Health Bill


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Mrs. Dorries: During the break, I had to go to Boots to buy another pair of glasses, because my old ones were not working. The new ones are not working terribly well, either. Frankly, I think I am better off without them. I shall try my best.

Clause 35 empowers the Secretary of State to rewrite the contract between the NHS and ophthalmic practitioners for the provision of general ophthalmic services. It opens up the real possibility of a PCT refusing to enter into a contract with an optometrist, or to vary the contract in such a way as to exclude those optometrists who the PCT feels are not needed. Nothing in the Bill would prevent that from happening.

The Minister has failed to assure us that any qualified optometrist or optician who meets the necessary criteria and who has the appropriate qualifications will be able to provide ophthalmic services on the high street for all those in the local community who wish to use their services. I am concerned about the responsibility of PCTs for commissioning general ophthalmic services. My PCT
 
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is running a £20 million deficit. In order to recover that deficit, it is restricting emergency services, which is almost a complete contradiction.

Given those deficits, one cannot help but put oneself in the shoes of a PCT chief executive and wonder how the trust would cope with the additional responsibilities of handling the GOS contract. In the face of increasing demand for ophthalmic services in the community, I doubt whether the PCT would honour the contractual rights of every optometrist and optician. The very nature of the Bill means that, at some time, cash will be limited, and that will enable the PCT to decide to whom it wants to award a contract. I know that the Minister gave some verbal reassurances this morning, but the wording of the Bill will not prevent that from happening.

Taking that one step further, were we a PCT we would try to get the best value for the budget that we were awarded because, if we limited the number of providers the flow of people would be restricted and we would have to start a waiting list. The PCT would not want to have to deal with the possibility of waiting lists for eye care services, so it could be tempted to negotiate the best deal possible with the bigger providers. We could even see the bigger players strategically planning new development and future growth based on such PCT-negotiated deals. I again ask the Minister to give the categorical reassurance that the eligible population will retain access to NHS sight tests at the practice of their choosing in their community—not at the choosing of the PCT, but still that of the patient.

A PCT could make such a choice because it felt that from an administrative point of view handling the process of a small number of claims from a small number of outlets would be easier and far cheaper, and that could be presented to the PCT as an advance in clinical governance and therefore become a quality issue. As we discussed this morning, and I think agreed, patient choice is the driver of quality.

The PCT could decide to put the general ophthalmic service contract out to competitive tender in order to save money and to acquire less volume. Every PCT we know is cash-strapped, almost all are running a deficit and it is easy to see how PCTs could choose to ignore or reprioritise patient choice in the face of financial pressure. After all, they have to take much tougher measures with arguably more vital services. As I said, my PCT is restricting emergency services. The prospect of having to restrict ophthalmic services would be a walk in the park; it would not even break into a sweat faced with that option. It would be easy for a PCT to decide that there were sufficient practitioners in a particular town or high street and that they simply did not need to award contracts to any more. We have not heard anything in Committee today from the Minister that would prevent that from happening. In fact, there is nothing in the language of the Bill to prevent such a scenario.

Were a large provider to be commissioned by a PCT, a similar fate could affect our opticians as has affected post offices or high street pharmacies. As we know, the people who feel the effects of closing post offices and high street pharmacies are the elderly, those
 
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in rural locations, the house-bound or those of restricted means. High street optometrists are of significant importance to those groups of people, as are post offices and high street pharmacists.

Optometrists and opticians are not a group of people that one would normally describe as radical or political. They are well behaved caring professionals, carrying out a vital role. However, as my mother-in-law frequently used to say, even a worm can turn. If the budget became cash-limited, if PCTs restricted budgets to optometrists, if not every optometrist and optician could obtain a contract, as they have a right to do now, one could foresee, as I described in my earlier intervention, their finding a way to withdraw their services, as dentists have done. Then, very much like dentists, people would see optometrists and opticians as a political punch-bag, as politically motivated or affected.

At the end of this debate we need to hear from the Minister a guarantee that every practising optometrist, ophthalmologist and optician will be able to practise in future; that they will have a right to the contract, as they have at the moment and have always had; that the budget will not be cash-limited; and that anybody in the community will have access to services, as they have now.

4.30 pm

Mr. Andrew Lansley (South Cambridgeshire) (Con): I want to ask a couple of questions under clause 35, which I do not think we have quite touched on.

Under the general ophthalmic services contract, the primary care trust will be able to contract with providers to provide not only the sight test but other services. There is a relationship between those, in so far as many practitioners offer a range of additional examinations attendant upon a sight test. Dependent upon who is doing the sight test, it varies from a minimum examination to something that is looking for pathology.

My first question is about the extent to which the Government are expecting to specify what the sight test is, using the powers in clause 35. To what extent are they open to looking again in the current consultation at the sight test and, with the Scottish example of an eye examination in mind, at whether it would be appropriate for it to tend more toward pathology, rather than being concerned simply with examining the qualities of somebody's sight?

Secondly, on the structure of payments, what are the Government expecting? If we look at these changes and those for GPs and dentists, the nature of the contracts has varied. All these contracts are concerned to varying degrees with quality, volume and cost. Concerning GPs, they have essentially been about quality and volume. With dentists, they have substantially been about volume. With ophthalmic services, there is a risk that they could be substantially about cost. What is the Government's intention in that respect? How far are they expecting to extend payment by results and the tariff into the determination of contracts for ophthalmic services? To the extent that
 
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the Government propose that, it diminishes the opportunity for primary care trusts to negotiate contracts by reference to costs. Can we have some idea about that, or are we simply legislating with no idea of what the regulations will be?

Steve Webb (Northavon) (LD): I want to give the Minister a brief opportunity to place on the record certain assurances regarding the ophthalmic services covered by this clause, which I understand have been given by the Minister of State, Department of Health, the hon. Member for Doncaster, Central (Ms Winterton), who is not with us today. Those assurances were about what the contracts cover, and they are headed in a briefing which Committee members may have seen from the Association of British Dispensing Opticians, the Association of Optometrists and the Federation of Ophthalmic and Dispensing Opticians.

I am sure that the Minister is familiar with the meeting that took place between her colleague and that group on 27 October, subsequent to which a letter was written on 8 November by a Mr. Derek Busby, Ophthalmic Services, Department of Health. Sometimes, where assurances are given by officials to professional bodies on behalf of the Government, it is worth ensuring that they are placed on the official record, so that they have greater weight, as it were. The gist of it was that, under clause 35, the new general ophthalmic services contracts will cover three things; essential, additional and enhanced services.

To ensure that my understanding, and indeed that of the professional bodies, is correct, can the Minister confirm, first, that there are essential services that all PCTs—and anyone holding a GOS contract—have to provide? The example given was of sight tests for eligible NHS patients. Secondly, can she confirm that there will be additional services that all PCTs, but not all contractors will have to provide? The PCT must ensure that someone is providing those services, but not all contractors will have to do so. Thirdly, might there be enhanced services? The professional bodies are recommending that those should, again, be covered within the contractual framework. Particular PCTs might judge that those are needed in their area.

Mr. Busby says, of what I have just described,

    ''This provides a framework for future service development . . . building on the success of the current GOS system . . . ensuring that PCTs have a duty to make sight tests available to meet the needs of their eligible populations on a similar basis to the GOS now''.

I would be grateful if the Minister confirmed that the assurances given to the professional bodies are also her understanding. To quote from one further sentence by Mr. Busby,

    ''the Bill enables the Secretary of State to define''—

those things that I have just talked about, but it then says:

    ''(in substance, although these terms are not in the Bill)''.

One is always wary when an official writes to a professional body, saying ''This is what the Bill means, but we don't use those words in the Bill.''

Can the Minister clarify whether these are informal equivalents of what is actually in the Bill, or are there
 
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reasons why that language was not used in the Bill and it was not felt necessary to specify that there? Clearly, the professional bodies have been reassured by that letter. I hope that the Minister can reiterate those reassurances and clarify how those things arose.

 
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