final details of the contract lie with the Department of Health. Debate about the precise details of the contract came through secondary legislation-the National Health Service (General Dental Services contract) Regulations 2005 Back

4   See Ev 137. The BDA has also written to Charlotte Atkins MP and Mike Penning MP to help clarify their constituency cases. Back

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