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Lord Jenkin of Roding: I completely agree with everything that the noble Lord, Lord Clement-Jones, has said—with the exception of his ever-generous reference to myself. I did not chair the committee that produced the recommendation, although I played some part in its being set up. Perhaps I may weary the Committee with just a couple of sentences of reminiscence.
I had been invited to join the council of the Guide Dogs for the Blind Association in the late 1980s. That brought me into contact with a number of other national voluntary organisations for the blind and partially sighted. There was no machinery at all for trying to bring those bodies together, although many worked for the same ends. I set up and chaired for 10 years the visual handicap group, which consisted of those national voluntary bodies. We produced a report on better services for the visually handicapped, which was widely received and commented on favourably, not least by the Department of Health. We produced another report on the training of people to work with the blind and visually handicapped—an issue that had fallen through the wickerwork since the old blind workers disappeared with the Seebohm changes in social work.
We also produced a report on low vision—the subject of Amendment No. 159. To many of us—this is not meant to be a pun—it was an eye-opener to see how inadequate services were across the country for people with low vision. Many patients who were examined by an ophthalmologist were simply told, "I am afraid that there is nothing more that medicine can do for you. You are going blind. Have you got somebody to take you home?". As the noble Lord, Lord Clement-Jones, said, it is a terrible shock for a patient to be told that they have an irreversible condition—although many people would now argue that some conditions are not as irreversible as they were once thought to be.
We found that in many cases across the country there were virtually no services to pick up those people and make sure that they were given the help they needed. Some areas were lucky in having an effective voluntary organisation. A year or two after we produced our report, I was presiding over a meeting of the Wanstead and Woodford association for the blind and partially sighted. A consultant from Chelmsford told us what the Essex Voluntary Association for the Blind was doing. He spelt out almost exactly the contents of Amendment No. 159. That was being done in conjunction with the health authority and the local authorities. However, that situation was exceptional. I am not in the least surprised that the body that followed on from the visual handicap group—the
body that the noble Lord, Lord Clement-Jones, referred to—came to the conclusion that something more positive is now needed to ensure that there are services to pick up and help patients who are diagnosed as having low vision. Many of them are elderly, but not all.I strongly support Amendment No. 159, because it seems to be the way ahead. I probably said when I was on the ministerial Bench that we already have a plethora of committees. I have some sympathy with that view, but I am convinced by the evidence that has been produced by Robin Birch and his Low Vision Services Consensus Group. The issue will be dealt with effectively only if every area has to have a low vision committee.
I am not wedded to the full details of Amendment No. 159. It is a brave start, but the issue needs to be discussed fully with Ministers and other bodies to ensure that the provision is effective and workable and not too expensive. However, it is clear beyond peradventure that there is a need for something. The amendment gives us a chance to express a view in support of that. I hope that we shall do so. As the noble Lord, Lord Clement-Jones, said, those with a visual handicap have not been properly recognised in services. There are individual services such as sight tests and people can get glasses, but so much more needs to be done to allow those with low vision to be able to play their full role and develop their potential in the community and to allow old people to live independent lives. We need to address that. It is good that the amendment does so and I therefore warmly commend it.
6.15 p.m.
Earl Howe: I have added my name to the amendments, which raise issues with far-reaching implications for the health service that I believe are of the highest importance for patients. I endorse everything that the noble Lord, Lord Clement-Jones, and my noble friend Lord Jenkin have said. It is difficult to overstate the extent to which eye disease and visual impairment impact on the lives of those so afflicted. As my noble friend has graphically described, to lose one's sight is a deeply traumatic event, which in many cases is a precursor to all kinds of misery, such as unemployment, state dependence and mental illness. As the noble Lord, Lord Clement-Jones, informed us, many people in this country are affected by uncorrectable sight loss and the numbers are growing.
Much eye disease is treatable and preventable if caught early. However, compared with some other countries, we are not nearly as good as we should be in giving eye health appropriate priority at primary care level. Partly because the scale of the problem is not sufficiently appreciated, we tend not to be good enough at bringing information and help to those visually impaired people who need it.
Information for the blind is not an add-on extra; it is an essential part of good quality care that can result directly in improved recovery from illness, the more effective use of health services and the avoidance of serious medical accidents.
In recent years, there has been what I can only call an abdication by some health authorities and trusts of services tailored specifically to the needs of the blind or partially sighted. In the face of that, it is difficult to have confidence that PCTs will be able to establish any more creditable track record without a bit of gentle prodding. If the relevant services are to improve, we need to ensure that there are people tasked specifically with making the right things happen at local level. Low vision services committees provide an ideal mechanism for taking that mission forward. As we have heard, those committees emerged out of the very useful work of the Low Vision Services Consensus Group three years ago, for which my noble friend Lord Jenkin deserves a great deal of personal credit. Since then they have been encouraged by grant funding from the Department of Health.
There are two elements to the rationale for those committees. One is to bring together all the key stakeholders in the delivery of services—doctors, ophthalmologists, social services, specialist workers, service users and others—so that everyone communicates properly. Without such grouping, there is inadequate co-ordination. The second might be called commissioning muscle. Users and voluntary organisations need to be assured that their voice will be heard and their needs will be fully taken into account by PCTs and local authorities when services are being planned. I am convinced that a statutory duty to establish and support those committees would make a huge difference to the current unsatisfactory pattern of services.
What about providing accessible information to the visually impaired? The work of charities such as the RNIB in monitoring the provision of such services goes largely unsung. It should not be up to voluntary organisations to shoulder the task on their own. It should be done at national level, preferably by CHI. Health authorities and trusts are on the whole very dilatory about identifying those in need and having proper procedures and training. We need national benchmarks.
For those reasons I urge the Government to take the amendments seriously. The Minister may say that these are essentially matters for local decision-making, but, as the noble Lord, Lord Clement-Jones, pointed out, the current mechanisms, such as pooling budgets, will not be enough on their own to do the trick, because they do not send out specific messages about the importance of low vision services.
I hope that the Minister will at least reflect on the amendments in a positive spirit before Report.
Lord Hunt of Kings Heath: This has been a very interesting debate. I think that we are all at one in wanting to ensure that good eye care services are available throughout the National Health Service. I
am very much aware of the recent survey by the Patients Association which suggested that provision of ophthalmic services is variable across the country and that, as the noble Lord, Lord Clement-Jones, said, eye care is not always seen as a priority by health authorities. I very much agree with the general sentiments that have been raised in this short debate.I have problems, however, with the suggestion that primary legislation is the route we should take to improve services. I also have problems with the suggestion that we should single out eye care services above all others to include in primary care legislation. I am sorry that the noble Baroness, Lady Cumberlege, is not with us today. In one sense, this debate seems to take us back to our earlier debate—which now seems a long time ago—on Clause 1 and the dilemma of developing policy and targets for the health service. The criticism in that debate was that the Government are setting the NHS too many targets, offering it too much guidance, and trying to constrain its functions and responsibilities in far too many ways. It is now being proposed that, in primary legislation, we should be very directional by telling the health service what it should do in particular spheres.
Noble Lords' reasons for wishing to do that are quite understandable. I am sure that all noble Lords wish to see improvement in eye care services. However, I am sure that noble Lords will also appreciate that the more we seek to constrain the work of the NHS, the more we shall have a problem of too many targets and too many priorities. It is a dilemma. I should therefore like to explain in a little detail the Government's work on eye care services, and then deal with the work on developing the eye committees which have been established in various parts of the country.
The Government's first action was to restore the free NHS eye test for everyone 60 and over, at a cost of £50 million annually. As the noble Earl, Lord Howe, suggested, that group is most vulnerable to eye disease and stands to benefit most from regular eye examinations. In 1999-2000, there were more than 2 million extra NHS sight tests, following the extension of eligibility for free tests. We are also taking steps to improve cataract services and have allocated an extra £20 million over two years to fund the capital costs of 60 schemes to improve treatment facilities and reduce waiting times. We believe that this investment will considerably improve the standard of eye care and greatly improve the quality of life particularly of older people. I am also glad to report that the number of NHS consultants in ophthalmology has increased by about 4 per cent in each of the past four years and will increase, from the current level of 651, to 895 by 2010.
I therefore hope that noble Lords will accept that the Government are committed to ensuring that good standards of eye care are provided for the population. As I said, I am not at all convinced that this group of amendments would help to improve the position. I know that the noble Lord, Lord Clement-Jones, has corrected the amendment—which was new Clause 24—and that he intended to require that health improvement plans should include strategies for improving eye health and eye care services. That would
require an amendment to Section 28 of the Health Act 1999, which places a duty on each health authority to prepare a plan that sets out a strategy to improve the health of those for whom they are responsible and the provision of healthcare to those people.I stress that health improvement plans—HIMPs—are strategic documents. We believe that, as such, it would be inappropriate for them to contain a lot of detail on specific activity in the health system. Surely it should be for localities to decide how to meet the identified priorities. I also question whether prescribing from the centre what HIMPs should contain would be contrary to the underlying principles of shifting the balance of power to the local level. All noble Lords seemed to agree with those principles when we debated them 10 days ago.
The HIMP process has to work effectively. In future, local voluntary organisations, service users, carers and the public will have a greater role to play in the development of the HIMP. The Health and Social Care Act 2001 underpins the patient's and the public's involvement in the development of the HIMP. The Act places a duty on NHS bodies to involve patients and the public in the planning and development of services. We shall also eventually, although probably not tonight, debate the issue of patient forums which will be established for every trust. They will play a very valuable role in discovering what patients think about the quality of local services, monitoring quality from the patient's perspective, and working with the local trust to bring about improvements. That, too, will inform the local priority-setting and planning process.
The position in Wales is similar. In line with the principle of devolution, the National Assembly will determine the form and contents of health and well-being strategies. The National Assembly intends to give advice about how the responsible bodies will work jointly to formulate and implement the strategy. The Assembly will also determine how prescriptive the regulations and guidance should be. Where possible, however, we hope that local partners are able to determine arrangements according to local priorities.
New Clause 159 would require each primary care trust in England or local health board in Wales, and each local authority in both countries jointly, to establish a low vision committee for the area for which that primary care trust or local health board was established. As mentioned, a report in 1999 by a consensus group of organisations on the future of low vision services recommended the establishment of local vision committees for the purpose of ensuring that services in the UK are provided in accordance with the report's recommendations. I pay tribute to the noble Lord, Lord Jenkin, for his role in the establishment of that group. However, having seen him play a starring role last night in the parliamentary choir's performance of "Messiah", I realise that he has very many hidden talents.
The Secretary of State for Health commended that report to the NHS and local government. As the noble Earl, Lord Howe, suggested, the department is contributing a grant of £120,000 over three years to
provide an implementation officer from the voluntary sector to help in setting up local committees. Good progress is being made. My understanding is that, at the start of the year, 24 committees had been set up, and a number of others are under consideration. The noble Earl also suggested that some gentle prodding is needed. The implementation project is set to run for another 18 months. My view is that it would be inappropriate now to impose a requirement for primary care trusts and local authorities effectively to establish statutory low vision services committees. I think that it would make sense to allow the project to continue and for an evaluation of the committees' impact on service provision to be carried out by the implementation group at the end of that 18-month period.I would also caution against an overly prescriptive approach. It may be possible to have a good, multi-disciplinary, low-vision service without a formal committee. In some areas the primary care trusts may not always cover the area that is sensible in terms of linking and providing low-vision services, and other models may emerge. Under the present arrangement, the committee is not in the ownership of one body, and that emphasises the essential joint working, which would be important for the successful functioning of any of those committees.
In the light of the debate tonight, the department will monitor what is happening and the progress by the implementation group. We already monitor the uptake of sight tests by eligible groups, and waiting lists. Sites that have been allocated funds for cataract improvement, for example, will also submit progress reports.
We are represented on the low-vision services implementation group, which receives progress reports on setting up local committees at its meetings two or three times a year. In addition, there is a requirement for the group to make six-monthly progress reports to the department. I assure noble Lords that the department will continue to take a close interest in the progress of the implementation project. I take the view that legislation is not the appropriate route down which we should go, but I hope I have reassured noble Lords that we take a keen interest. I accept that having made progress in the past two or three years, more progress needs to be made.
6.30 p.m.
Lord Clement-Jones: I thank the Minister for that reply which, in its latter parts, was positive and helpful. In one way it was the reverse of what I expected him to say. I thank the noble Lord, Lord Jenkin, and the noble Earl, Lord Howe, for their supportive comments. The noble Lord, Lord Jenkin, was clearly so enthusiastic and such a major contributor to the group that the people who briefed me thought that he chaired it. I suspect that that was a sign of his influence on them. I took the point he made that we should not expect to replicate best practice in a voluntary sense; we need an engine to spread it in a more statutory way.
I turn to the points made by the Minister on the health improvement plan. If we are not careful, as the Bill goes through the House the Minister will accuse all those who believe in having a pro-active set of national standards of being centralisers. I do not believe that the essence of devolution is to simply wriggle about and say, "I'm sorry; this is not really something we can legislate for or be prescriptive about". "Prescriptive" is a weasel word which has perhaps come back to haunt this side of the Chamber. In the past, we have accused the Government of being over-prescriptive. But there is a median way. The detailed implementation in a decentralised system is a matter for the local primary care trust and the people on the ground. However, when it comes to stating national standards as to how one produces a health improvement plan and what it can contain, one can be entirely strategic in those circumstances.
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