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
10 Not printed here. Back
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