Select Committee on Health Written Evidence


Memorandum submitted by the International Glaucoma Association (CP 37)

INTRODUCTION

  The question of co-payments and charges is best divided between health service provision and amenities, although there may be some areas, such as car parking, where the two overlap.

  Consideration should be given to: The potential health consequences of a financial disincentive to the take up of the service. The quality of life of the patient and those issues related to health outcomes. In all cases, the transparency of charges should be improved, so that people can make a properly informed choice when making their decision.

  In this submission I will be concentrating on optical services as this is our area of expertise. I have listed our responses in the order of the terms and references, followed by a detailed review of optical provision.

1.  EQUITABLE AND APPROPRIATE CHARGES

(a)  Treatments

(i)  Prescriptions

  Not equitable across a range of long term conditions eg a Type II Diabetic patient may not require medication for the control of their condition, but they are entitled to NHS funded prescriptions. A glaucoma patient for whom eye drop medication is essential for the preservation of sight must pay unless entitled to NHS funded prescriptions for another reason.

(ii)  Dentistry

  Generally equitable and appropriate where provision is available. However exemptions do not apply to private treatment which is often the only treatment available in a given area. Dentistry is only a partial NHS service with many citizens unable to take up the minimal NHS service provision for routine check up appointments.

(iii)  Optical Services

  Generally equitable and appropriate, however the limitations of funding in terms of the examinations available under NHS funding leave many conditions under-detected.

(b)  Hospital Services

(i)  Telephone and TV

  Generally equitable, however, it is often the case that no extra provision is made for people of limited means and the level of charging especially for incoming calls to patients is excessive.

(ii)  Parking

  Generally equitable, but too little provision is made for disabled or elderly patients and visitors.

2.  OPTIMAL LEVEL OF CHARGES

  Charging in the NHS should be set at a level where it does not act as a disincentive to those who are required to pay, to take up the service concerned. Both dentistry and optometry detection referable diseases for which the symptoms are not immediately apparent, the treatment of the conditions is vital to the health of the individual concerned. Prescription charging has a significant impact on the take up of prescribed medications.

3.  IS THE SYSTEM OF CHARGING SUFFICIENTLY TRANSPARENT

  No. A specific example being an NHS funded eye examination for a relative of a person with glaucoma. Only one of the three necessary tests is funded by the NHS with the other two being chargeable additions to a test that is supposedly NHS funded in order to detect glaucoma at the earliest possible stage.

4.  CRITERIA TO DETERMINE WHO SHOULD PAY AND WHO SHOULD BE EXEMPT

  Simple ability to pay is an insufficient ground for this decision as it is important to include the disincentive to seek treatment for asymptomatic conditions that a charge causes. Many conditions are better treated at an asymptomatic stage and many cannot be reversed if they become symptomatic. Glaucoma and diabetic retinopathy (the two leading causes of preventable blindness in the UK) are prime examples, but likewise intracranial cancers, hypertension, ocular hypertension, diabetes, multiple sclerosis, etc (optical detection), mouth cancers (dentistry) may be missed without routine examinations.

5.  MAKING PATIENTS AWARE OF THE EXEMPTIONS

  Exemption criteria are complicated, and in many cases difficult to understand. It is probable that a person actively seeking will make their initial descisions on the basis of a perceived cost, rather than fact.

  This is of particular concern in people with.

6.  WHETHER CHARGES SHOULD BE ABOLISHED

  From a practical point of view it is probably impossible to abolish most of these charges. However, in terms of prescription charges there is clear evidence of a disincentive to comply with prescribed treatment regimes for chronic conditions (particularly those which are asymptomatic) which is seriously detrimental to the long term outcomes in such cases. Access to primary care ophthalmic services may also be reduced due to a perception that an appointment, (whether charged for or not), will result in the need for replacement spectacles and a pressure to purchase these from the optometrist practice concerned (ie the mixture of medical and commercial activities within the one facility).

REVIEW OF OPTICAL SERVICES

  The purpose of the standard General Optic Council eye examination (the eye test) is generally considered to have two parts:

    1.  to correctly identify and rectify, by means of spectacles or other optic aids, poor vision caused by long or short sightedness, astigmatism or other deficiency.

    2.  to detect signs of ocular disease or abnormality that requires referral to an ophthalmologist within the secondary care system.

  A consequence of the standard test to examine the interior of the eye (ophthalmoscopy or slit lamp microscopic examination) in the detection of high blood pressure, diabetes, some types of cancer, multiple sclerosis and other systemic conditions can be detected in the eye, often before symptoms become apparent.

  Technically an optometrist does not diagnose referable diseases such as glaucoma, diabetic retinopathy or macular degeneration, this being the role of the ophthalmologist or hospital specialist.

  In terms of glaucoma, the Government has recognised the importance of early diagnosis of this condition, by means of the provision of NHS funded eye tests for first degree relatives of glaucoma sufferers over the age of 40 ever since the introduction of eye test fees.

  However, the Government has not recognised the importance of the two additional tests required for the earliest possible detection of glaucoma in a primary setting by providing funding for these tests to be carried out. In 1996 this Association carried out a large scale analysis of 275,000 eye tests by 189 different optometrists across England and Wales to establish the relative effectiveness of the different modes of glaucoma screening[10]. This research showed that the one mandatory and funded tests (ophthalmoscopy) would only detect about 25% of the detectable people with glaucoma who were presenting for an eye test. The additional two tests; tonometry—a measurement of the pressure within the eye and perimetry; a check of the field of vision gave a detection rate of about 75% and about 100% respectively (when applied in addition to one another).

  These two additional tests are available in most optometric practices today, but both may attract a charge despite the possibility of the remainder of the test being NHS funded. From the patients' point of view, these charges seem suspect because their test is being funded as a result of their increased risk of developing glaucoma, yet if the purpose of the NHS funded eye test is to find early cases of glaucoma in people at increased risk of developing the condition and these tests are essential for that early diagnosis is to be achieved.

  Glaucoma is more common in the elderly population, the re-introduction of the NHS funded tests was an important advance, however the failure to fund all three tests needed for about 100% detection rate, has reduced their value preservating sight. The transparency of charging and also the NHS receiving value for money by minimising sight loss will inevitably become more severe as the general population ages and as newer diagnostic techniques such as the Heidelberg Retinal Tomograph become more readily available in primary practice.

  It is not unreasonable for people who are able to pay for an eye test, to be asked so to do. Where there are known additional risk factors or disincentives for people to use the facilities provided by the optometric community, there should be a significant and sustained effort encouraging people to ensure their long term vision by going for a test. It is important to note that some racial groups are at particular risk of certain conditions and these groups often have a low usage of chargeable NHS services.

  A prime example of this are people of African Caribbean origin who are more prone to developing glaucoma than the Caucasian population and that such glaucomas tend to be more difficult to control effectively, making early detection even more of a priority if vision is to be preserved for life.

  Glaucoma remains the leading cause of preventable blindness in this country with approximately 50% of those with the condition currently undetected and consequently without treatment. This is because the most common forms of glaucoma do not give warning symptoms until a late stage when irreversible damage has already been done to their vision.

  As one eye tends to fill in for the other, glaucoma does not usually become symptomatic until between 40% and 50% of the visual field has been lost. A loss of this magnitude would generally be considered to equate to a loss of between 80% and 90% of the nerve fibres within the optic nerve. These losses cannot be recovered and are permanent. While treatments for glaucoma are now very effective, the combination of the natural loss of nerve fibres that occurs with age and the losses due to the glaucoma means that the remaining 10% or so of nerve fibres at the time of symptomatic presentation are extremely vulnerable and permanent visual impairment is much more likely than for someone diagnosed at an earlier stage. Approximately 2% of people over the age of 40 have glaucoma in the UK with less than half detected and under treatment. If the precursor condition to glaucoma (ocular hypertension) is added to the equation, as many as 2.2 million people are at increased risk of permanent visual impairment.

  The second most common cause of preventable blindness in the UK, and the leading cause among the working age population is diabetic retinopathy. Diabetic services are well developed in most parts of the country, with eye tests being provided by the NHS without charge to the patient. However, the best way to detect signs of diabetic change within the eye is through a special form of ophthalmoscopy, called fundoscopy, which requires that the pupil be dilated for the examination. While as with glaucoma, many, probably most optometrists do not make an additional charge for this test, when combined with the additional liability to glaucoma of diabetic patients and their consequent best practice requirement for the additional two glaucoma tests, this is another potential point of misunderstanding or missed diagnosis due to a lack of understanding of the system.

  To the patient NHS funded means "free" and any additional charges are likely to be viewed with suspicion which means that some will opt not to have the necessary additional tests, and also that their confidence in the eye care professional concerned may be damaged.

  This concern also applies to dentistry where it is not the treatment of damaged teeth that is the most significant element of the work, but rather then detection of other conditions such as cancer that can be extremely significant in terms of the health of an individual and the population as a whole.

SUMMARY

  All charges levied for NHS treatment are by their nature undesirable, some areas such as optometry are of particular concern because of the prevalence of serious sight or life threatening disease within the population. The standard eye test does not provide a comprehensive examination in terms of the detection of some of these conditions at the most appropriate stage and this undoubtedly results in unnecessary blindness that is disproportionately biased towards the less educated and affluent communities within society. The costs of this blindness also fall disproportionately on both the people and the social services within these communities.

  More should be done to highlight the exemptions to charges that are already in place and much more should be done to provide comprehensive examinations (to prevent false negative results from tests) and to encourage take-up of the available services. Particularly in the area of optometric services, a more realistic scale of payment to the optometrist should be considered taking into account the provision of tonometry and perimetry and any other tests that may be necessary for the timely detection of ocular disease. The introduction of shared care community based systems for the management of glaucoma is an ideal opportunity to improve the provision of these essential detection systems.

International Glaucoma Association

January 2006







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