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
| Year | GOS spending on sight test fees at 2003-04 prices omitting extension of free tests £m
|
| 1994-95 | 110.6 |
| 1999-2000 | 117.6 |
| 2000-01 | 122.3 |
| 2001-02 | 126.6 |
| 2002-03 | 125.6 |
| 2003-04 | 127.9 |
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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 over | 42.3 |
| Children under 16 | 21.6 |
| Under 19 in full time education | 4.4
|
| 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 sufferer | 6.0
|
| Relatives 40 and over of Glaucoma sufferers—(parent, brother, sister, son or daughter)
| 5.4 |
| Registered blind or partially sighted | 0.2
|
| Needing complex lens vouchers | 0.4
|
| Vouchers (GB) | Percentage of vouchers
|
| Children under 16 | 26.5 |
| Under 19 in full time education | 6.0
|
| 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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