Health Bill


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Stephen Williams: Another anomaly is that when someone gets their prescription from the optometrist, they can leave the premises and take their prescription somewhere else, where a wider range of spectacles might be available. The cross-subsidy is not guaranteed.

Dr. Murrison: The hon. Gentleman makes a good point. The Committee will notice that I am wearing a pretty snappy pair of spectacles. They are the bendy ones, which are particularly good for sport, apparently. I do not do much of that, but nevertheless they are a nice pair of spectacles. I got them from an optician who had better remain nameless, but the scenario described applied to me. I am a guileful sort of individual and, arguably, I can shop around—with plenty of time perhaps—but I suspect that many people do not do so.

Almost certainly, the vast majority of individuals who go for an eyesight test will buy their specs from the establishment where they have had the test, not least because people must usually go through a sort of mall full of specs to get to the optician's room, and in those circumstances, it is difficult to take the prescription and run off down the road to another dispensing optician—if, of course, one is available. We should not necessarily assume that everyone lives in a large urban setting where more than one optician is available. Many small towns are lucky to have one, so choice is restricted.

I entirely agree with the hon. Gentleman. Indeed, the point will probably come up again later. If PCTs are to determine the level of fee for the sight test—

Caroline Flint: But they are not.

Dr. Murrison: We shall have to explore the matter. The Minister has admitted that, as drafted, the legislation allows that; she should accept an amendment to ensure that it does not happen. I had hoped to debate an amendment to clause 35 that would ensure that the Minister's intentions, of which she has just told us, are carried out.

The Minister admits that, if only in theory, one PCT could set a low fee. If that were to happen, everyone would be piling into that PCT area and getting cheap eyesight tests—those who were
 
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unfortunate enough not to have a free test—and then crossing the boundary into another PCT area to buy their spectacles. If one operator realised that that was happening, all sorts of perversities could arise. For instance, some of the larger chains, such as Specsavers, could take advantage of the situation to gain a competitive advantage in what I understand is a cut-throat business. The point is extremely well made, and I hope to return to the subject.

I saw a flurry of activity from the Minister as the subject came up, and I hope for some answers, particularly on why something similar to amendment No. 33 has not been introduced as a Government amendment. If her intentions are genuine—I am sure that they are—she should table an amendment to ensure that the risk that she identifies and admits to can be circumvented. PCTs should not be able to negotiate their own sight test fee, as it would result in all sorts of unhelpful perversities that the profession would not wish to see.

We are a little worried that the provisions might somehow be cash-limited. At the moment, part of the cost of the eyesight test is funded from central sources, and that is not limited. Will the Minister say whether the apportionment of moneys will be done in a way that will prevent PCTs from capping the amount of money provided for the eyesight test fee? It is difficult to see how that could not happen. PCTs have to make judgments on how to assign their priorities; and the worry is that, for whatever reason, they might decide to take money away from eyesight tests.

The Minister may say that it is for PCTs to make their own decisions. However, we have recently seen an outbreak of localism, and both parties agree that as many decisions as possible should be taken locally; but one consequence could be that the eyesight test service is de-prioritised. I would be interested to hear what the Minister thinks the implications might be.

I fear that, in their ignorance, PCTs might be tempted to take the view that there is more scope for private subsidy, particularly as there is an interface between the private and public sectors, but that might lead them to the wrong conclusions. That would be a problem because the ophthalmic services' pick-up rate for medical conditions is probably the tip of the iceberg. It has the important job of picking up illness—and, more importantly, remediable illnesses.

Screening is wonderful, but it is often applied incorrectly: it is applied in areas in which, even if something is picked up, prognosis will not be improved, with not much chance of making a big impact on that condition. The conditions that are screened for day in, day out, by high street opticians and picked up—4 per cent. of eyesight tests result in referral—are remediable. That is vital, and applies to both ophthalmic conditions and general medical conditions that have some sort of ophthalmic manifestation, which is why this is so important.

11.15 am

We had a similar debate in connection with oral health and the screening value of NHS dentistry. I
 
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agree with that entirely; it is a valid position for the dental profession to take to say that its services in that respect are highly valuable. In this area, we have the same issues, but they are compounded. Many diseases have some eye manifestation, so I cannot think of any area in which screening is more appropriate. If PCTs decide for some reason, such as deficits, that they must cut back—perhaps through a salami-slice-type cutting back—on optician services, I fear that general health will suffer in their constituent populations. That would be extremely bad for public health.

One hallmark of dispensing opticians and optometry is the huge choice. In what other area of our health services is there so much choice? I cannot think of an example. For two reasons, there is a high level of cross-party consensus at the moment on the importance of choice—certainly between my party and the Minister's; I am not so sure about the Liberal Democrats, who appear to be taking a subtly different approach to health services. Choice is right in principle and it tends to drive up standards across the board. If one embraces the concept of choice, one should surely do nothing that will damage it. I fear that these seven clauses will not improve choice in the range of services that we are discussing, and that they stand a real chance of damaging it. The Minister will have to address that accusation head on, reassure us and tell us how she will ensure that the clauses will not reduce the excellent level of choice that people currently have.

If PCTs can pick and choose, decide who their latest best friend is among high street opticians and exclude the rest, that will restrict people's choices and may, in certain circumstances, remove choice altogether in small market towns such as those that I represent, in which there may be few opticians, or even just one. It may remove such providers altogether, particularly as there will be measures, which we will consider later, that will enable individuals to be excluded from providing the free eyesight test, for reasons that are a little opaque. It seems that a characteristic of the seven clauses is their restriction of that important element of choice. It is impossible to see how choice will be enhanced by the proposals. I hope that the Minister will reassure us about that.

Will patients be able to choose an optician away from their PCT area? I hope that the Minister will tell us that they will. At the moment, people might choose, if they work in London, for example, to go down the road here to have their eyes seen to, and to get any specs or a prescription that they may need, because it is more convenient for them. We know that the Minister is terribly keen on things such as walk-in centres at major London termini, apparently to improve choice for commuters. However, there is a risk that the legislation will mean that people will have to go to a dispensing optician that is local to where they live for their free eyesight test, if they are eligible for it. I do not see why PCTs will not be able to insist that that be the case. I hope that it will not be, and that the Minister can reassure me about that, or at least say that it is not her intention to restrict choice in that way in any locality.

We should know why proposed new section 16CD(4)(b) makes provision for PCTs to take on
 
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primary ophthalmic services themselves. That seems a departure from the excellent model that we have had for all time—certainly since the advent of high street opticians—whereby the services are provided on the high street by a private individual, with the provision of a free test for those who are eligible. The Bill suggests that primary care trusts might wish to take primary ophthalmic services on board themselves. Perhaps the Minister has a particular model in mind, such as circumstances in which it would be useful for PCTs to take on that service directly themselves. I am not clear what such circumstances would be. Perhaps it has to do with expanding the role of primary ophthalmic services; I hope that we shall come on to that matter later. Perhaps she has in mind domiciliary services of one sort or another. That would be a departure from the service norm that currently applies, but perhaps that is why she wishes to make provision for PCTs to take on that service directly. That rather cuts against the remarks made last year by Sir Nigel Crisp about PCTs divesting themselves of the direct provision of services, but if that is the Minister's intention, she should say so. We would like some clarification as to why she has brought that item in under proposed new section 16CD(4)(b).

The clause requires co-operation between primary care trusts. It would be useful to hear from the Minister why it requires that. One naturally assumes that there would be co-operation between PCTs. However, it apparently needs to be emphasised in the Bill. Perhaps it is required in the context of the remarks that I made earlier, which I hope she will answer shortly, to do with the potential for a differential in the sight test fee. Co-operation between PCTs would obviously be useful in expunging the possibility of a differential occurring, and for advantages and disadvantages being introduced into the system as a result. It would be interesting to hear from her precisely what is in her mind about that, as well as about what pain and grief there would be if PCTs did not co-operate. What mechanism would there be for ensuring that they did co-operate, and at what level would it take place? Is that provision just a throw-away, in which case perhaps we should consider removing it from the Bill in order not to degrade the currency?

It would be interesting to hear from the Minister what she considers constitutes primary ophthalmic services under the anticipated regulations. Most people are clear about what constitutes general medical practice. I think I am less clear about what constitute primary ophthalmic services. It would be useful to hear what she thinks. Indeed, proposed new sections 16CD(1)(a) and 16CD(7), taken together, suggest that de minimis primary ophthalmic services could be defined as just the sight test. That would be a pity, and it would be interesting to hear whether that is the Minister's understanding of what primary ophthalmic services are. If so—if they are just one element of the service—we should know. Does she, as I hope, have in mind a more comprehensive service from opticians and optometrists? The Bill needs to be a little clearer.
 
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The profession was concerned about the absence of reference to additional and enhanced services. I know that the Minister of State, Department of Health, the hon. Member for Doncaster, Central, has spoken to the profession about that, and it has been given some reassurance about ministerial intentions as to additional and enhanced services, but it is regrettable that there is no direct mention of that in the Bill. We should like to know what is intended for those services.

If we assume that the Bill is all about improving health, an opportunity is being missed. Although we have concerns about many aspects of devolution to Scotland and Wales, we must observe the systems there that work well, and it seems that things have been moving in quite a positive direction for dispensing opticians and optometry in Wales and Scotland. There have been many good examples of the role of such professionals being expanded usefully.

Just as pharmacy expansion has taken place in England and throughout the UK, there is room for optometry and opticians to grow professionally. The Bill is a regrettable missed opportunity for England. It would have been useful for the improvement of health if the Bill mentioned how services could be expanded. I am thinking of such things as a red eye service from high street opticians, pre- and post-operative surveillance for cataracts, which could, theoretically, be carried out by high street opticians, and a referral service from GPs to optometrists; a direct referral service from optometrists to ophthalmologists would be useful and the profession would welcome it.

Perhaps a service for the removal of foreign bodies could be provided. I recently attended accident and emergency in Salisbury with my fourth daughter, who had a foreign body in her eye. I could not remove it myself because I did not have the necessary slit lamp, which I used to use when I was a casualty officer to remove foreign bodies quite easily from people's eyes. That equipment is of course available on the high street, and I am sure that optometrists would be capable—it seems that they would be willing—to assist with procedures of that sort. That would hugely improve the eye care services available to our constituents. Those are examples of provisions that I should have expected to constitute additional and enhanced services. However, they have been mentioned only belatedly, when the professions involved have sought to meet with Ministers following the publication of the Bill. In failing to herald such innovations, the Bill is a missed opportunity.

11.30 am

I have in this clause stand part debate introduced some of our concerns. My list is not exhaustive, although it might have been exhausting to those who have had to listen to it. I have laid out some of our principal concerns about the seven clauses. I shall be grateful if the Minister answers as many of them as she can head on. Where she is unable to do that, will she come back on Report to expunge the clauses—which are flawed, if necessary at all—pending the review that we have been promised for so long, or at least improve
 
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them so that they stand no chance of damaging what is currently an excellent service?

 
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