Examination of Witnesses (Questions 340
THURSDAY 9 FEBRUARY 2006
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
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
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
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 evidencethat does not mean to say that it definitely
does not happento 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
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
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.
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
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
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.
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,
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.
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
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
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
See Ev 137. The BDA has also written to Charlotte Atkins MP and
Mike Penning MP to help clarify their constituency cases. Back