Clause 34 - Provision of primary ophthalmic services

Health Bill – in a Public Bill Committee at 10:35 am on 10th January 2006.

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Photo of Stephen Williams Stephen Williams Shadow Minister (Health) 10:35 am, 10th January 2006

I beg to move amendment No. 79, in clause 34, page 28, line 41, leave out from 'all' to end of line 11 on page 29 and insert 'persons'.

Good morning, Mr. Illsley and may I wish you and all members of the Committee a happy new year. There is a very fraternal atmosphere in my party at the moment, as I am sure you will realise. I did a quick calculation this morning and discovered that we had 47 clauses, four new clauses and five schedules to get through today. I therefore intend to be brief and I hope that other hon. Members will be brief too. The purpose of the amendment is to provoke a discussion on the disparities in access to eye health services for different groups of the population within England, particularly compared with the much enhanced access in Scotland and the different system in Wales under the new devolved arrangements.

The amendment deletes all references to the groups of the population in new section 16CD(2) who currently receive free eye tests: those who are under 16; those who are over 16 but in full-time education; various people who are in receipt of means-tested benefits; and the over–60s. The clauses in this chapter of the Bill deal with the general ophthalmic services contracts and what we would normally describe as eye tests. The significant part of GOS is certainly eye tests.

I had a most useful meeting with optometrists and ophthalmic dispensers in my constituency back in November. I learned a great deal about how the existing service operates. I was quite shocked to   discover that the NHS eye test fee is currently only £18.39, which for a visit to a well-qualified professional person seems very small. That is rather less than one would expect to pay for a visit to the local garage to have one's car repaired, let alone various other medical services. I was staggered to discover how low the eye test fee is. However, 66 per cent. of the tests currently offered by optometrists are funded by the NHS, albeit at a low rate. The second part of the GOS contract is the voucher system, which contributes towards the cost of children's spectacles.

The purpose of the amendment is to provoke a discussion on access to eye care for all sections of the population of England. The major worry that the eye care profession has about chapter 2 of the Bill relates to the provisions for the existing GOS contract in England. The management will be devolved from the central NHS to the primary care trusts that operate in all our constituencies. They will have discretion over the management of contracts. Several amendments to later clauses will deal with that, so I shall not dwell on the matter now. However, it will be worth hearing from the Minister why in England only the groups specified in new section 16CD(2) in clause 34 have access to a free eye test and eye care, when the devolved Administrations have seen the value of giving all sections of the population free and easy access to an optometrist, not only to detect a defect in natural sight but to look for other health concerns that only a qualified optometrist can identify.

There is an analogy here with dental services. I went to a most useful presentation before Christmas about mouth cancer—I am sure that the Under-Secretary attended it too—where I learnt that, as part of their standard contract with the health service, dentists look for early signs of mouth cancer. The analogy is that, as well as doing the obvious thing of testing somebody's vision, a qualified optometrist will look for other potential defects. The issue involves more than the standard eye test.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

May I wish you, Mr. Illsley, and the Committee a happy new year—especially the hon. Member for Bristol, West (Stephen Williams), given the excitement currently surrounding his party, although I hope that it is not too happy.

I am interested in the amendment. I thought that the Liberal Democrats were going to talk about extending access, and that that was the purpose of removing the qualifying words in new section 16CD(2). However, the hon. Gentleman did not talk about that. The gist of what he had to say related to access. I put it to the Minister that, on access to dispensing opticians and optometry, we do pretty well. One of the defining things about optometrists and dispensing opticians in this country at the moment is that there is fantastic access to them. No other part of our health care system that I can readily think of has no absolutely no waiting lists. One simply wanders in off the high street for an eye test or ophthalmic appliance. There is no waiting whatever. Without being too complacent, access is right there, right now. The Minister will have to explain how these seven clauses relating to optometry will improve the service.   We shall come back to the matter as we go through the clauses, but she must say why she feels that there is a problem that requires her intervention. Nowhere is that more the case than in respect of access, which is the gist of the hon. Gentleman's amendment.

The hon. Gentleman might have been saying that primary care trusts should be asked to make provision for eye tests and optometry for everyone, without exception. That is a cause of confusion because of the issue of free eyesight tests and vouchers and the provision of optometry services. I hope that PCTs, if they are to be empowered in the way suggested, will act to ensure that access is as good as possible for everyone, whether they are entitled to free services or are among the 34 per cent. who pay for them. That is important; it is what we have at present. I will explain why we are worried about the matter as we go through the proposals. The Government's intervention by virtue of the seven clauses will reduce choice and access. Before we are prepared even to consider supporting the Government on these proposals, the Minister must reassure us in that respect.

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health) 10:45 am, 10th January 2006

Happy new year to everybody—some are happier than others, I imagine. I hope during our proceedings to be able to reassure my hon. Friends, the hon. Member for Westbury (Dr. Murrison) and his hon. Friends and the hon. Member for Bristol, West, that we have no intention of disrupting what I think is a very good service or unnerving those who provide it. I have been a recipient of opticians' services since I was a child; I am very short-sighted, and I now use glasses and contact lenses. I therefore have a vested interest in the matter.

We recognise that a clearer framework is needed. I will endeavour to reassure those who have a particular interest that access to sight tests and the national negotiating framework for the fee will not be diminished by our proposals. I will come to those matters later, as I want to address the amendment, which would extend eligibility for NHS-funded sight tests to the whole population of England.

Free sight tests on the NHS are already available to priority groups: children under 16, those aged 16 to 18 in full-time education, people on low incomes who might otherwise be deterred by the cost of a private sight test, and defined categories of people at risk of developing eye disease. Before 1 April 1989 there was universal entitlement to free sight tests, but from that date eligibility was restricted to the groups that I mentioned. In April 1999 we extended free sight tests to everyone aged 60 and over because those in advancing years may have associated health problems that can be picked up by opticians. The eligibility criteria for NHS-funded sight tests are designed to ensure that the groups to which I referred are not discouraged from having their sight tested. However, we have to make some tough choices and a further extension would not be the best use of funds available for the development of the NHS.

In 1999, we reviewed the eligibility rules and extended eligibility for sight tests to those over 60,   and the available evidence suggests that it resulted in a transfer of sight tests from the private sector to the NHS rather than any material increase in the overall number of sight tests undertaken. I have to tell the hon. Member for Bristol, West that that does not suggest that a further extension of eligibility and the associated increase in NHS funding is likely to affect significantly the overall number of sight tests undertaken or the associated health outcomes. The cost of extending free sight tests to all those who currently pay privately would be an additional £92 million, based on the 2005–06 rate of £18.39.

The hon. Gentleman also mentioned his concern about the rate. The rate for the test is negotiated nationally. I understand that negotiations for 2007–08 are about to begin and I would like to reassure the Committee that there is no intention, as part of this legislation, to move away from that national negotiating framework or to undermine in any way access to sight tests, either for those who are eligible for support through the NHS or for those who pay privately. The hon. Member for Westbury mentioned that point.

There are choices to be made in health. As we discuss these clauses, we can also reflect on the opportunities, outside the areas that are part of a nationally provided service, for PCTs to consider, based on local need, what other enhanced services might be suitable in the local community. Contracting for the provision of eye tests in a residential care home is just one example of provision for which PCTs might in future want to contract. The proposals in the Bill, including in the clauses that we shall discuss this morning, provide a greater opportunity for such areas to be thought about in relation not only to eye health but, possibly, to other health issues that may arise out of such contracts.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

Will the hon. Lady confirm that the legislation as drafted will allow PCTs to negotiate with providers at differing levels of fee for the sight test—in other words, that the matter could be decided at local level?

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

The Bill could possibly allow for that, but I want to make it clear that there is no intention on the part of the Government to allow for a locally or regionally negotiated sight test fee basis. We have given assurances, and the Minister of State, Department of Health, my hon. Friend the Member for Doncaster, Central (Ms Winterton), met a number of different stakeholders just before Christmas to reassure them that our intention is to continue under the present system, which is to have a nationally negotiated sight test fee. That will be provided for. There is no question of that being varied at local level or of unnecessary lower or upper levels being set for the number of sight tests, with the proviso that if there were a possibility of fraud, a PCT would look into that—but we shall cover that under later clauses. I hope that that answers in a straightforward way the hon. Gentleman's question.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

I thank the Minister for that. I take it, therefore, that she will support amendment No. 32.  

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

We have not reached that amendment yet, but I shall not support it, for reasons that I shall come to later.

Finally on amendment No. 79, the way in which we provide sight tests at the moment is a tried and trusted system. I am pleased that we were able, within the finances that the Government have, to extend eligibility in 1999. However, I do not believe that there is a case for a further extension. I say to the hon. Member for Bristol, West that whoever is elected as the leader of the Liberal Democrats may want to reflect on the issue as part of their future financial plans if they ever want to be in government.

Photo of Stephen Williams Stephen Williams Shadow Minister (Health)

I have listened carefully to the Minister, and essentially she has said that no one should be afraid of the measures proposed in the Bill. There will not be a change to the centrally negotiated NHS fee, which is currently £18.39, and there should not be any worries about the range of services provided in the high street, to which the hon. Member for Westbury also referred. One does wonder, then, what is the point of the legislation. I wonder why the Government did not take the opportunity, as was done in Scotland, to review the entire GOS contract in consultation with the eye care profession and then come forward with proposals to improve eye care in this country.

I was interested to learn that the estimated cost of extending free eye care to all parts of the population, not just the groups specified in the Bill, was £92 million. In the great scheme of things in Government funding that seems rather a small amount. What discussions has the Minister had with her counterpart in the Scottish Executive, who took a different decision from that she proposes for England? Presumably they thought that there was a public health advantage to extending free eye tests to all sections of the population in Scotland.

The Minister mentioned that PCTs may be able to look at the contracts for domiciliary care for when an optometrist visits a care home. That point was made to me at my meeting with practitioners in my constituency. Currently the fee for an optometrist visiting a care home is £50.77 for the first and second persons, but thereafter it is only £10 for each consultation. That seems quite strange. There is scope for PCTs, or the NHS centrally, in negotiation with the profession, to look at that fee structure too.

I listened with interest to what the Minister had to say, and as we will be discussing several other clauses this morning, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Question proposed, That the clause stand part of the Bill.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

This is the first clause in a series of seven dealing with an important matter. We dealt with the heat and light aspects—smoking—earlier, and given the time that we had to spend on that it is fortunate that we have reached this point. It would have been wrong to have completed the Committee stage without devoting adequate time to these clauses.  

I should like to pay tribute to optometrists and dispensing opticians in this country who, by their own admission, tend to be a fairly self-effacing and quiet group. We will all have received their briefing notes in which they point out that in the past they have generally acquiesced in the requirements of the Government of the day, but at this point in their evolution and history they have become quite concerned. They would say that since the war they have provided a fantastic service—a landmark service—in our health services in this country. Who can doubt the quality of the service we get where there are no waiting lists and waiting times? That is unique in our health services.

Very few of us receive complaints from our constituents about the quality of ophthalmic services. I have received none. Indeed, of the 43,000 written complaints received in 2004 by family health services, only five related to ophthalmics. That is quite extraordinary. Given that there does not appear to be a problem, the Minister has to tell us what she has identified in the range of services that she is endeavouring to fix. I do not understand it at all. So far she has not given me the feeling that she has identified a problem. No doubt she will expound at length on the problem and we can then determine whether these clauses are the solution.

I put it on record that we are not convinced that there is a problem. We pay tribute to these services, which do such brilliant work for our constituents. The providers of the services rightly point out that, every year, they refer 200,000 people whose tests reveal medical conditions such as glaucoma, hypertension, various forms of cancer and the more obvious ocular-related conditions, such as cataracts, which would otherwise would not have been discovered.

Ophthalmic services are a huge benefit to the NHS. Elderly people who have their eyes tested and are found to have defective vision because of conditions such as refractive errors and cataracts can usually have them satisfactorily remedied. There are no figures to support this, but one can only imagine the savings to the NHS when people in advanced years have their sight tested and corrected, as poor vision can lead to problems such as fractured hips and a range of other medical conditions. I feel strongly that, if work is not being done to determine the contribution that opticians make to health care generally, it should be. The figures would be very interesting indeed.

There is a catalogue of good-news stories from the sector. The Minister seems to be providing a solution when there is no identifiable problem. Will she tell us why she has introduced these proposals? Did the Health Bill just happen along and she felt that it would benefit from having something on ophthalmic services bolted on to it? If that is the case, it is pretty extraordinary, because the Government have been talking about holding a review of general ophthalmic services. That is perfectly reasonable, as eye services have been conducted in the same way for a considerable time.  

The profession has some problems in the way things have been working—gosh, which profession does not?—and would like some minor changes. In that context, a review would be reasonable. We have all spoken to opticians, not least when we go for an eyesight test, and if they know that we are MPs, they bend our ears. My optician certainly did so about the cross-subsidy between the provision of optical appliances—glasses and so on—and the eyesight test.

A review has long been promised, but nothing has come of it. It is a bit like dentistry; things were promised, but months and years go by and nothing seems to happen, and so it is with general ophthalmic services. All there is this proposal. The Minister does not even bother to wait for the review, she simply promises it, which puts the entire review and the consultation process into the long grass.

I mentioned consultations in earlier clauses and the effect on their validity of the Government putting the cart before the horse. That discredits, degrades and demeans their value and makes people less willing to take them seriously and to contribute to them. If and when the review of general ophthalmic services comes to pass, people will ask what on earth is the point of contributing to the review and taking it seriously because the legislation has pre-empted it.

If the Minister had held the review, come to the House and said, ''These are the results. We have identified these difficulties and this is how we propose to deal with them,'' that would have been all well and good, but it has not happened. She has promised us the review for a long time, but it simply has not happened. Perhaps she can tell us what progress has been made with the review, what its terms of reference are, who sits on the review board, how far they have got, how many meetings they have had and so on. That would be extremely useful.

Perhaps there are even some preliminary conclusions that might inform this discussion. If the Minister can give us some idea about those, we might be a little more favourably inclined towards the proposal, but that has not happened so far. Instead, while promising the review, she has cracked on and drawn up these clauses, which are pocked, like other bits of the Bill, by references to regulation. Presumably that enables her to fill in the gaps. A bit like a child colouring in a stencil, she intends to colour in the Bill at a later stage, because she has allowed the regulations. That seems to be her approach to the Bill and nowhere is that more the case than with these seven clauses.

These clauses are pocked with references to regulation, and we have to assume that, at some later stage, the Minister will tell us what she really wants to do—based on the review, I hope—using those regulations. As we have said before, that would not have been our approach. We would have conducted the review. It is right and proper to hold a review at this stage and for the legislation to be informed by it, but we have not had that. I hope that the Minister will give us some idea of why the review has not happened and what stage she is at with it. Is it still planned to take place at all, or has it been overtaken by events?   Have these clauses superseded any plan that she had to review GOS?

I am concerned about the sight test fee. I have identified the fact that a cross-subsidy applies. The hon. Member for Bristol, West said that the fee was very cheap, and indeed it is. Most of us have experienced various other forms of what amount to compulsory fees when we have had to get our car fixed, our plumbing repaired or whatever. Set against such expenditure, the sight test fee seems ludicrously low. I tend to agree with the hon. Gentleman on that. Particularly when one takes into account the cost of the equipment required to do a proper sight test, the experience and expertise of those who carry out the tests and their need to maintain premises and staff, the fee seems extraordinary, but of course there is a cross-subsidy between the provision of spectacles, for example, and the sight test.

Photo of Stephen Williams Stephen Williams Shadow Minister (Health) 11:00 am, 10th January 2006

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.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

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—

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

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   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.

We had a similar debate in connection with oral health and the screening value of NHS dentistry. I   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   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.  

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.

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   them so that they stand no chance of damaging what is currently an excellent service?

Photo of Nadine Dorries Nadine Dorries Conservative, Mid Bedfordshire 11:30 am, 10th January 2006

I, too, add my good wishes for the new year to everybody.

As people are talking about their own spectacles and giving examples, I should like to show the Committee my beautiful leopard-skin-printed glasses, which I purchased for £9.99 from a local gift shop. Unfortunately, they have not served me well. Last time we sat in the Chamber, I was the butt of a number of jokes, not least those that went, ''Now Nadine, take the glasses off.'' That is not why I am now seeking the help of an optician. I am doing that because I have been squinting. I cannot read the Order Paper. I could not read menus in restaurants over Christmas, and I was in a rather dire state.

This morning, I decided to see an optician. Before the Committee started, I initiated two phone calls: I made one of them, and I got my researcher to make the other after me. I wanted to check whether the service was equitable, easily accessible and fair to all. I rang a local high street chain, pretending to be somebody on benefits, with no money at all, who needed glasses. The shop—I shall not mention its name, but the second word is ''savers''—told me that I could go in tomorrow and have my eye test, and that I would be given a voucher for £39 that I could take to any high street store—a supermarket, pharmacy or anywhere—that I chose in order to have a pair of spectacles dispensed to my prescription.

For me, the disappointing part of the exercise was that the voucher would have been for £39, but the cheapest pair of glasses and lenses that I would have been able to purchase was £79. That left me with a deficit. I said, ''I do not have any money. I am on benefits. How do I go about it?'' but there was no way round it; the cost of the glasses and lenses was going to be more than the value of the voucher.

Then my researcher phoned and pretended to be me, wanting a private eye test and not having any benefits. He was given exactly the same information in that he was told that he could go in tomorrow for an hour for a similar appointment. We have a service that, regardless of one's position—whether one is on benefits or able to pay for an eye test—is fair, accessible to all and of a high quality. One can go in whenever one wants to, and can take the prescription anywhere on the high street. It is a service that works. That is particularly useful for me, because within an hour I can have my prescription dispensed and come out with my glasses. Unlike my hon. Friend the Member for Westbury, I do not have the time to go around looking for better options. I want to go in, get my prescription and get out. It works.

Why are we considering the introduction of legislation that might distort a service that works so well? It might reduce the number of opticians or optometrists on the high street and that would reduce competition, which is also important. We all know that competition, patient choice, is what drives up   quality. The service is of a high quality. Why would we want to bring in legislation that might restrict quality and choice? Why is the Minister proposing legislation that is not needed? The service is not broken; it works adequately—very well, in fact. Why are we trying to repair something that is not broken? What is the reason for the legislation?

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

I should like to emphasise and be upfront about the fact that the clauses mirror the existing obligations on primary care trusts in many respects. However, they put those obligations in a new framework. Several members of the Committee asked why we are making changes at all, so let me point to one example.

At present, primary care trusts can contract for NHS sight tests only with providers who are optometrists, ophthalmic medical practitioners or corporate bodies registered with the General Optical Council. Businesses owned by dispensing opticians or lay people who employ those whom I mentioned to do eye tests cannot contract with primary care trusts. Several members of the Committee talked about choice, and our approach in the clauses is partly about providing an opportunity to extend contracts with dispensing opticians or lay people much more transparently, provided that they meet quality standards and that clinical provision, particularly the provision of sight tests, is carried out by optometrists or ophthalmic medical practitioners.

That is important because the present arrangements have led to a situation in which businesses have had to restructure, so that they can register with the General Optical Council, or to have an agreement with an employee who is an optometrist or ophthalmic medical practitioner and who is therefore able to contract with PCTs. As a long-term measure, that way of getting round the system—that is what it is, although I am not saying that it has necessarily led to less quality—is not particularly helpful or satisfactory. Indeed, the present measures were introduced when it became clear that there had been failures to comply with the regulations.

We are trying to move to a proper legal framework for the provision of ophthalmic services, and the Bill is the first available vehicle that allows us to do so. The planned changes will enable PCTs to contract directly with optical businesses without the current restrictions on ownership and they reflect the reality of service provision. However, there must be quality assurance when PCTs contract with organisations with which they cannot presently contract directly.

It is ridiculous that we continue to endorse a roundabout way. Let us not forget that, in some places, there are optimists—sorry, optometrists, although optimists as well—who serve several different businesses. If we say that the PCT should contract only with that roving individual, that raises questions about the service that is being provided and about who is responsible for providing it, for the access points and for other issues. A prime aim in the clauses is therefore to provide greater opportunity while recognising that there must be clinical safeguards.  

I hope that that answers the questions from the hon. Member for Mid-Bedfordshire (Mrs. Dorries) and others about what is significantly different about the proposals. Their introduction in no way undermines what I acknowledge is a very good service, but it gives us greater opportunities to have a more realistic discussion with those in the business of providing services on the business and clinical sides.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

I am grateful to the Minister for giving way, because I do not really understand a lot of what she has said. She talks about providing greater opportunity, but I question for whom one is providing it, because Opposition Members have certainly not had representations from professional bodies or providers about the lack of opportunity. The Minister has not said how providing greater opportunity will improve patient care or access. Will she rewind, and explain things again? It is soon after Christmas and perhaps I am being dim.

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

As the hon. Gentleman is aware, the services are provided by a number of different organisations; there are big corporate bodies and brands such as Specsavers, and smaller opticians. Certain services are already provided in other businesses.

I make it clear that at present primary care trusts can contract with providers for NHS sight tests only if they are optometrists, ophthalmic medical practitioners or corporate bodies registered with the General Optical Council. That means that businesses owned by dispensing opticians or lay people who employ optometrists or ophthalmic medical practitioners to do sight tests cannot contract with PCTs. In that situation, the contract must be with the employee of a business rather than the business itself.

The Government believe that is a ludicrous situation, because it leads to a convoluted set of arrangements. The oversight of local contracts and discussions on the provision of more and enhanced services are disjointed, as the hon. Gentleman said, as the PCTs do not deal with those who provide the premises and the environment for the clinical services.

This does not apply to other primary medical services, such as dentistry, and we are trying to create a more practical, transparent and legal framework in which dispensing opticians and lay people who employ clinical professionals can be part of and engaged in the contracting process.

Photo of Nadine Dorries Nadine Dorries Conservative, Mid Bedfordshire

Is the Minister saying that at present if I bought premises and employed an optician to run the business and provide the service, I would not be able to have a contract with the PCT, but that, under the legislation, if an individual wanted to establish a business employing optometrists or ophthalmologists, they could have a contract with the PCT? Is she saying that at present the only people who can have a contract with the PCT are registered optometrists, ophthalmologists or opticians and that if I wanted to set up a business, with people working in that business, I would not be able to have a contract?

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

What I am saying is that there are limitations at present on those individuals within the profession who can contract with a PCT. At the   moment, where a lay person or a dispensing optician has a business, the named person who has the contract with the PCT has to be the employee who is brought in to provide the clinical services. That seems ridiculous, considering that we are talking about businesses with which one may want to discuss providing a range of enhanced services outside of or in addition to the sight test procedures. Later, we will discuss the local committees, on which we want clinical professionals and contractors to be represented.

There is an anomaly at the moment, which the clauses try to address, but at the same time the Minister of State, Department of Health, my hon. Friend the Member for Doncaster, Central and I have to ensure that the necessary arrangements are clear and that clinical expertise is provided for by whoever is given a contract by the PCT.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

The Minister is generous in giving way. A bit of a seam has been opened up in this debate, because nothing is explained in the verbiage of the guidance notes. That underscores the obvious need for the proposal to have been subject to a full review before the Bill was introduced. I am most grateful to her for shedding the information at this stage but it is new to us and we will have to give it serious consideration.

The Minister mentioned dentists and pharmacies and I will need time to discover to what extent the proposals marry with the contracts that the Government or their agencies want to establish with those professional groups.

It does not seem to me that the general dental services and personal dental services regulations that were laid before the House late last year bear any resemblance to the arrangements that the Minister is now proposing for optometrists and dispensing opticians. That seems to be a central tenet of the Minister's argument; she is trying to harmonise the arrangements that PCTs enter into with various professional individuals and corporate groups. I am completely at sea as to what the Minister is trying to get at. It is all new material, which we should have been apprised of well before now. The Minister dealt briefly with the issue of quality. That is a serious concern. One does not register with professional organisations for no reason at all.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

Mr. Illsley, I shall return to the matter at a later date; I think that we will cover it at some length.

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

I had not finished my speech, but in answer to the hon. Gentleman's first point, the fact that he has not done his research is down to him, not the Government. Part of the core of the discussions with professional groups was about the opportunity for PCTs to contract with dispensing opticians and lay persons. I have seen the briefings provided by a number of the professional groups because I was sent them as an MP and went through them. I have read a number of things and it is clear, as it is clear from the   discussions, that the extension of the opportunity to contract in a transparent and open way with the individuals I have described is a core part of the reason why we are bringing the clauses forward. Second to that are the issues of fraud and the important role of the PCTs as a watchdog to ensure that it does not take place, whether in the delivery of the sight test or in the provision of vouchers for purchasing optical accessories.

The clause gives primary care trusts a duty to provide a sight-testing service for eligible patients. It mirrors their existing obligations but in a new framework. Eligibility for the service will be maintained through the regulations—that is nothing new—which will be made in respect of all those currently eligible. Primary care trusts will also have a new duty to provide any other primary ophthalmic services that may be prescribed and any further services that they judge necessary to meet reasonable need in their area. Those could be for individuals who are diabetic—we are obviously aware of the issues about sight and diabetes. They could be post-treatment care in the local community for individuals who have had a cataract removed or had glaucoma. I will come on to that when I address the points that have been made about the review process.

PCTs will reimburse opticians and a central budget will reimburse the PCTs. There is no ceiling on that as long as the provision is in line with the standards that we expect and the eligibility requirements. That is the position now and it is what is intended for the future. The sight-testing service will be mandatory under the clause and PCTs will have no scope to reduce it.

A point was made about co-operation. This is a standard provision that mirrors those for dental and medical services. There is a risk of failure to co-operate. It is a slight risk, but there is always such a risk and we have to provide for that. The clause gives the basis for a strategic health authority or the Secretary of State to intervene and remind NHS bodies of their duties. As I said before, there are issues in the legislation that complement the review.

It is desirable for PCTs to provide services should there be an unwillingness to provide them privately in a community, although such unwillingness is most likely to occur in the provision of services other than sight tests. To that end, it is not apparent that the provision would necessarily have to be used by PCTs, but it is important to ensure that it is linked to a duty to provide sight tests. Where sight tests are not provided privately, rare though that may be, it is important to have the provision so that the PCTs may seek to provide that service.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

Will the Minister help me to understand the nature of the budgetary arrangements to which she is committing the Government? Is it a central budget to fund sight tests or primary ophthalmic services? The comparison with dentistry, for example, would be of a fund that was centrally distributed but ring-fenced and devolved. What precisely will be held centrally and not cash-limited?  

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

My understanding is that the current process and framework for negotiating the sight tests and the reimbursement will continue.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

I understand that, but the question then is whether the Government intend there to be global primary ophthalmic services budgets for PCTs, against which the resources for sight tests would be offset, or whether the central budget for sight tests will be completely separate from the devolved budget for primary ophthalmic services, so that an increase in the uptake of sight tests in a PCT will not have the negative consequence of an adverse effect on the additional services that are bought locally.

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

The answer to the last point is yes. An increase in the number of sight tests that are carried out in a certain area and the seeking of reimbursement for those tests will have no relationship to any other services provided for locally. In the same way, we are not setting a minimum or upper limit on the number of sight tests.

The only concern about volume relates to abuse of the system, whether financial or in relation to the quality of the sight tests being carried out. A contractor may employ someone who is qualified to carry out sight tests, but the number of sight tests that they carry out in the hours for which they are contracted may beggar belief, and there may be doubts about whether there is any real quality assurance. I do not, however, want that to be taken as suggesting that such practices are common.

I agree with everything that hon. Members have said about the flexibility and choice that already exists in the system, but it is important to be aware that there is abuse of the system. According to the latest reckoning, some £10 million of fraud is committed every year. That amount has gone down, but we do need more measures to clamp down on it. I hope that that reassures the hon. Gentleman. So far as I am aware, there is no connection between reimbursement for sight tests and any other funding issues for other services that the PCT may wish to provide, although that may of course depend on issues in the local community.

Photo of Andrew Murrison Andrew Murrison Shadow Minister (Health)

The Minister mentioned £10 million of fraud. It would be useful to know how much the new arrangements will cost, given that avoidance of fraud is one of the important reasons why she wants the seven clauses to be implemented. It is not clear how much the arrangements will cost, but it is self-evident that there will be a cost to the service for PCTs to administer them.

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

I do not believe that there will be a huge additional cost, because we are simply widening the scope of contractors who can be part and parcel of provision locally. The provision therefore simply widens the pool of contractors. PCTs already contract with services locally to provide the facilities available on the NHS. All that we are doing in that respect is widening the pool and making opportunities through the local committee to have the sort of discussions that are currently held, but also opportunities to address local issues as and when they occur. Nothing in these proposals indicates   additional costs of themselves. They are simply to deal with some of the anomalies in the system and make it clearer and more transparent so that everyone knows what they are dealing with.

Photo of Nadine Dorries Nadine Dorries Conservative, Mid Bedfordshire

The Minister mentioned £10 million worth of fraud. If we are to take on additional costs to put in a new system, what safeguards will there be against fraud? We may go through the process and find that next year the fraud has escalated to £10 million; the new arrangements will do nothing to limit that.

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

We come to that later in the clauses. The 1999–2000 baseline shows that losses through optical patient fraud were measured at £13.25 million per annum. That was reduced in 2001–02 to around £10.17 million. The Counter Fraud and Security Management Service is currently undertaking a further risk measurement exercise in ophthalmic fraud focusing on both patients and contractors in England and Wales and expects to produce statistics by the end of this financial year.

I was not sure what point the hon. Lady was making in her earlier contribution. Obviously, when people ring up and pretend to be something that they are not, there is not a lot that one can do about it over the phone. I thought that she was going to make the point that she then went to the opticians and they did not ask for proof of her status and issued a voucher and so forth. If that was the case, she can see me afterwards with the name of the opticians and we will send the fraud people along to them.

She also seemed to suggest that it was unfair that the voucher for optical equipment did not meet the full price of the glasses themselves. I was not sure whether she was suggesting that we should up the rate for the optical voucher to a price that is consistent with some of the more highly priced commercially available glasses. She might want to look at Hansard. She then asked what it was all about and why were we changing it. I hope that I have managed to explain the wider opportunities for much more direct and straightforward arrangements and contracts with businesses that are providing services.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health

Of course, there is a point there. People who are held not to have any money to pay for their sight test get a test subsidised by the NHS, but the subsidy is considerably below the actual cost of providing the test and is cross-subsidised from the sale of spectacles. If those people then go on to receive a voucher that meets only part of the cost of their glasses, in effect they are paying for part of their sight test. That is all theoretical. The question for the Government is whether they intend that the cross-subsidy between the sale of spectacles and sight tests should continue or, as is the case elsewhere in the NHS, that remuneration should much more accurately reflect the cost.

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

That point of view has been expressed by others. There is a claim that the NHS sight test fee does not meet the actual cost of the test and is subsidised by the sale of glasses. Our position is that we negotiate the sight test fee nationally with the representatives of the profession and the sale is a   private matter for them to determine. But the fact is that we have national negotiations for the level at which the price should be set for the sight test. I do not accept that there is a cross-subsidy. [Interruption.] That is their view. Negotiations will begin for 2007–08 and I have no doubt that those issues will be raised there.

There are glasses available at a lower cost, but choice is a factor. When I started wearing glasses, one had either the NHS tortoiseshell square ones or the John Lennon metal round ones. That was the basic choice on the NHS; if one wanted to use the voucher to buy one's glasses, those were the glasses one got. People wanted more choice and wanted to add to that, which is why there is now a greater range. Two of my children are short-sighted—I am afraid that I have passed that on—and when I go with them to see what glasses are available, I see that there are ranges of glasses for under £50 and under £100, and lots of deals are available, such as buy a pair of glasses and get sunglasses free; then there are the glasses by Armani and so on. It is about choice.

The alternative, which would deny choice and flexibility, would be to say, ''We will pay for the glasses, but there are only three types that you can have; that is it.'' We could control what is provided in that way. In the provision of other NHS appliances—for want of a better phrase—that is the position, but some people feel that it is far too centralist and restrictive. When budgeting, one must decide whether to give people the opportunity to take their voucher and add to its value or whether to say, ''Right, I'm sorry, if you're going to have the voucher, this is the limited choice of glasses that you can have.'' I think that the former is a better way of giving assistance without creating a sort of Stalinistic system in which NHS patients are given limited choice and flexibility on eyewear, which is important to people. Clearly, the hon. Member for Mid-Bedfordshire is interested in how her glasses look, and there is no reason why anyone else who receives such services should not be similarly concerned by the look of their glasses. However, there is an issue, taking into account the market and the range of costs of glasses, as to what price the taxpayer is prepared to pay. Nothing is perfect, but I think that the current system is about as good as it gets.

I shall touch briefly on the review and give the Committee some information. The review is under way and discussions are continuing. One reason for the review and its terms of reference is the need to emphasise the importance of making better use of primary care resources. For example, undertaking primary care rather than secondary care where appropriate, and developing patient choice.

As I said earlier, the post-treatment care of people who have been in hospital for the treatment of glaucoma or for cataract removal is only provided in hospital settings in some cases, but might better be provided in a community-based setting. As part of the review, we are discussing with the profession and others how we can deliver such services closer to home and develop patient choice. We are currently funding pilot projects that test model pathways in those areas.   I am happy to write to the Committee with information about those pilots.

The review is also looking at wider development in England, with PCTs being responsible for health services. We decided to extend the review, because we listened to people in the profession who wanted more time to explore such issues, and because of our White Paper, ''Your health, your care, your say'', as there are clearly some overlaps in those areas. The review is likely to finish later, rather than earlier, in 2006. We recognise that this issue links into several areas to do with providing health care outside hospital. However, the provisions in this clause and others do not necessarily have to await the outcome of the review.

These clauses provide a better, more transparent system for the contract arrangements and ensure that primary care trusts have a duty in legislation to provide the NHS sight-testing service for eligible patients. In answer to the question asked by the hon. Member for Westbury, I shall deal in a moment with where people take the test.

Photo of Andrew Lansley Andrew Lansley Shadow Secretary of State for Health 12:00 pm, 10th January 2006

The Minister referred to the debate on the White Paper. One of the central debates on the White Paper relates to the extent to which PCTs should provide services in future. The implication of the Government's proposals thus far—although one never quite knows where they are on this issue—is that primary care trusts should not be both purchaser and provider of services. However, the structure of clause 34 expressly allows primary care trusts to be both purchasers and providers of primary ophthalmic services.

Clearly, people in the profession might reasonably worry that PCTs will make the kind of provision that has been seen in dentistry with dental access centres, which they control and which is turning the profession into a salaried, NHS-employed profession, rather than one made up of independent practitioners—unfortunately, at much greater cost than independent provision. That seems perverse to people in the dental profession, and it would certainly be perverse in the profession that we are considering. Will the Minister tell us why, as my hon. Friend the Member for Westbury said, proposed new section 16CD(4)(a) contains provision for a PCT to become a provider?

Photo of Caroline Flint Caroline Flint Parliamentary Under-Secretary (Department of Health)

As I outlined earlier, that is to allow for those circumstances in which sight tests are not provided by the private sector. This is about access for individuals. I said earlier that, given the already very good service that is provided in terms of access to sight tests in a variety of settings, it would be rare for PCTs to feel that they had to make such provision, but we felt that there could be circumstances in which it was an issue, and therefore the measure allows what I have described to happen.

On PCTs and the provision of services, my right hon. Friend the Secretary of State for Health has been clear. It is up to PCTs to determine whether they provide services; but in relation to the hon. Gentleman's last point, it is also important for PCTs   to demonstrate that the services that they pay for provide the necessary outcomes and value for money, particularly if they are commissioning those services and run them themselves. That is a role for the strategic health authorities to oversee, too.

The hon. Member for Westbury asked a direct question about whether an individual could go outside their PCT area and still have access to a sight test. The PCT's duty is to provide or secure provision in the area, not for persons in an area. The situation is exactly the same as the current arrangements. The sight-testing service remains catchment-based rather than resident-based. Therefore, if someone is on holiday or working in a different area from where they live, they can have a sight test. There is no change in that regard to the flexibility and choice of service.

I have covered a number of issues that were raised this morning, and I hope that I have reassured members of the Committee and those outside listening to the debate that clause 34 is an attempt not to undermine any existing arrangement, but to build on what I think everyone agrees is a good service by making better sense of some anomalies, which people get around but which do not contribute to a much more open and straightforward contracting relationship and do not allow PCTs to explore with contractors the sort of work that they might want them to do beyond the sight test—the sort of work that they would be responsible for funding and for which they would negotiate based on local need.

Clause 34 ordered to stand part of the Bill.