Amendment proposed [this day]: No. 29, in clause 35, page 32, line 47, at end insert—
'( ) Regulations under subsection (2) must make provision for all those with entitlement to GOS to retain the right to have that delivered by the provider of his or her choice.'.—[Dr. Murrison.]
Question again proposed, That the amendment be made.
I remind the Committee that with this we are taking the following amendments: No. 30, in clause 35, page 32, line 47, at end insert—
'( ) Regulations under subsection (2) must make provision as to the right of those qualifying for a GOS sight test to have that sight test, and for the provider to be recompensed without any limitation on the number of sight tests carried out either in total or at any listed practice.'.
No. 31, in clause 35, page 32, line 47, at end insert—
'( ) Regulations under subsection (2) shall direct that the Primary Care Trust will not be able to place any limitation on the number of providers or performers listed in their area, or deny the right of any performer listed by another Primary Care Trust to undertake sight tests in their area.'.
Your arrival was impeccably timed, Mr. Illsley. We now reach our final sitting, and I do not know about anybody else, but I am certainly exhausted, notwithstanding the Christmas break. However, we still have many clauses to plough our way through. There is plenty of stuff to get stuck into and plenty to entertain us for the next three hours or so.
We have discussed clause 35 at some length, and it is important that we have done so, because it deals with the significant issue of choice in ophthalmic services. As we said, we are most concerned about the choice element in the seven clauses that deal with primary ophthalmic services. Choice is what we have on the high street now, and our concern is that the Bill will impinge on the choice that our constituents have across this particular spectrum. The Minister probably got the impression that I am very much a fan of ophthalmic services as they are currently configured, and I hope that she did, because I am. That part of what I might broadly define as our health services is well worth emulating, and that is nowhere more true than on the crucial issue of choice and people's ability to go wherever they want.
So far, the Minister has offered a pretty good, robust defence of the Bill and particularly of why it is necessary to introduce the seven clauses. If I am correct, the reasons centre on enhancing the opportunity to provide services and on a concern to address fraud within ophthalmic services. We have discussed fraud to some extent and have asked her to compare and contrast the cost of the administration that PCTs will undoubtedly have to shoulder as a result of these seven clauses with the estimated £10 million of fraud that she is rightly attempting to eschew from the system—I am not sure where that estimate comes from, but it does not sound unreasonable, given the turnover that we are discussing. It is important that we contrast those figures, because it emerged in our deliberations this morning that counter-fraud is one of the cornerstones on which these seven clauses are based. Even at this stage, I hope that she can give us a greater insight into how, or indeed whether, she has compared the money that she hopes to save by removing fraud from this element of health service transactions with the cost that the clauses will undoubtedly involve—the undefined cost that PCTs will apparently have to bear. That will be translated into employing more people to carry the business forward, to do the contracts and the rest of it.
Towards the end of this morning's deliberations, as we were getting into the debate on the amendments—this is the after-dinner part of it—we discussed whether it might be appropriate to have a national contract and national arrangements at least for the sight test. Earlier today, we managed to tease out the difference between the sight test fee and moneys that might arise as a result of the provision of primary ophthalmic services. I am grateful to the Minister for clarifying what we mean by those two things, because they seem to be different in that one is not cash-limited. It is a centrally identifiable sum of money, although it is handled by PCTs, but it is not cash-limited, and that is quite important. That becomes interesting in the context of the basing of the contracts. We can foresee a situation in which a practice exhausts its contractual obligations for any given year and then, as I said earlier, has to sit on its hands for the rest of the year.
Although it is not their principal aim, our amendments would address that situation, because they would ensure that people could choose which practitioner they went to. That cuts both ways: it would also ensure that people were not sitting on their hands for a whole month at the end of the financial year once their practice had discharged its obligations and they had no more work. We have not really heard much from the Minister on that. It has a parallel with the dental contract in one respect, and that is the margin. Last year, in relation to the dental charging regulation, we debated the margin of error that the dentists will be allowed in relation to their contracts. It is rather tight. Just a small divergence from the contract would result in a penalty. The professions will be interested to know what penalties—
On dental comparisons, many dentists have chosen not to provide NHS services. In my area, one cannot find a dentist who will treat NHS patients. If that situation were allowed to develop and optometrists and opticians found themselves running out of budget and unable to treat patients, having waiting lists, and experiencing difficulty negotiating with PCTs, they, too, might decide to withhold their services and become solely private providers. Then they would not have any contract with the PCT and would operate, much as dentists do, as wholly private opticians.
We would then find the situation in relation to optical services the same as the one in relation to dental services. Somebody who needs an eye test but cannot afford one might not be able to have it because the opticians will have opted out of the system.
My hon. Friend makes an interesting point. At the moment, there is no incentive for that to happen, because the fee is remarkably low for a variety of reasons. One of them is the cross-subsidy between the provision of specs and the NHS test. In fact, one of the beauties of the way in which the system has evolved is that there is no real market. There is a sight test that is well respected; people know what they are going to get when they go for a test and they are content to have it. I cannot imagine that people going to see an ophthalmic practitioner in the high street really differentiate between NHS and non-NHS in the way that they most certainly now do in dentistry. To that extent, the two are not directly comparable, but I understand what my hon. Friend means.
Again, I emphasise that ophthalmic services seem to be a model to be emulated by other parts of the service. They have evolved in a way that—I sound like a salesman for the sector, which I do not mean to be—offers value for money and is incredibly accessible. No other part of our health service is quite as accessible as this one. The Minister will no doubt say that there are walk-in centres, and one can always go to an accident and emergency department to get immediate treatment, but that is not the same as obtaining primary ophthalmic services on the high street. One would have to go to continental Europe to find anything remotely similar in the provision of health services, broadly defined.
That is why we are very cautious about anything that will fundamentally change that element of health care. In that, we appear to be joined by the profession, going by the briefing notes to which the Minister referred earlier. Her reading of them is slightly different from mine, but it appears clear that the profession is very concerned about these changes. We also know that from the evidence of our constituency mailbags. In nearly five years of being an MP, I have not had one complaint about primary ophthalmic services, and we know that complaints about such services form a tiny proportion—a fraction of 1 per cent.—of all complaints received by family health services committees. That is set against the very large number of consultations that are going on year in, year out.
The lack of complaints is our assurance of quality and backs up our position. The Minister did a fine job this morning defending these seven clauses, but she will forgive me if I say that Opposition Members have the imperative on this issue and we are backed in that by the profession and by the statistics and figures, which support our contention that this is a high-quality service, providing what people want. We should not be trying to affect it or to change it fundamentally. We should be trying to emulate it elsewhere in the health service.
Amendment No. 32 was, sadly, not selected, for reasons that I have discussed. However, I am not sure whether I am permitted to mention it in the clause stand part debate. If I may just describe it in general terms—
Thank you for that clarification, Mr. Illsley. I will raise the amendment as part of the clause stand part debate and I am grateful for your willingness to hear comments on it in that debate, because it is quite important.
May I deal with what I am enjoined to discuss: the three amendments in this group? I hope even now that the Minister may be able to smile favourably on the amendments, which relate entirely to choice. I hope that she will reconsider her remarks about audit and inspection, because she seemed to be quite dismissive of the cost that may be involved, through the PCT, in overseeing her arrangements to do with the contract. It seems counterintuitive to suppose that, if someone enters into a contractual arrangement with a provider, they will not have any obligation to check the arrangement more thoroughly than if they simply have somebody on a list.
I think that we deal with the list in a little more depth later in the Bill and I would be grateful to know what it means in terms of primary care trusts. We maintain that such a list would perhaps be better held centrally, by which we mean nationally. That might be a way of getting around some of the expense that I identified earlier. With that, all that I need to do at this juncture is to withdraw amendment No. 29 and look forward to the clause stand part debate, which I am sure will be exhaustive. I beg to ask leave to withdraw the amendment.
Amendment, by leave, withdrawn.
Question proposed, That the clause stand part of the Bill.
Several hon. Members rose—
We are all leaping to our feet. We now come to the bit that I thought we were at. My apologies, Mr. Illsley: my lunch was obviously rather better than I planned and I got ahead of myself in my enthusiasm to get to amendment No. 32. You will recall that that amendment was ruled out of order for technical reasons that are slightly lost on me because I do not have the abilities of the parliamentary draftsmen available to the Minister, or the paraphernalia that supports her performance in this Committee. Essentially, the amendment would insert the following:
''Regulations under section 16CD(4) shall direct that the remuneration paid to providers for each sight test shall be a nationally negotiated fee as agreed from time to time by the Secretary of State.''
The Minister might say, ''Well, that is funny, because the Conservatives are keen on deciding things locally.'' Indeed, there is cross-party consensus that we should, where possible, negotiate things locally. That is right and proper, and it is nice that we should have such consensus, but it might seem a little odd that we should insist on a national fee.
It seemed to me, although I am not entirely sure, that the Minister suggested in her remarks earlier today that, de facto, that is what will happen. I hope so, for a raft of reasons, which we have dealt with to some extent, such as that such a system would get around the problem of different fees being negotiated in different primary care trusts. The Minister said that it was her intention that that should not happen, but admitted that it might. She is vastly more experienced than I am, but it seems to me that it would be strange to rely on her assurance in this Committee that there is a theoretical possibility that a particular outcome might happen, but that it is not her intention that it should. That is unacceptable. We must close such loopholes. That is why we spend hours and days going through the Bill bit by bit, clause by clause, and comma by comma.
In the light of the Minister's earlier remarks, I should have thought that she welcomed the amendment, which you, Mr. Illsley, disallowed for technical reasons. Nevertheless, I recommend to her the burden of what it says. I am sure that she and her parliamentary draftsmen colleagues could craft a form of words that got around that apparent technical difficulty and ensure that the figure is negotiated centrally and will apply to all PCTs, thus getting away from the possibility of competitive advantage and disadvantage applying from one place to another. It would prevent guileful people such as me from getting tests more cheaply in one part of the country and going to another part for their specs, and would prevent the big providers from acting in a similar perverse fashion. I am sure that it is not the Minister's intention that such situations should arise. More particularly, for the public service, it would mean a saving for PCTs. This morning, we rehearsed the argument, which I do not want to go over again too much, that PCTs are overburdened with administrative cost and bureaucracy. They have the dental contract coming in a few weeks. It will be interesting to see what happens with that. The National Audit Office is rather concerned about PCTs' capacities for managing those contracts, and here is another one on which they have to negotiate—potentially on individual terms.
Before I withdraw the amendment that was not selected and which I did not move, if I may make that tautology, will the Minister give some assurance that she hears what I say, that it is categorically not her intention that the fee should be different from one PCT to another and that she will, in some way that she can describe, make sure that that illogicality is not built into the Bill? It seems to us that a central contract administered through the Business Services Authority might be a more appropriate and cheaper way of doing things. It would certainly be a lot more cost-effective in terms of PCTs and in the context of trying to save money. The Minister admitted that she wants to save money on fraud. We need to find savings where we can. We must not, in the course of that, burden organisations with more bureaucracy and cost, thereby diluting any efficiency savings that might be achieved. I am sure that we are all singing from the same hymn sheet on this issue, and I commend our general thinking to the Minister.
There are a few technical points relating to the clause that it was not appropriate to deal with through amendments, but I hope that the Minister will expand on them. Proposed new section 28WB contains no reference to qualifications or registration levels for practitioners, which seems a bit strange. Clause 36, which we will come to shortly, deals with the issue in a little more depth but is really not that specific. This morning, we talked about entering into contracts with various people and the Minister talked about expanding the opportunity for various organisations to provide services. It is important to know about the qualifications and registration of those operating the services, and to know what the Minister is expecting to see.
Across the whole range of medical health services we rely on qualifications and registration, yet these seven clauses seem to be fairly qualification-light. We have not talked much about the differences between the various practitioners, except to get tongue-tied over some of them. It would be interesting to know why the Minister has not felt it necessary to stipulate the qualifications of the various persons who may be involved with the contracts. As far as I recollect, that stands in contrast to the Government's changes in relation to pharmacies. I recall spending a considerable time talking about qualifications in that context. Some comment on that from the Minister would be most welcome.
Proposed new section 28WC refers to the disqualification of persons from entering into a GOS contract, but it does not really tell us much about the grounds for those disqualifications. Are they professional? Are they to do with probity, which the Minister mentioned earlier; with negligence, although the incidence of complaints is very low, so I suspect that that issue would not come up often; or with contractual disputes? If the latter, that is when the provision potentially becomes a little more sinister, because applications for disqualification could be based on organisations that are perceived as being a little difficult. For example, a high street single-handed practitioner might be regarded as more difficult to work with than Specsavers. We seek reassurance about what the Minister means with regard to disqualification, and what the grounds might be for disqualification.
We know that there is an appeals mechanism through a committee set up by the Secretary of State for Health, and that is right and proper, but such a committee would, of course, involve considerable outlay by the appellant, and would mean time, effort, anxiety, uncertainty, and potentially lost trade. It is important to understand the grounds for disqualification, so perhaps a little detail from the Minister might be appropriate.
We have not talked at great length about the cost of the contract. That is strange, because in general when we discuss legislation we are used to having a regulatory impact assessment that goes into that subject in some detail. The Minister has assured us that she does not think that the new arrangements will involve a great cost. The more I think about it, the more I think the costs will be considerable. We are breaking down the contract into a myriad little bits that will have to be individually negotiated and worked through by primary care trusts. It will be new for the PCTs, which will have to set up new structures as a result. That will take manpower time. We all know what happens in such circumstances. Before anyone is appointed, the position has to be advertised. The PCT—the trust in my area is quite small—will suddenly have to take on additional staff to deal with ophthalmic services. That will represent a significant increase in the overheads that PCTs will be expected to shoulder.
Blithely to say that the proposals will be cost-neutral—that it will be a zero cost venture—is somewhat disingenuous. Considerable costs will be involved, and it is appropriate to set them against the £12 million identified as fraudulent, especially as the Minister gave that as the cornerstone for these seven clauses, and one of two reasons identified this morning. If it is so very important to save that £12 million, we need to consider setting it against the costs resulting from the implementation of chapter 2. My ''back of a cigarette packet'' calculations—if I may use such a phrase, given our earlier deliberations—suggest that the cost of the provisions might start to approach that sum. A more reflective assessment by the Minister of the cost of implementing the GOS contract through the continuing myriad of PCTs would be appreciated.
I am grateful, Mr. Illsley, for your indulgence in allowing me to expound at length on the clause. It deals with a number of important issues and I look forward to the Minister's assurances on the points that I have raised.
During the break, I had to go to Boots to buy another pair of glasses, because my old ones were not working. The new ones are not working terribly well, either. Frankly, I think I am better off without them. I shall try my best.
Clause 35 empowers the Secretary of State to rewrite the contract between the NHS and ophthalmic practitioners for the provision of general ophthalmic services. It opens up the real possibility of a PCT refusing to enter into a contract with an optometrist, or to vary the contract in such a way as to exclude those optometrists who the PCT feels are not needed. Nothing in the Bill would prevent that from happening.
The Minister has failed to assure us that any qualified optometrist or optician who meets the necessary criteria and who has the appropriate qualifications will be able to provide ophthalmic services on the high street for all those in the local community who wish to use their services. I am concerned about the responsibility of PCTs for commissioning general ophthalmic services. My PCT is running a £20 million deficit. In order to recover that deficit, it is restricting emergency services, which is almost a complete contradiction.
Given those deficits, one cannot help but put oneself in the shoes of a PCT chief executive and wonder how the trust would cope with the additional responsibilities of handling the GOS contract. In the face of increasing demand for ophthalmic services in the community, I doubt whether the PCT would honour the contractual rights of every optometrist and optician. The very nature of the Bill means that, at some time, cash will be limited, and that will enable the PCT to decide to whom it wants to award a contract. I know that the Minister gave some verbal reassurances this morning, but the wording of the Bill will not prevent that from happening.
Taking that one step further, were we a PCT we would try to get the best value for the budget that we were awarded because, if we limited the number of providers the flow of people would be restricted and we would have to start a waiting list. The PCT would not want to have to deal with the possibility of waiting lists for eye care services, so it could be tempted to negotiate the best deal possible with the bigger providers. We could even see the bigger players strategically planning new development and future growth based on such PCT-negotiated deals. I again ask the Minister to give the categorical reassurance that the eligible population will retain access to NHS sight tests at the practice of their choosing in their community—not at the choosing of the PCT, but still that of the patient.
A PCT could make such a choice because it felt that from an administrative point of view handling the process of a small number of claims from a small number of outlets would be easier and far cheaper, and that could be presented to the PCT as an advance in clinical governance and therefore become a quality issue. As we discussed this morning, and I think agreed, patient choice is the driver of quality.
The PCT could decide to put the general ophthalmic service contract out to competitive tender in order to save money and to acquire less volume. Every PCT we know is cash-strapped, almost all are running a deficit and it is easy to see how PCTs could choose to ignore or reprioritise patient choice in the face of financial pressure. After all, they have to take much tougher measures with arguably more vital services. As I said, my PCT is restricting emergency services. The prospect of having to restrict ophthalmic services would be a walk in the park; it would not even break into a sweat faced with that option. It would be easy for a PCT to decide that there were sufficient practitioners in a particular town or high street and that they simply did not need to award contracts to any more. We have not heard anything in Committee today from the Minister that would prevent that from happening. In fact, there is nothing in the language of the Bill to prevent such a scenario.
Were a large provider to be commissioned by a PCT, a similar fate could affect our opticians as has affected post offices or high street pharmacies. As we know, the people who feel the effects of closing post offices and high street pharmacies are the elderly, those in rural locations, the house-bound or those of restricted means. High street optometrists are of significant importance to those groups of people, as are post offices and high street pharmacists.
Optometrists and opticians are not a group of people that one would normally describe as radical or political. They are well behaved caring professionals, carrying out a vital role. However, as my mother-in-law frequently used to say, even a worm can turn. If the budget became cash-limited, if PCTs restricted budgets to optometrists, if not every optometrist and optician could obtain a contract, as they have a right to do now, one could foresee, as I described in my earlier intervention, their finding a way to withdraw their services, as dentists have done. Then, very much like dentists, people would see optometrists and opticians as a political punch-bag, as politically motivated or affected.
At the end of this debate we need to hear from the Minister a guarantee that every practising optometrist, ophthalmologist and optician will be able to practise in future; that they will have a right to the contract, as they have at the moment and have always had; that the budget will not be cash-limited; and that anybody in the community will have access to services, as they have now.
I want to ask a couple of questions under clause 35, which I do not think we have quite touched on.
Under the general ophthalmic services contract, the primary care trust will be able to contract with providers to provide not only the sight test but other services. There is a relationship between those, in so far as many practitioners offer a range of additional examinations attendant upon a sight test. Dependent upon who is doing the sight test, it varies from a minimum examination to something that is looking for pathology.
My first question is about the extent to which the Government are expecting to specify what the sight test is, using the powers in clause 35. To what extent are they open to looking again in the current consultation at the sight test and, with the Scottish example of an eye examination in mind, at whether it would be appropriate for it to tend more toward pathology, rather than being concerned simply with examining the qualities of somebody's sight?
Secondly, on the structure of payments, what are the Government expecting? If we look at these changes and those for GPs and dentists, the nature of the contracts has varied. All these contracts are concerned to varying degrees with quality, volume and cost. Concerning GPs, they have essentially been about quality and volume. With dentists, they have substantially been about volume. With ophthalmic services, there is a risk that they could be substantially about cost. What is the Government's intention in that respect? How far are they expecting to extend payment by results and the tariff into the determination of contracts for ophthalmic services? To the extent that the Government propose that, it diminishes the opportunity for primary care trusts to negotiate contracts by reference to costs. Can we have some idea about that, or are we simply legislating with no idea of what the regulations will be?
I want to give the Minister a brief opportunity to place on the record certain assurances regarding the ophthalmic services covered by this clause, which I understand have been given by the Minister of State, Department of Health, the hon. Member for Doncaster, Central (Ms Winterton), who is not with us today. Those assurances were about what the contracts cover, and they are headed in a briefing which Committee members may have seen from the Association of British Dispensing Opticians, the Association of Optometrists and the Federation of Ophthalmic and Dispensing Opticians.
I am sure that the Minister is familiar with the meeting that took place between her colleague and that group on 27 October, subsequent to which a letter was written on 8 November by a Mr. Derek Busby, Ophthalmic Services, Department of Health. Sometimes, where assurances are given by officials to professional bodies on behalf of the Government, it is worth ensuring that they are placed on the official record, so that they have greater weight, as it were. The gist of it was that, under clause 35, the new general ophthalmic services contracts will cover three things; essential, additional and enhanced services.
To ensure that my understanding, and indeed that of the professional bodies, is correct, can the Minister confirm, first, that there are essential services that all PCTs—and anyone holding a GOS contract—have to provide? The example given was of sight tests for eligible NHS patients. Secondly, can she confirm that there will be additional services that all PCTs, but not all contractors will have to provide? The PCT must ensure that someone is providing those services, but not all contractors will have to do so. Thirdly, might there be enhanced services? The professional bodies are recommending that those should, again, be covered within the contractual framework. Particular PCTs might judge that those are needed in their area.
Mr. Busby says, of what I have just described,
''This provides a framework for future service development . . . building on the success of the current GOS system . . . ensuring that PCTs have a duty to make sight tests available to meet the needs of their eligible populations on a similar basis to the GOS now''.
I would be grateful if the Minister confirmed that the assurances given to the professional bodies are also her understanding. To quote from one further sentence by Mr. Busby,
''the Bill enables the Secretary of State to define''— those things that I have just talked about, but it then says:
''(in substance, although these terms are not in the Bill)''.
One is always wary when an official writes to a professional body, saying ''This is what the Bill means, but we don't use those words in the Bill.''
Can the Minister clarify whether these are informal equivalents of what is actually in the Bill, or are there reasons why that language was not used in the Bill and it was not felt necessary to specify that there? Clearly, the professional bodies have been reassured by that letter. I hope that the Minister can reiterate those reassurances and clarify how those things arose.
I will try to deal with those points, but in some respects I shall repeat points that I made earlier on the purpose of the clauses. Nothing in the clauses is seeking to undermine some of the good ways in which the service is currently delivered.
I have to say to the hon. Members for Westbury (Dr. Murrison) and for Mid-Bedfordshire (Mrs. Dorries)—he is a doctor and she is a nurse—that there has been a lack of understanding, in some of their contributions, of the present arrangements by which those providing services locally have to engage with PCTs.
It is important that the present sight testing system is maintained, but we are trying, through widening the opportunity for PCTs to contract with people, to get around an anomaly that currently exists, whereby dispensing opticians and lay members cannot directly contract for services and take a roundabout route by which a qualified optometrist has to be the link person whom they are employing for the contract. We are trying to make a more open, transparent system in that regard.
The following points may cover a number of the points that were made. We envisage the sight testing service operating exactly like the general ophthalmic service that is currently in use. On patients being able to choose their GOS contractor, there is no way that we are trying to limit the opportunities for individuals to have a sight test under proper conditions wherever they want.
The point was made about contractors being able to have a GOS contract, provided that they meet agreed national criteria. That will be subject, as now—I emphasise as now—to local decisions on matters such as quality of service, including inspection of equipment and premises. Clearly, that is more easily done locally, and it is done less bureaucratically by not necessarily having a national body to inspect the premises and equipment to ensure that they are up to standard.
We will also, as I have said repeatedly, continue to have a centrally negotiated sight test fee and access to sight tests will not be constrained locally by individual PCT budgets. I have said that several times, but it does not seem to have been picked up by the hon. Member for Mid-Bedfordshire.
No, the hon. Gentleman made a number of points and I should like an opportunity to answer.
Comments have been made about the level of the fee. National negotiations take place on that matter year in, year out, but there is no way that the centrally provided, nationally negotiated fee for sight tests is connected to local provision by PCTs. The clauses ensure that there is a duty on PCTs regarding sight test provision in their local communities—not on a residence basis, enabling someone to go out of their residential area to have a sight test, but on a catchment basis.
Whatever the PCT wishes to do to enhance services or to provide other services—I have given a number of examples of what those services might be—it in no way depends on any link to the fees and reimbursement for the sight tests prescribed in legislation and in regulations and guidelines about who will carry them out and what standard of qualification they should have. I hope that that is clear.
The reality is that at the moment there is no right, per se, for anyone to have the contract—that provision does not exist—so there is clearly some misunderstanding, despite the conversations that Committee members have had with their opticians locally. There is no right, per se, for someone to have a contract to deliver NHS services. On the other hand, there is no right per se, unless the people concerned do not meet standards, for PCTs to deny the contract. That has been explained many times in Committee and I cannot understand why some members of the Committee cannot understand it.
It is important that we deal with the way in which services are to be provided; questions were raised in the previous debate. As to disqualification, regulations, on which we shall consult fully, will set out how that will work. It is likely that possible reasons could be history of fraud and a demonstrated unsuitability to provide a service, such as the use of unqualified staff. There would also be the possibility of an appeal to the Family Health Services Appeal Authority, which is a permanent, quasi-judicial body, with wide experience in the field, to guard against inappropriate application. That should serve as a brake on any PCT in the unlikely event of an attempt to disqualify someone who did not deserve the penalty. As I have said, there will be full discussion of and consultation on that matter before regulations are developed.
As to costs, a regulatory impact assessment is being prepared. There has not been a detailed assessment of costs for the Bill, partly because much of the detail will be in regulations, but, in many respects, the Bill reconfirms the practices that already exist at local level, albeit allowing dispensing opticians and lay members to act directly in the contracting of services. People who currently cannot appear on the contractor list may do so in future, because it will be possible for them to discuss the contracting of services directly, instead of in the roundabout way that has been happening.
I read out the exact figure for optical voucher fraud: about £10 million a year. That relates to patient fraud, not fraud by contractors or opticians. There are, I understand, no figures currently available for the amount of contractor fraud. However, the clauses relating to optical voucher fraud relate to contractor fraud, not patient fraud, and are therefore not directly linked to the £10 million a year. I mentioned earlier that the section or department that considers fraud issues is currently reviewing patient fraud and what more could be done to reduce the figure of £10 million. It has dropped by £3 million since a few years before 2001, but clearly we should like it to be reduced even further.
Earlier, the Minister made the important point that the seven clauses are largely based on the need to tackle fraud, and she cited the figure of £10 million. Is she now saying that that relates to voucher fraud and would she therefore agree that the seven clauses are unlikely to affect the £10 million? We are now dealing with a sum of money—presumably several million pounds—that we have little handle on. Having identified the fraud and put a figure of £10 million on it, the Minister is now saying that it was not the fraud she was thinking of, but some other kind. I am even more confused than I was.
When at the start of our debate I talked about the £10 million of fraud, based on the latest figures, I did refer to patient fraud, because I read it from one of my briefing notes. We also had a discussion about the lists, and the hon. Gentleman spoke, too, about whether a limit would be set on the number of sight tests that could be given. What I said, if I recollect correctly, was that no floor or ceiling has been put on the number of tests that can take place—we will not say that once a certain community has reached 3,000 tests, that will be it. However, if a PCT were suspicious that the number of tests an individual contractor claimed for did not sit with the number of qualified staff able to do those tests—if, basically, the number of tests and the hours available suggested a lack of quality and possibly fraud, because tests were not carried out to a proper standard—it should be able to consider that. If there was some confusion in Committee when the hon. Member for Westbury linked that to the figures I raised earlier, I apologise if I was inadvertently responsible.
If we look back at Hansard I think that we will see that the discussion was about the hon. Gentleman's point on setting any upper limit on the number of tests and why it would be necessary for a PCT to question the number of tests carried out by an individual contractor. It was at that point I gave an example of how somebody could carry out more tests than appropriate for the number of qualified staff, which would link to a concern about the quality of those tests. I hope that I have clarified that matter.
Without discussing amendment No. 32, which was not selected, the principal point that has been made about the NHS sight test fee is whether it should be in the Bill. We do not think that that is necessary, because it is not in present legislation. Everybody is agreed that it is so far, so good, and its not being in legislation has not led to concern about its existence. Hon. Members have said that it is important that Ministers make things clear in Committee and give reassurances. We feel that the fee will continue to be negotiated nationally. It will have a separate budget from anything provided to PCTs and in that sense there will be no change. For that and other reasons it is not necessary to have such a provision in the Bill. It has not been in such legislation before.
To be absolutely clear on the meat of discussions on the clause, at present all clinicians who carry out NHS sight tests are listed with a PCT and all contractors must be listed with each PCT where they provide the service. As now, contractors will be able to have an NHS contract provided that they meet national criteria subject to local decisions on matters such as quality of service and the inspection of premises and equipment. National standards will be inspected locally before a provider can go on the list to have a GOS contract. There could be questions about whether a national contract would ensure quality assurance, because we would have to think about who would carry out that necessary local inspection. I hope that that makes it clear that we are not suggesting a huge leap from where we are now. The debate has allowed us to explore how much more clear and transparent the arrangements should be. A number of members of the Committee are clearly on a learning curve in that respect.
The hon. Member for Westbury raised the question of the payment of the fees and mentioned the NHS Business Services Authority. The Business Services Authority has an established work programme and, clearly, any additions need to be carefully considered. As part of a general discussion we are talking about whether claims for optical payments should be processed by the Business Services Authority, but it would not be appropriate to specify such activity before reaching a conclusion. We are considering the issues alongside our review of which other services could be provided in the community outside of hospitals, closer to where people live.
In drafting the proposal we followed the model provided by medical and dental legislation in relation to essential, additional and enhanced services; the terms appear in regulations but not in primary legislation. We have a duty nationally in what we pay for and provide centrally, which has been the subject of much debate today. The clauses provide the opportunity for PCTs to consider other services that they think are appropriate for the communities that they serve, and it is important that is recognised in the Bill. Alongside that there are discussions on the White Paper on services outside hospital and our review, with the profession and others, of the opportunities and potential for other services to be provided locally, which PCTs might wish to contract.
During the break between our sittings, the hon. Member for South Cambridgeshire (Mr. Lansley) asked me whether a large contractor with a chain of contracts around the country could suggest to PCTs that he would provide other services without any change in the fee. The hon. Gentleman asked whether the PCT would look kindly on that contractor, rather than adding other contractors who could provide on-site services to the list. I hope that reflects the scenario that the hon. Gentleman put to me. My advice is that we would not endorse such a tactic and we would seek to ensure that regulations would prevent that from happening. I was told that it could be illegal, but the hon. Gentleman should not quote me on that; the lawyers will have to look at it. We would not want a large organisation to enter into such an arrangement, which would cause difficulties.
There is no major national chemist or fast-food chain in my mining constituency, or even a major supermarket or bookshop, as hon. Members will see for themselves if they come to Don Valley. Community pharmacies and local stores are very important in such constituencies, as my hon. Friend the Member for Barnsley, East and Mexborough (Jeff Ennis) recognises. Many services are amply provided for in some constituencies but in others they do not exist. Therefore, smaller stores and community services are vital, whether or not the health services are involved.
I hope that I have covered most of the points raised, including those mentioned by the hon. Member for South Cambridgeshire. I understand that the sight test will, as now, be provided under the Sight Testing (Examination and Prescription) (No. 2) Regulations 1989. The hon. Gentleman asked whether that could be extended beyond the sight test itself. The powers of the new primary ophthalmic services are to provide services beyond sight tests but there will continue to be an ongoing discussion about the delivery of primary health care and the range of services that can be offered at any one time and—I shall be honest with the Committee—the amount of services that the public purse can afford to provide in a complete package. These discussions will be ongoing in the same way as in 1999 when we decided to extend the free sight test to those over 60, which was removed under the previous Conservative Administration.
I am particularly pleased to intervene, because it seems that the Minister was about to make a political point, and we would not want that, would we? As a matter of interest, do the sight test regulations include the need to screen for, say, glaucoma? Perhaps I should know the answer, but I do not. This is important, because most opticians carry out such a test as a matter of course, and I suspect that the Minister, who has referred to the sight test regulations, will know whether the regulations in fact include that need.
I do not think that they do, but I am happy to write to the Committee on exactly what the sight test regulations cover, if that would be helpful. I think that that is all.
On the tariff point, I do not know whether payment by results would apply to these services, but some issues are totally separate. The dental contract, for example, is totally different from the payment by results service. My hon. Friend the Minister of State, Department of Health, has been very forward-looking in getting dentists away from the old system of payment simply for drill and fill rather than considering people's real dental health needs. That will contribute hugely to preventing unnecessary drilling and filling, and will give dentists more of an opportunity to provide a full service. I will write to the hon. Gentleman about that if there are any issues that connect those two areas.
Question put and agreed to.
Clause 35 ordered to stand part of the Bill.