Duty of Registered Opticians to Refer Certain Persons to Registered Medical Practitioners

Orders of the Day — National Health Service (Primary Care) Bill [Lords] – in the House of Commons at 6:01 pm on 12th March 1997.

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'.—(1) Section 31 of the Opticians Act 1989 (matters with respect to which the General Optical Council may make rules) is amended as follows.

(2) In subsection (5) (power to make rules requiring registered optician to refer persons to registered medical practitioners except in certain circumstances), for the words from "except" to "take the prescribed steps" substitute "except—

  1. (a) in an emergency,
  2. (b) where that person is consulting him for the purpose of being given treatment in accordance with rules under subsection (1)(d) above, or
  3. (c) in such other cases as may be prescribed,
take the prescribed steps".

(3) After subsection (5), insert—

"(5A) Rules made by virtue of subsection (5)(c) may impose conditions which must be satisfied if the exception for which those rules provide is to apply." '.—[Mr. Malone.]

Brought up, and read the First time.

Photo of Mr Gerald Malone Mr Gerald Malone , Winchester 6:08 pm, 12th March 1997

I beg to move, That the clause be read a Second time.

Photo of Miss Janet Fookes Miss Janet Fookes , Plymouth Drake

With this, it will be convenient to discuss also the following: New clause 9—Provision of special ophthalmic services under a pilot scheme—

  1. '.—(1) This section applies to any pilot scheme under which special ophthalmic services are provided.
  2. (2) An agreement which constitutes, or is one of the agreements which together constitute, a pilot scheme may be made by an authority only with one or more of the following—
    1. (a) an NHS trust;
    2. (b) a person on an ophthalmic list;
    3. (c) an NHS employee or a pilot scheme employee;
    4. (d) a qualifying body;
    5. (e) an individual who is providing special ophthalmic services under that or another pilot scheme.
  3. (3) In this section—
  4. "NHS employee" means an individual who, in connection with the provision of services in the health service, is employed by—
    1. (a) an NHS trust;
    2. (b) a medical practitioner whose name is included in a medical list; or
    3. (c) a medical practitioner who is providing personal medical services in accordance with a pilot scheme;

ophthalmic list" has the same meaning as in section 4A(3) of the National Health Service and Community Care Act 1990 or section 17AA(3) of the 1978 Act;pilot scheme employee" means an individual who, in connection with the provision of special ophthalmic in accordance with a pilot scheme is employed by an individual providing those services;qualifying body" means a company which is limited by shares all of which are legally and beneficially owned by persons falling within paragraph (a), (b), (c) or (e) of subsection (2).'.

New clause 10—Charges for special ophthalmic services—'.—(1) In the 1977 Act, after section 78A (as inserted by section 26 above), insert— "Charges for special ophthalmic services under section 28C78B. No charge may be made for special ophthalmic services provided under section 28C arrangements.(2) In the 1978 Act, after section 70A (as inserted by section 26 above), insert—"Charges for special ophthalmic services under section 17C70B. No charge may be made for special ophthalmic services provided under section 17C arrangements.".'. Amendment No. 77, in clause 1, page 1, line 14, after 'authority)', insert or (c) special ophthalmic services are provided (otherwise than by the authority)'. Amendment No. 78, in page 1, line 16, after 'services', insert 'or special ophthalmic services'.
Amendment No. 79, in page 2, line 34, after 'Ace, insert '; and special ophthalmic services" means sight testing and related services provided to persons over the age of 60; and "sight testing" has the same meaning as in section 36(2) of the Opticians Act 1989'. Amendment No. 80, in clause 21, page 12, line 21, after 'Authority)', insert', or '; special ophthalmic services are provided (otherwise than by the Authority)'. Amendment No. 81, in page 12, line 24, after 'services', insert 'or special ophthalmic services'. Amendment No. 82, in page 13, line 25, at end insert ';and "special ophthalmic services" means sight testing and related services to persons over the age of 60; and "sight testing" has the same meaning as in section 36(2) of the Opticians Act 1989;'. Amendment No. 83, in page 13, line 40, at end insert—

  1. '(ca) in the case of an agreement under which special ophthalmic services are provided—
    1. (i) a person on an ophthalmic list;
    2. (ii) an individual who is providing special ophthalmic services in accordance with section 28C arrangements or section 17C arrangements;'.
Amendment No. 84, in page 14, line 27, at end insert— '"ophthalmic list" has the same meaning as in section 4A(3) of the National Health Service and Community Care Act 1990 or section 17AA(3) of the 1978 Act;'. Amendment No. 85, in page 15, line 10, after 'services', insert'; and special ophthalmic services" means sight testing and related services provided to persons over the age of 60; and "sight testing" has the same meaning as in section 36(2) of the Opticians Act 1989'. Amendment No. 86, in page 15, line 19, after 'Board)', insert or (c) special ophthalmic services are provided (otherwise than by the Board)'. Amendment No. 87, in page 15, line 22, after 'services', insert 'or special ophthalmic services'. Amendment No. 88, in page 16, line 18, at end insert '; and "special ophthalmic services" means sight testing and related services provided to persons over the age of 60; and "sight testing" has the same meaning as in section 36(2) of the Opticians Act 1989'. Amendment No. 89, in page 16, line 33, at end insert—
  1. (ca) in the case of an agreement under which special ophthalmic services are provided—
    1. (i) a person on an ophthalmic list;
    2. (ii) an individual who is providing special ophthalmic services in accordance with section 28C arrangements or section 17C arrangements;'.
Amendment No. 90, in page 17, line 18, at end insert— 'ophthalmic list" has the same meaning as in section 4A(3) of the National Health Service and Community Care Act 1990 or section 17AA(3) of the 1978 Act;'. Amendment No. 91, in page 17, line 49, after 'services', insert '; and special ophthalmic services" means sight testing and related services to persons over the age of 60; and "sight testing" has the same meaning as in section 36(2) of the Opticians Act 1989'. Amendment No. 92, in clause 22, page 18, line 16, after 'services,', insert 'special ophthalmic services,'.
Amendment No. 93, in page 20, line 18, after 'services,', insert 'special ophthalmic services,'.

Photo of Mr Gerald Malone Mr Gerald Malone , Winchester

I shall first deal briefly with new clause 1, on which there is consensus in the House. In Committee, I noted that we were in broad sympathy with a new clause tabled by the hon. Member for Dulwich (Ms Jowell) aimed at regularising the practice that optometrists follow when they find that a patient has an injury or disease of the eye. I am pleased that I think that I can honour my undertaking to the Committee.

New clause 1 replaces section 31 of the Opticians Act 1989 and would enable the General Optical Council to submit a new rule on referrals for consideration by the Privy Council. It would cover all optometrists in whatever context they worked, and give the General Optical Council virtually full discretion in prescribing, through the new rules, when an optometrist should refer a patient with a disease or injury of the eye to a registered medical practitioner. The only constraints would be that it would have to provide exemptions for emergencies or for a patient referred to the optometrist for orthoptic treatment—that is, a patient already under the care of a registered medical practitioner.

The doctors are most affected by the changes are general practitioners and ophthalmologists. Their representatives on the General Optical Council are ready to contribute to the drafting of a new rule. We would also take the views of the medical profession into account in any advice that we gave to the Privy Council on a new rule.

The amendments of the hon. Member for Southwark and Bermondsey (Mr. Hughes) are all linked to the objective of providing free NHS sight tests to everyone aged over 60, so I shall take them together. We did not exclude ophthalmic services from the pilot schemes because we judged that optometrists were different or inferior to doctors and dentists, but because powers already exist for us to conduct trials of nearly all the permutations by which a health authority might wish to provide ophthalmic services. There are no restrictions on admission to the ophthalmic lists kept by health authorities, and by health boards in Scotland, except that applicants should be appropriately qualified.

There are many examples, as hon. Members know, of shared eye schemes whereby optometrists contribute to monitoring the eye health of patients with sight-threatening diseases such as diabetes and glaucoma. We intend to give powers to health authorities to regularise such arrangements through the NHS contract provisions in clause 30. Many of the hon. Gentleman's objectives are already met by the Bill.

Photo of Simon Hughes Simon Hughes Opposition Deputy Chief Whip (Commons), Shadow Spokesperson (Health)

The Minister is right to say that the amendments are linked. Ophthalmic services are not given parity with personal medical and dental services in clause 1. The rest of the drafting of the amendments replicates that of the Bill. Parity of treatment is the purpose of the amendments, and I do not think that that is covered by the current arrangements.

Photo of Mr Gerald Malone Mr Gerald Malone , Winchester

That does not need to be enshrined in primary legislation, because there is already a power to bring it about. If the hon. Gentleman wants an undertaking that we view the role of optometrists as important and ophthalmic services as essential to the provision of a range of primary care services, I am happy to give such an assurance. We intend to give powers to health authorities to regularise existing arrangements such as shared eye schemes through the provisions on NHS contracts in clause 30. The matter is not explicitly covered in the Bill because we do not need to write in such a power.

I give the hon. Gentleman the assurance that I suspect he seeks—that we view the matter as being of great importance. We want to regularise the excellent schemes that are already growing up in the service, such as shared eye schemes. I think that I mentioned that to the hon. Gentleman in Committee.

I do not believe that giving health authorities and health boards powers to extend the criteria for eligibility for free NHS sight tests would be an appropriate use of development funds. We believe that people who can afford it should pay for their sight tests. I have often put that argument to the House. I am glad that it seems to be catching somewhat, at least with Labour Front-Bench spokesmen, if not with the hon. Member for Southwark and Bermondsey.

Any help that is available, especially from development funds, should be concentrated on vulnerable members of the community. When dealing with problems such as this, targeting is important. About 40 per cent. of the population are eligible for NHS sight tests, including people on low incomes and those at special risk of eye disease. The policies are framed precisely to target available resources on those at greater risk.

We estimate that removing all restrictions on eligibility for NHS sight tests would cost about £140 million a year, while making everyone over 60 eligible would cost £32 million a year. As so often with health care, we are talking about proper targeting to bring about the best possible results. That £32 million could pay for about 4,000 cataract operations. Cataract surgery is one of the most effective eye care interventions and leads to improved visual acuity for more than 80 per cent. of patients treated. That such targeting is effective is shown by the fact that between 1984 and 1995 the number of eye lens operations, which are mainly for cataracts, increased by 174 per cent.

As I said, we are no longer alone in our judgment of priorities. The hon. Member for Islington, South and Finsbury (Mr. Smith) was quoted in last week's press as saying that the Opposition had no commitment to restoring universal free sight tests. In that light, I have every confidence that they will join me in rejecting the amendments. I commend new clause 1 to the House.

Photo of Simon Hughes Simon Hughes Opposition Deputy Chief Whip (Commons), Shadow Spokesperson (Health) 6:15 pm, 12th March 1997

I am grateful for the opportunity to speak on this group of amendments. I do not take exception to new clause 1, but I would like to speak on the amendments grouped with it. The Minister's evaluation of my reason for tabling new clause 9 and our other new clauses and amendments was right. It is to ensure that we can go back to having, under the NHS, both piloted ophthalmic services and the ability to return to free dental and eye checks.

I understand the debate about targeting and generalising. There is an honest intellectual debate about that—I do not pretend otherwise—and I doubt whether I can persuade the Minister. If I am wrong, I would achieve a significant but slightly unexpected change of Government policy. However, I want to give the serious argument on the other side of the debate to that which the Government espouse and to cite the helpful evidence from answers from the Minister's Department supporting it.

The change in policy in relation to eye and dental checks was controversial. If we could include, as new clause 9 does, pilot schemes under which special ophthalmic services are provided and also, as clarified by amendment No. 79, pilot schemes for sight testing for the over-60s, we would achieve good primary health care. That is what the debate is about.

I would like to go further than the amendments. I do not want someone to say later, "You only included sight testing for the over-60s—what about the rest?" Our policy is to do everyone. However, for the purposes of conciliation and compromise with other parties, I am only putting forward, in amendments Nos. 77 and 79, sight testing for the over-60s. I want to speak specifically about amendment No. 79.

The Department, in timely fashion, gave me yesterday a parliamentary answer with figures for the increase in cataract problems. The crude figure shows that there has been a 57 per cent. rise in treatment for cataracts and a 44 per cent. rise in treatment for glaucoma in the past four years. The figures, which come from the Department of Health, are not disputed.

I shall not speak at length on the figures, which are available in Hansard. However, they are—at least—worrying and, I would say, frightening. Some 58,289 more people received cataract treatment in 1995 than in 1991, and 7,651 more people received treatment for glaucoma. Figures from the Library show that an average cataract removal operation costs £1,800, which means that the total bill to the NHS for cataracts alone is £105 million—a significant sum. Just so that people do not accuse me of being nationalistic or partisan, the Welsh figures for cataract treatment are up by 64 per cent. and the Scottish figures are up by 48 per cent.

There is broad support for the case made to Ministers by the Royal National Institute for the Blind, whose representatives came to me and said that they were off to meet the Secretary of State for Health immediately afterwards. The RNIB produced a report some weeks ago and, in support of that report, there are 100 signatures on an early-day motion on the matter—eight Conservative Members, 71 Labour Members and the remainder from my party. The early-day motion argues for a return to free eye tests for this limited category.

The Minister said that we must target the most vulnerable, and in this context no one will be surprised to learn that those most vulnerable are the elderly. Therefore, this proposal is targeted at reintroducing free eye tests for the over-60s. The Minister has given figures from parliamentary answers which suggest that reinstating free eye tests for everybody would cost £100 million, but that reinstating free eye tests for the over-60s would cost only £32 million.

I believe that there would be huge public support for a return to free dental and eye checks, and the Government and the Labour party are making a mistake in not supporting this. I am disappointed, to say the least, that the Labour party—as confirmed a couple of weeks ago—is not supporting the proposal. If it cannot find £32 million to restore free eye tests for the over-60s, its welfare policies must be even thinner than people imagine.

Early diagnosis is essential in preventing the eventual development of serious eye conditions, and the evidence from the RNIB is clear. I was privileged to open the new lecture theatre at the Institute for Optometry at the Elephant and Castle in my constituency. That profession wants to be able to do additional work, and there are huge amounts of work for qualified optometrists. We need more of them, and this debate should be a plea for more people to come forward to qualify to work in this part of the health and medical services.

I shall not detain the House much longer. The figures make the case and, historically, Members from all parties have made the case. We could do some practical work by passing new clause 10. If the new clause were to be passed, I imagine that the Minister would concede that the other amendments could go through on the nod. We should reinstate as a primary care pilot scheme the ability to give free eye tests to the over-60s. I ask the House to support the new clause enthusiastically.

Photo of Tessa Jowell Tessa Jowell Shadow Spokesperson (Health)

We welcome the Minister's support for new clause 1, and we congratulate him on fulfilling his commitment in Committee by moving the clause today. The new clause is welcomed by the Association of Optometrists, and it allows proper professional discretion for optometrists. It is consistent with the spirit of innovation that we supported throughout the Committee. We would argue that those who look most at eyes, and at eyes most of the time, are competent to make judgments about whether patients need a referral for further medical advice.

I shall refer briefly to the amendments tabled by the hon. Member for Southwark and Bermondsey (Mr. Hughes) and his hon. Friends. We do not think that this is the place to raise these issues again. When the Government imposed charges for eye tests, we opposed them and fought hard against the abolition of free tests. But we are sick and tired of the hon. Gentleman, his hon. Friends and candidates from his party going on public platforms up and down the country making promises that they know they have not the slightest likelihood of ever having to take responsibility for implementing. It is rank hypocrisy, and I shall be perfectly prepared to give way to the hon. Gentleman after I have asked him to confirm whether he joined the Opposition in the last Parliament when this matter was put to the vote.

Photo of Simon Hughes Simon Hughes Opposition Deputy Chief Whip (Commons), Shadow Spokesperson (Health)

I can deal with both matters. We are committed to the Budget figure, and to finding the money. On the question of the votes on this issue, I have been here for all such votes, except one, in the past 14 years.

Photo of Tessa Jowell Tessa Jowell Shadow Spokesperson (Health)

I see. When we had a chance in the last Parliament to defeat the Government on the imposition of charges for eye tests, the hon. Gentleman was absent. That makes my case and suggests how his amendments should be dealt with. We are glad to support new clause 1.

Photo of Mr Gerald Malone Mr Gerald Malone , Winchester

The hon. Lady had better tread with care, as I understand that the hon. Member for Southwark and Bermondsey has said in print that in the event of a hung Parliament—which I think is unlikely, in view of our impending victory—he intends to be Minister for Health in a coalition Government. She had better have a care when insulting someone who may be a future colleague.

Photo of Tessa Jowell Tessa Jowell Shadow Spokesperson (Health)

There are two words which deal with that ambition: "Dream on".

Photo of Mr Ieuan Wyn Jones Mr Ieuan Wyn Jones , Ynys Môn

I rise to support the amendments tabled by the hon. Member for Southwark and Bermondsey and his colleagues, as it is important to stress that other parties would like to see the reintroduction of free eye tests generally and, in the context of this debate, for the over-60s. I have not had the benefit of listening to all the debates in Committee, but I have read some of the Minister's comments. One of the issues highlighted is whether the Government have properly assessed the risk of sight loss involved.

The Minister said in Committee on 27 February: we believe that it is important to develop policies to ensure, where possible, that resources are targeted to where they are needed—to those sections of the population especially at risk. However, the RNIB report "Losing Sight of Blindness" clearly shows that despite age being the most significant risk factor in terms of developing eye conditions, older people are not eligible for free eye tests on the ground of age alone. Those at the highest risk ought to be those who get free eye tests.

The Minister went on: It is important to meet any proven possibility of providing better care. When we are talking about a limited resource, it is better to look at the principle of targeting care than to re-establish something general that is less easy to prove has a definable result."—[Official Report, Standing Committee D, 27 February 1997; c. 198–99.] Again, the RNIB makes it clear that people aged 60 and over are the group most at risk of developing eye disease because of their age. It is consequently believed that there is a proven need to target that group as the most high-risk group.

We all agree that not only is early diagnosis and treatment vital to prevent avoidable sight loss, but it is cheaper when compared with the full health and social care costs for an individual with advanced eye disease. Poor vision and blindness lead to greater reliance on social services, limited mobility and expensive medical interventions. Sight disability imposes additional expenses on the individual that are not adequately compensated for in the benefits system. Poor eyesight is a significant contributory factor to accidents among older people. Although there is an estimated cash saving of £32 million from not providing free eye tests for people aged 60 and over, that will be more than offset by those other costs, especially the costs of looking after elderly people who have lost their sight or whose sight is deteriorating.

6.30 pm

It is important to note that there is a clear and genuine dispute about the Government's figures on the number of people going for eye tests. Research carried out in 1994–95 showed that the number of people going for eye tests was 12.7 million, but the Government's change in the methodology resulted in the figures for that year being 14.6 million—clearly the Government wanted to show an increase. While there is considerable dispute about the figures, there is clearly a disincentive for the elderly in particular to go for tests when they have to pay for them.

It is vital that the quality of the eye tests is ensured. By law, an eye test must include a comprehensive eye examination to check for any disease, injury or abnormality that may be present. I am sure that the Government will want to ensure that the those tests are carried out to the proper standard. In addition, there is widespread misunderstanding about who qualifies for exemption under the current rules. Many people are not aware of the exemptions, which should be more widely promoted.

We know that older people have a far higher level of eye disease than other age groups: 90 per cent. of blind and partially sighted people are aged 60 and over. At just over 1 million people in the United Kingdom, that is a significant number. Given the high incidence of visual impairment among the over-60s, it is of great concern that that high-risk group is not exempt from charges on the ground of age alone. In 1995–96, it was estimated that almost 4.5 million eye tests were carried out on people aged 60 and over, of which only 43 per cent. were done on the national health service; therefore, 57 per cent. paid for the tests. It is clear that the single most significant factor in developing eye disease is age. There is a proven, clear and discrete need and I want the Government to recognise that in the context of the debate on free eye tests.

Question put and agreed to.

Clause read a Second time, and added to the Bill.