Select Committee on Health Written Evidence


Memorandum submitted by the Association of Dispensing Opticians, Association of Optometrists and the Federation of Ophthalmic and Dispensing Opticians (CP 26)

1.  OVERVIEW

  1.1  There are over 7,300 opticians premises in Great Britain. They range from large stores with multiple consulting rooms to small practices in local shopping parades. Optical practices are equipped to carry out full eye examinations and the diagnosis and monitoring involved in co-managing patients with GPs or hospital ophthalmologists. After a sight test, patients are issued with a prescription or a statement saying that a prescription is not required. Patients are also informed if the prescription has not changed. Patients can have spectacles or contact lenses dispensed in accordance with their prescription wherever they choose. NHS vouchers are available to qualifying groups to help with the cost of spectacles or contact lenses. They vary in value according to the lens powers prescribed. Vouchers can be used as a contribution towards the cost of any spectacles or contact lenses.

  1.2  The current NHS sight test fee is £18.39. This is for the final year of a three year agreement. The profession negotiated with the Department of Health for revised fees from 1 April 2006. The current sight test fee is about half the actual cost of providing a sight test (estimated at about £37). With advancement in technology and an ageing population requiring more information and assurance, the sight test now takes longer to perform and has become more expensive to deliver.

  1.3  The total GOS spending has hardly changed in real terms since 1999-2000 and excluding the effect of the extension of free sight tests has been static as the table 1.4 below shows. Without the increased exemptions total spending can be estimated at £127.9 million in 2003-04. In contrast the total NHS expenditure rose by 20% in real terms over these three years and by 45% over the whole 10 years.

  1.4
YearGOS spending on sight test fees at 2003-04 prices omitting extension of free tests £m
1994-95110.6
1999-2000117.6
2000-01122.3
2001-02126.6
2002-03125.6
2003-04127.9
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  1.5  It is clear that the optical sector has provided improved value for the NHS. The sight test fee at £18.39 is well below the cost of providing the test (£37). The fee to the NHS has been subsidised through the sales of spectacles. This has not been an example of good practice in government contracting where fair prices are agreed without hidden cross-subsidies on third parties. It is widely accepted that: (a) the Government should pay a fair market price for services, and (b) that it should minimise distortions to free economic activity.

  1.6  According to a recent survey carried out by FODO, the average interval between sight tests has increased from 23 months to 26 months. We estimate the average interval for working-age adults is over 30 months.

  1.7  At present there are no current definitions of strategic priorities for improving health in the optical field. A National Service Framework or a set of quality standards, which could serve as the basis for definitions of quality in service, does not underpin the current GOS. Nor is there much information on visual standards or on problems that could be encountered as a result of poor sight. The lack of information is one reason for the almost total absence of any emphasis on the importance of eye health or visual/ophthalmic standards from government review or strategies. Neither the recent White Paper on public health nor the latest DoH paper on NHS improvement, mention visual standards: nor did any of the Wanless Reports. The only issue to gain any attention has been that of waiting times for cataract operations.

2.  WHO IS ELIGIBLE FOR AN NHS SIGHT TEST?

  2.1  NHS Sight tests
Sight tests (GB)% of NHS sight tests
Aged 60 or over42.3
Children under 1621.6
Under 19 in full time education4.4
Benefit Claimants—Income Support, income based Jobseekers Allowance, Pension Credit Guarantee Credit, etc 17.8
Named on a valid HC2 or HC3 certificate-the sight test fee (or voucher) will be reduced by any amount the claimant is assessed as being liable to pay 1.5
Diabetes or Glaucoma sufferer6.0
Relatives 40 and over of Glaucoma sufferers—(parent, brother, sister, son or daughter) 5.4
Registered blind or partially sighted0.2
Needing complex lens vouchers0.4
Vouchers (GB)Percentage of vouchers
Children under 1626.5
Under 19 in full time education6.0
Benefit Claimants/HC2—HC3 (see above) 55.6/5.9
Complex lenses—a registered optician can advise on entitlement 0.8

3.  BUYING SPECTACLES, CONTACT LENSES AND GETTING AN NHS EYE TEST

  3.1  Around two thirds of the 7,300 optical practices in the community stock a range of spectacles within the price of the lowest value NHS voucher, currently £32.90. Many patients exercise their right to use a voucher as part payment to purchase more expensive options. This is reflected in the figures below.

  3.2  6% of sight tests resulted in patients choosing contact lenses. According to the Association of Contact Lens Manufacturers Annual Report 2004 the number of people wearing contact lenses in 2004 rose to 3.21 million—6.5% of the adult population, an increase of 16% since 2001. The majority wear frequent replacement lenses. Over one million adults (34% of wearers) wear daily disposable lenses, 180,000 (6%) wear silicon hydrogel lenses and 345,000 wear rigid contact lenses (11%).

  3.3  According to a RNIB report and Laing & Busson over one million older people live at home or in care, unable to visit a high street optician unaided yet only 344,000 domiciliary sight tests were carried out last year. This suggests that a great deal more needs to be done in this area. Research shows over 189,000 people with visual impairments fall each year at an estimated cost to the NHS of £269 million (research carried out by the University of York). Of course visual impairment doesn't just result in trips and falls, it can cause painful headaches which make life exceptionally difficult.

4.  AVAILABILITY OF NHS EYE EXAMINATION IN THE FUTURE: OUR VISION FOR THE FUTURE

  4.1  We believe that as an essential NHS service the eye examination should be available to patients on a national basis irrespective of where they live and independently of the funds available locally. Eye care is an essential primary care service and should be available without restriction to eligible citizens on the basis of need. The current non cash-limited funding system ensures that all eligible patients who have a genuine need can have a NHS sight test whenever and wherever they need it. It also provides the essential foundation without which the current vigorously competitive market could not operate. This gets new providers to enter the market freely, set up in business to provide eye care (subject to General Optical Council and primary care organisation quality controls) and offer alternatives to existing providers on the basis of quality, access and cost.

  4.2  A wider range of procedures should be available for NHS patients

  The eye examination should be redefined to include a wider range of procedures offered on the basis of patient need and the practitioner's clinical judgement. An essential part of any health service should be health. The current GOS sight test which has existed largely unchanged for the last 60 years is primarily a refraction service to provide spectacles but with elements of health screening and opportunistic health checks included. This has led to the current sight test being primarily a means to provide spectacles or contact lenses, rather than acting as the primary examination in response to a range of eye symptoms and conditions. The more advanced optometric techniques that can currently be performed are either charged for privately, or provided free to the patient and the NHS as a gesture of goodwill. This is a poor model for providing essential care. If services are not properly designed for the needs of patients, patients will not access them and the service will not satisfy their requirements. If the service is inadequately funded there is every likelihood that the service will just not be provided to a consistent and high enough standard. The fact that optometry provides such a high level of service under these conditions and with such a low level of complaints is testimony to the commitment of opticians and ophthalmic medical practitioners to their patients. However it is not a situation that can continue. A new NHS eye examination has been developed in Scotland which removes the mandatory refraction and allows practitioners greater professional freedom. It will consist of a primary and a supplementary examination, both of which will attract funding more appropriate to the actual time spent with patients. This will allow practitioners to examine patients and provide a more appropriate service. This will also act as the corner-stone for an integrated service amongst optometrists, ophthalmic medical practitioners, dispensing opticians, GPs and social workers in primary care and ophthalmologists and orthoptists in hospital.

  4.3  A properly funded NHS examination

  The eye examination should be properly funded on the basis of an independent survey of full costs. It is widely recognised that the current NHS sight test fee is significantly under-priced not least by Department of Health negotiators who rely on the cross-subsidy from the sale of spectacles and contact lenses—in effect making it a loss leader for product sales. This has suited successive governments who have not wished to invest in NHS eye care. However, there have been significant downsides. In particular the public has comet to undervalue the importance of eye care and the need for regular checks and to view the eye examination as simply a test for correcting sight and a "grudge payment". As a result patients attend for eye checks less frequently that they should. This will in turn have led to missed pathologies and blindness involving far higher long-term costs to the NHS. The last costs survey was carried out in 1992. It concluded that the cost of providing an eye examination was £18.42 (£25.97 at 2005 prices) and this was conducted at a time before a number of significant technical advances which are now commonplace and which have enhanced the clinical effectiveness of the sight test but made it more expensive to equip for and deliver. As the population grows older and as patients generally become better informed and require more information and reassurance, the average sight test now takes longer to perform. The optical sector is very happy to participate in a new independent survey of the costs of providing a sight test and other aspects of eye care. Additional NHS eye care services should also be properly funded. Such a survey could also include the costs of services described as "additional primary care" and "enhanced services" as is in the Health Bill.

  4.4  End cross subsidies

  There should be no cross subsidy between clinical services and sale of product. It is well established that subsidies distort markets. The NHS has not paid for improved standards of sight testing. Rather, the sight test fee represents a declining proportion of the costs. There has been increasing cross subsidisation of the costs of the sight test fee by sale of spectacles. Total General Ophthalmic Service expenditure in England has risen from £248.8 million in 1999-04 to £321.6 million in 2003-04. However, much of this rise has been accounted for by the extension of eligibility for free sight tests in 1999-2000. Since then, total gross expenditure has risen from £315.2 million in 2000-01 to £321.5 million in 2003-04.

  It is not in the long-term interests of the NHS, the optical sector or patients for providers to be inadequately remunerated for the clinical care they provide. The current low level of the NHS sight test fee means that, effectively, NHS patients who, following a sight test, need spectacles or contact lenses, are subsidising eye examinations for those who do not. This contravenes the founding principles of the NHS and is the reverse of the situation in the rest of health care.

  4.5  New Business Services Authority

  Submission of claims and optical payments should be centralised in the new Business Services Authority (in the same way as for pharmacists and dentists) to improve efficiency and reduce bureaucracy costs and fraud. Common services agencies and PCTs (even when merged) will always be relatively small organisations. It is inefficient to deploy scarce resources on payment functions at this level. It was for this reason that the Department of Health established the Dental Practice Board and Prescription Pricing Authority at the start of the NHS for dentist and pharmacist payments. These bodies are now being merged into a new NHS Business Services Authority (BSA) for the NHS.

  They have well-established and efficient payments systems which could easily include optical payments. It would therefore make sense for optical payments to be handled centrally by the BSA on behalf of primary care organisations. It would also make sense for optical payments to be built into systems developments at the BSA from the outset to avoid greater costs later on. As all costs impact on prices, improved efficiency will benefit patients and increase the value of NHS investment. Additional benefits for the NHS would be greater efficiency, freeing-up resource at local level, a rich database for interrogation, policy monitoring and development, and effective electronic monitoring for counter-fraud purposes.

5.  HOW ARE SCOTLAND AND WALES DIFFERENT FROM ENGLAND

  5.1  Optometry Scotland has been working with the Scottish Executive Health Department and ministers to develop a new contract in Scotland. It includes new primary and secondary eye examinations, new fees and new investment. It is the most significant change in legislation concerning the provision of eyecare in Scotland for 60 years and places optometry firmly within the NHS as the principal provider of eyecare.

  5.2  The Welsh Assembly Government (WAG) has continued to achieve great success with the development of WECEs (Welsh Eye Care Examination) and the PEARS (primary eye acute referral scheme) provided by over 80% of the optometric workforce. Similarly, the Wales Low Vision Examination has been operational for 17 months, moving the provision of low vision services into primary care. Waiting time and appliance provision has dropped from 18 months to eight weeks. Both schemes have been developed as a result of WAG funding, and with all with participants being able to participate to ensure equity in patient choice. Significant savings in secondary care have accrued as a result.

John O'Maoileoin

Association of British Dispensing Opticians (ABDO), Association of Optometrists (AOP) and Federation of Ophthalmic & Dispensing Opticians (FODO)

December 2005





 
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