NATIONAL HEALTH SERVICE CHARGES

HC Deb 05 February 1976 vol 904 cc1555-76

10.15 p.m.

Dr. Gerard Vaughan (Reading, South)

I beg to move, That an humble Address be presented to Her Majesty, praying that the National Health Service (Charges) Amendment Regulations 1975 (S.I., 1975, No. 1945), dated 27th November 1975, a copy of which was laid before this House on 5th December, be annulled.

Mr. Speaker

I understand that it will be for the general convenience of the House to take at the same time the following motions: That an humble Address be presented to Her Majesty, praying that the National Health Service (Remission of Charges) Amendment (No. 2) Regulations 1975 (S.I., 1975, No. 1946), dated 27th November 1975, a copy of which was laid before this House on 5th December, be annulled. That an humble Address be presented to Her Majesty, praying that the National Health Service (Charges) (Scotland) Amendment Regulations 1975 (S.I., 1975, No. 1987), dated 1st December 1975, a copy of which was laid before this House on 11th December, be annulled. That an humble Address be presented to Her Majesty, praying that the National Health Service (Remission of Charges) (Scotland) (Amendment No. 2) Regulations 1975 (S.I., 1975, No. 1988), dated 1st December 1975, a copy of which was laid before this House on 11th December, be annulled.

Dr. Vaughan

I do not intend to go into great detail on these Regulations. We have put down the Prayer to obtain information from the Minister regarding the Government's attitude towards charges generally in the National Health Service. It is not clear from the Government's history and the speeches of Labour Members, including Ministers, what attitude they have towards charges in this area. There is an extraordinary contradiction between what they say and do. It is a matter not of practising what is preached but of preaching one thing and then, in Government, practising something quite different. I saw a sign recently which read "'Do not adjust your mind. There is a fault in reality." That seems to be the message of the Labour Party.

Even on a narrow subject like charges for health care, the Labour Government do not seem able to say and then do the same thing. In 1949 a Labour Government passed the Act allowing charges to be made. In 1951 a Labour Government imposed charges for the first time for dentures and spectacles. At the 1964 General Election the Labour Party, it seems, had no difficulty in saying "Our aim is to provide as rapidly as possible a completely free health service." It depends what is meant by "as rapidly as possible". The reality was quite different from what the Labour Party had been saying.

When Labour left office in 1970, every charge had not only been abolished but was far higher—not a little higher—than in 1964 when Labour took over. The prescription charge was up by 25 per cent., dental treatment was up by 50 per cent. and dentures and spectacles were up by 25 per cent. Labour did exactly the opposite of what it said it would do.

Not surprisingly, as soon as the Labour Government were out of office, out came the pledges again. In 1973 the Labour Party said that it would phase out all National Health Service charges. In February 1974 we heard it again. It was not "phase out" then, but "abolish", suggesting by the use of that word some greater decision and action. A month after the election the Secretary of State, who was here a few moments ago, was in full cry saying "Our goal is a free health service."

In October 1974 the Labour Party manifesto, not in any way disturbed by past actions, stated that a Labour Government would strengthen the provision for dental care"— whatever that means— by freezing the level of dental charges for patients". Then comes the inevitable catch-phrase—to continue the progressive elimination of prescription charges". It was a case of shouting "Onward" while walking backwards. Now we have exactly the opposite of what they said they would do. They are putting up charges yet again.

The Minister should admit that a completely free service is not only undesirable but unrealistic and not in accord with any sensible system of priorities for the National Health Service.

He knows the view of myself and many of my colleagues that some sort of charging system is necessary from the demand point of view and in terms of financial common sense. Will the Minister confirm that the Labour Party's policy of abolishing all charges is an utter and total nonsense and explain why the Labour Party manifesto is Holy Writ when it comes to pay-beds but can be totally ignored on dental and spectacle charges?

What was meant when the official Press hand-out of 20th November described these charges as a "New, improved system of dental and optical charges"? How, on Labour's past policies and statements, can getting an extra £16 million from people be described as an improvement? Perhaps, like Humpty Dumpty, words mean anything the Minister wants them to mean. The improved system is to make patients pay the full cost of dental treatment up to a maximum of £3.50 or, for dentures, £12.

What is the effect of this likely to be on patients? That is what concerns us. The Government are right to put up charges a little. These Regulations are probably right, but will they not mean that people who need a comparatively small amount of treatment—say, one or two fillings—will have to pay more than before and will have a disincentive to go to the dentist? Will these charges be a disincentive to people having regular small services from dentists? The argument is that the deterrent effect for those having a good deal of treatment will be reduced, but the Minister should consider the effect on people having a small amount of treatment. They will have to pay more.

I know that some of the spectacle charges do not apply to children, but will the dental charges discourage children from the joy of attending the dentist? We should bear in mind the British Dental Association's statement that dental decay often occurs in early childhood and the survey by Winter and others in 1971 that 25 per cent. of children between the ages of one and four have at least one decayed tooth needing treatment.

There may also be disincentives for people getting help with spectacles. The main effect of these charges is that the majority of patients who require rela? tively simple lenses will have to pay £2 or £3 more than previously.

I hope that the Minister will tell us his estimate, after taking account of these increased charges, of the total revenue to the NHS from charges in a full year. He may not wish to tell me, but I want to know how this figure is expected to be made up between prescriptions and dental and spectacle charges. I estimate the total for a full year to be about £150 million, but I should be glad if the hon. Gentleman would confirm that figure.

On what will the extra revenue of £16 million which the Minister hopes to raise be spent? I would like to see some of it going towards preventive dentistry and dental education. We also need increased use of dental auxiliaries and, now that we have received the report of the Royal College of Physicians, an extended use of fluorides. The total annual revenue from all these charges will be far in excess of the £38 million which the Government think is essential for the mentally sick but which, they claim, cannot be found for them.

I hope that tonight the Minister will ignore his Left-wing extremists and confirm that these charges are consistent with the Government's real view, which is that they are a necessary element for financing the National Health Service. I hope he will now admit openly and honestly that charges of this kind are here to stay and that it would be totally dishonest for the Labour Party to continue to promise at each General Election that it will reduce or abolish the charges only to do precisely the opposite when it is elected.

10.31 p.m.

Mrs. Lynda Chalker (Wallasey)

I wish to intervene only briefly in the hope of getting an assurance from the Government. I have always been concerned that the high basic rate of charge for dental care, which is what these Statutory Instruments amount to, will deter regular check-ups by young people. We have been trying so hard to instil this habit in young people in the hope that they will carry the practice through into adulthood. I am concerned that we should extend—not contract—preventive dentistry. Yet in spite of all the verbiage I have seen in the newspapers and other journals on this subject, we have heard very little from the Government about it.

I am also concerned about the problems of accessibility to dentists and the numbers of dentists in certain areas. In 1974 there was a great deal of talk about the shortages of dentists. Before the second General Election of that year the Government were even talking about what they would do to meet this shortage. We heard that there would be additional remuneration. In August 1974 it was stated in The Guardian that newly-qualified dentists in selected areas would be offered rent-free, fully-equipped surgeries and guaranteed minimum salaries. This issue seems to have gone very quiet since then and since a number of Questions were put down to the Secretary of State on the subject.

We have no idea whether the Government's promises of 1974 held good once they had managed to win the second General Election that year. Perhaps we may be told by the Under-Secretary this evening. Do the Government intend to make sure that city centres which have been short of dentists will get special attention in order to cut back, by preventive dentistry, on the enormous wastage incurred on giving dental care to people suffering from dental caries?

It amazed me to read in the British Dental Health Federation paper "Preventive Dentistry" that dental health was second only to mental ill health as the most costly single item in the nation's health budget. That expenditure is out of all proportion to the amount of attention we devote to providing preventive care. We have always accepted that it would be right to encourage and promote the health, particularly the dental health, of the public. Numerous Government speakers have said so on public platforms. But what we have heard and what we have seen in terms of firm decisions and a timetable of when it might be carried through are two entirely different matters. If we are to save money, which we know we desperately need to do, we have to set about preventing dental caries through greater efficiency and greater availability of treatment at an early age when decay begins its attack.

Already my hon. Friend the Member for Reading, South (Dr. Vaughan) has mentioned the 25 per cent. of pre-school age children, aged one to four, who have an average of more than one decayed tooth each. But when it comes to 75 per cent. of five-year-olds having at least one decayed, missing or filled tooth—I mean missing by extraction, and not missing because it has been pulled out for a sixpence under the pillow—we know that right at the bottom of the scale we are still not getting through in terms of preventive dentistry.

When we consider the adult figures of 19.2 decayed, missing or filled teeth, we begin to see how the size of the problem in regard to secondary teeth is one to which we pay little attention in a preventive way as compared with other aspects of health care.

Whatever the Government may or may not do, information about diet and the effect of sugars on teeth can be made more widely known at little expense. We know that eating habits are ingrained in many sections of our population. However, if we can educate people about all the other free services which the present Government wish to give away—I do not quarrel with them about some of these services—we ought also to be able to give out information about what happens if one does not take care of one's teeth.

It is indicative of the way that the present Government are thinking that they are setting a minimum charge which is high and which is likely to stop the regular preventive visits to the dentist, yet they are doing nothing, on the other hand, to increase health education in relation to teeth. There are a number of things that we need, and not only health education techniques.

After a lot of thought, I have decided that I shall put my vote to adding or allowing people to add a very small part of fluoride to our water, because that can prevent the bill that we now face by reducing caries in teeth by one-half. To those who say "No, it should not be mass medication"—a topic that we often hear about—I say that there are other ways. There are mouth washes. There are tablets. Some school dental clinics and some dentists now give their patients regular mouth washes with 0.5 per cent. sodium fluoride in them. This undoubtedly, as is proved by research, is helping to reduce the amount of dental caries.

When I first started in the research world I was amazed to learn that back in 1952 less than 50 per cent. of our population used toothpaste. I could hardly believe it. I regret to say that north of the border the figure was even worse. Things have improved. We have gone some way to increasing dental care, but by no means have we gone the distance that is required if we are to prevent the cost of £140 million per annum that we spend on dental care—not preventive care, but all the fillings and extractions and all the "nasties". It is not just a question of the money. We also lose 600,000 working days a year just through bad teeth.

Therefore, if we are really to change our system of charge, the Minister should look again at the question whether there should not be a minimum charge for regular check-ups, because it is through regular check-ups that much of the decay is prevented. It is also prevented through regular teeth-cleaning—which his Department could promote if it had the will rather than just the word—and through regular descaling of teeth. By these means we should be preventing what has become a major scandal in wasted money, because we do not prevent the decay when it sets in.

This may seem a small subject. However, it involves a large amount of money and a lot of pain and misery. Therefore, when the Under-Secretary considers altering charges he should also consider his wider responsibility for prevention.

10.35 p.m.

Mr. David Penhaligon (Truro)

I am grateful for the opportunity to talk about dentistry but it will not take long since my knowledge of the subject is limited.

The hon. Member for Reading, South (Dr. Vaughan) used some amusing phrases. He said that the Government were going forward while moving backwards. However, he only adds to my confusion by moving the annulment of an Order with which he agreed. But I am new to the House, and no doubt I shall understand its peculiarities before long. I understand that those of us who would like to vote against the Order will now not be able to do so. Perhaps someone can explain that to me later.

The Liberal Party has always been against charges to any recipient of medical services. The hon. Member for Reading, South apparently considers the so-called lunatic Left of the Labour Party to be the only people who now agree with us on that. If so, then on this subject at least I say, more power to their elbow. I only wish a few more had been here to force a vote.

What is the net income from these charges, after allowing for administration, which must be substantial? Has there ever been an investigation of the long-term effect of charges? Like many others, I have long criticised these charges because they put people off seeking help for a minor problem and wait until the treatment is extensive and therefore expensive. I have always suspected that the only saving achieved by charges is in putting people off seeking the initial medical services when required. If that is the reason for them, the Government should admit it. If it is not, I should like to know what the reason is.

The hon. Member for Wallasey (Mrs. Chalker) drew attention to the variation in dental services between different regions. I recently asked the Minister for the number of people per dentist in each of the area health authorities. I was staggered at the discrepancies—from just under 2,500 in London, which seems to have the best services in just about everything, to 5,000 in the Trent area. In my area and the North-East, the figure was 4,500. In the worst areas, are people's teeth in a terrible state? Are there enormous queues for even minimum attention? If not, what do London dentists do for a living?

I understand that the Order also covers National Health Service lenses. An optician in my constituency considers it foolish to recommend anything but toughened lenses for the children he sees. He considers that there is a substantial risk of injury from the non-toughened glasses, and contends that there is a reduction in risk by having toughened glasses. He assures me—I do not know whether it is true—that toughened glasses result in a charge to my constituents. Will the Minister comment on that?

I only wish there were some way in which we could cast a vote at the end of the debate, but I suspect that this will not be possible.

10.41 p.m.

Mr. George Thompson (Galloway)

The hon. Member for Wallasey (Mrs. Chalker) pointed out that the position in Scotland concerning dental health and care is worse than that on this side of the border, and I am afraid we have to admit that that is the case. We have poor teeth, and a larger number of people left with no teeth earlier in life than in other parts of the United Kingdom. I am quite sure that wrong diet and an addiction to sugar and starchy materials play a role here.

I do not know much about the use of toothpaste in the past, but when I was in the Army I had a friend from the Glasgow area who cleaned his teeth—I suppose very effectively—with carbolic soap. I believe that Scout masters are sometimes addicted to ordering their charges to wash out their mouths with carbolic soap when they have used language considered to be against the Scout law. People probably cleaned their teeth in the past, though perhaps not in the right way.

However, the real problem, on which I should like to have some assurance from the Under-Secretary, is how he assesses the chances of this increase in charges discouraging younger people from having the dental treatment that they should have as soon as they need it. This is the real problem.

There are people who, after they leave school, simply stop having dental treatment at all. This was certainly true in the past. Their view was that the sooner all the teeth were bad and and out and a denture inserted, the better off they would be. I am sure that this view has changed, because I have observed among ordinary working people at home a far stronger desire to go to the dentist now than in the past. I suppose this is partly because many of them, through their trade unions, have agreements which allow them to have time off for treatment. I should like to have an assurance on this point from the Under-Secretary.

10.43 p.m.

Mr. David Crouch (Canterbury)

We are talking about dentistry and dentists, and the problem of dental care and the care of the teeth. I should like to ask the Minister, as we pray against this Statutory instrument, whether he is satisfied that the dentists have a sufficiently strong voice in the new reorganisation of the National Health Service.

As the Minister knows, I serve on the South-East Thames Regional Health Authority, and I have heard concern expressed—certainly within England—that the dentist's voice is very much less powerful than that of the ordinary doctor.

My hon. Friend the Member for Wallasey (Mrs. Chalker) made an extremely interesting, constructive and thoughtful speech, lifting the problem of the care of the teeth and the preventive care of the teeth out of the general medical problem.

As the Minister seeks—as I am sure he will—to answer some of the questions, will he also state whether he is satisfied that concern about the care of teeth is being expressed administratively at district level, area level, regional level, and in his Department?

I know that dentists feel that their particular specialised knowledge of this aspect of medical care is sometimes rather low in the queue of priorities, and that their voice is overpowered by the voice of the medical man and the medical administrator in our reorganised health service.

In my own region we are rather lucky, in that the senior medical administrator of the region, the regional medical administrator, is qualified both as a medical man and as a dentist. We are rather fortunate in that he qualified, as my hon. Friend did, at Guy's. We are lucky to have a man with a dual qualification, and in this region that satisfies both sides of the profession. It means that the administration is taking care of these two aspects of our health care.

My hon. Friend the Member for Wallasey mentioned a figure of £140 million for dental care. I think that that must be the figure for England and Wales. She said that it was a small sum, and it is small compared to the total vote of the National Health Service, which is approaching £4,000 million. I should, therefore, like to think that the voice of the dentist is heard and that what we have said tonight will be taken into account by the Minister and reflected upon after the debate. I hope that the views that have been expressed will be covered in a note from the Department to the authorities to be aware that there is this concern among all those connected with the administration of the Service both in this House and on the various boards of management.

I agree with what was said by my hon. Friend the Member for Reading, South (Dr. Vaughan), as I do with the thoughtful remarks of my hon. Friend the Member for Wallasey. I hope that the Minister will take on board what I have said about the absorption of the dentists' voice in the administration of the Health Service.

10.47 p.m.

Mr. Robert Boscawen (Wells)

I should like the Minister to explain these increases very carefully, because I consider them to be pretty high. Fortunately, we do not often have increases in charges for dentures and optical equipment, but when we do the increases are apt to be fairly steep. My researches show that the increase in 1971 amounted to 121 per cent. What is the average increase, particularly for dentures, on this occasion? It is a fairly steep increase, particularly where a full set of dentures is required.

Reality has come through to the Government. They have to make these increases to give them room for manoeuvre in other parts of the Service. I recall in 1971, early in my career in the House, listening to the debate in which my Government sought to increase the charges, not because we wished to do so but for no reason other than to enable the then Secretary of State to do more in other directions within the Service.

We were pilloried at that time. We were told that the increases would be resisted by the then Opposition with all their strength. The right hon Lady the Secretary of State for Prices and Consumer Protection called it "death by a thousand cuts" of the National Health Service, and she went on to pillory us for the method of proportional charging for dentures. I should like to know the method of proportional charging for dentures on this occasion.

I hope that we shall hear from the Government a fairly contrite explanation of these increases. I hope, too, that the Government are being realistic and not overcharging for teeth, because I feel that many people will find these charges particularly hard to meet at this time.

10.49 p.m.

The Under-Secretary of State for Health and Social Security (Mr. Michael 'Welcher)

This has been a valuable and interesting debate. Although it was rather short, important questions have been raised, and we have heard some curious anecdotes such as the one about the use of carbolic soap for cleaning teeth.

The hon. Member for Reading, South (Dr. Vaughan), who opened the debate, normally makes constructive speeches, and his speech tonight was constructive. Even if there were one or two lapses, he asked a number of reasonable questions, and I shall try to give him a number of reasonable answers.

I am rather surprised that the Opposition should pray against the Regulations, because there is no question but that the changes we have made are generally welcomed by the relevant professions. They have ended the damaging system introduced by the Conservatives, which not only led to an automatic increase in dental charges as costs rose but in certain cases, such as when patients needed extensive dental treatment, led to what can only be regarded as a real disincentive to treatment.

The hon. Gentleman made a mistake, and the hon. Member for Galloway (Mr. Thompson) made the same mistake, when he suggested that there might be a disincentive for children. Dental treatment for children up to the age of 21 is exempt from the charges.

I also take issue with the hon. Gentleman on his general philosophy about charges, in one very important respect. The hon. Gentleman said that he believed in the necessity for charges, and not only from the financial point of view. That is an important consideration for any Government who are pressed financially as much as we are, and as much as most Governments normally are. But the hon. Gentleman also said that charges were needed from the demand point of view. That seems to suggest that charges are imposed with the aim of rationing the meeting of need. We in the Labour Party have resolutely set our face against that. If what the hon. Gentleman said were correct, there is a real difference of philosophy, because we do not believe in a system of charges. It is still our clear intention to move away from them when economic forces permit.

The decision to increase the revenue from dental and optical charges at the same time as we revert to what we regard as a much fairer system of charging was not easy for the Government, because charges of any kind in the National Health Service are alien to our philosophy. But we faced an extremely difficult problem of soaring costs, with substantial increases both in the cost of supplies and labour and in the remuneration of dentists and opticians at a time of rapid inflation. Over the past two years, for example, the overall effect has been to increase the items on the dental scale of fees by an average of more than 50 per cent. Unless some contribution were obtained from increased patients' charges, the extra costs could be found only at the expense of other Darts of the National Health Service, at a time when we face the greatest financial stringency.

The gross cost of the National Health Service in Great Britain has increased from just over £3 billion in 1973–74 to an estimated £5 billion in 1975–76. The combined gross cost of the general dental and ophthalmic services has increased by 66 per cent, over the same two-year period. Those are masive increases.

When the Labour Government came to office in 1974 we decided against any further increases in lens charges, despite increases in costs. We also froze the charges for spectacle frames. In October 1974, when dentists' fees rose by 23 per cent., we froze dental charges at the 1973 level, and we thus protected all patients from any increases in charges for more than a year. Even though it has not been possible to maintain the "freeze "against the rapid rate of inflation that we have seen recently, the proposed increases in what are only occasional items of expenditure are still modest.

I was asked by the hon. Member for Reading, South to give the reason for the increase in charges and how the charges are determined. Our purpose is simply to restore the proportion of the yield from charges to the total costs of services to that which obtained when dental charges were frozen in 1974, that is, 18 per cent. of the cost of the dental services, leaving aside the cost of sight

tests which have always been free to the patient, and 54 per cent. of the cost of ophthalmic services. The increase in dental charges imposed under the Order is £8 million to £9 million a year and in optical charges it is £5 million to £6 million a year. The total revenue, taking into account these estimated increases, for optical and dental charges in a full year is about £66 million, which is substantially short of the figure which the hon. Gentleman mentioned.

Dr. Vaughan

I was asking for the total revenue charges for the whole of the National Health Service and what proportion of those charges came from prescription charges, dental charges and ophthalmic charges.

Mr. Meacher

I shall certainly give the hon. Gentleman the figures for prescription charges in writing. Tonight we are debating optical and dental charges and I have given the total revenue, including the increase under the Regulations, which is about £66 million. I have indicated the purpose for which we believe this increase is required.

The hon. Member for Wallasey (Mrs. Chalker) made a number of comments about the purposes for which she would like to see the increased revenues used. Although I am at one with her on most of her objectives, I want to comment on one or two matters. She mentioned the scheme which has been announced to encourage dentists in certain areas because the distribution of dentists is far from uniform throughout the country. Dentists are independent contractors under the family practitioner committees and, as such, they are entirely free in that capacity to accept or decline any patient for National Health Service treatment even in an emergency. Under the present system they cannot be compelled—and I do not suppose that the hon. Lady is recommending any change—to take part in any rota to be on call or other emergency arrangement, or even be directed to practise in any particular part of the country.

We are concerned about this and I assure the hon. Lady that following the report of the working party on the dental services, consultations are progressing at present between the Health Departments and the British Dental Association which are aimed at setting up several experimental emergency services to examine whether such services can be justified. The object is to determine the true extent of the problem by an experiment which can be properly designed and monitored. I can at least give the hon. Lady an assurance that we are concerned about the distribution of dentists and are seeking measures to improve it.

Mrs. Chalker

The question I asked was: what happened to the proposals announced at the end of July 1974 by the Secretary of State in reply to the hon. Member for Wolverhampton, North-East (Mrs. Short)? The Secretary of State said that the Government would provide rent-free fully-equipped centres for dental care in the deprived health areas. That proposal gave hope to the people who were fighting a battle for the deprived areas. Since that promise was given nothing has happened.

Mr. Meacher

As I said, negotiations with the British Dental Association on that scheme are still continuing. I am as concerned as is the hon. Lady that we should find an effective means to improve the distribution of dentists, but a number of complex financial and administrative problems have to be studied. I hope that we shall be able to make an announcement before long.

If the Regulations were to be annulled, as is proposed by the Conservative Party, it would be necessary either to cut expenditure on other parts of the NHS or to raise revenue from the charges in a different way. If we were to revert to the cost-related system introduced in 1971 by the then Conservative Government, it would mean an increase in lens charges of about 100 per cent., making the cheapest single-vision lens about £2.30 and the most expensive single-vision lens a staggering maximunm of £6.40. By contrast, these Regulations provide for one standard charge of £2.25 for a single-vision lens whatever its type or power.

To give the House an independent view, I will quote the judgment of the optical profession as expressed by the Secretary of the British Optical Association in the journal Ophthalmic Optician last November. He said: Cost-related charges"— those introduced by the Conservative Government—

acted unfairly against those most in need clinically, and complicated the administration at both practice and family practitioner committee level, to say nothing of confusing the patient. That was said of the system we are proposing to change tonight. That view shows the desirability of making these changes, quite apart from the cost aspects.

If we were to revert to the Conservative system of dental charges it would mean that all dental charges would increase by an average of 53 per cent., and many patients would have to pay the £10 maximum for a course of treatment. By restoring the system followed by the previous Labour Government, whereby the patient pays the full cost up to a much lower maximum, we ensure that the patient can seek dental treatment in the certain knowledge that he will not have to pay more than £3.50 for a course of treatment, except where dentures are supplied. The Regulations provide a real improvement for those who are most in need of either dental or optical treatment. We have reverted to the flat-rate system of charges in force under the previous Labour Government.

The Government regard health charges in general as entirely alien to the philosophy of a National Health Service which is free at the point of need. If at a time of desperately scarce resources we must have charges, we believe it makes a mockery of the concept of the NHS to impose the highest charges on those most in need of treatment. That was the principle of the 1971 Conservative system. That is why we have always condemned it vigorously and why we have changed it. The Regulations do away with the cost-related approach under which those who needed the most expensive treatment and the highest-powered glasses had to pay most.

For dental treatment we have returned to the system under which the patient pays the full cost—that is, the current authorised fee—but only up to a maximum of £3.50. That compares with the maximum charge under the previous scheme of £10. The charges for the supply of dentures, or a bridge replacing the same number of missing teeth, vary from £5.40 to £6.60, with a maximum charge of £12 per course for more than one denture. Where a course includes both treatment and the supply of denture or dentures, the charge is the total of the cost of treatment, subject to the maximum of £3.50, the appropriate fixed charge for the denture, subject to an overall maximum of £12. That is basically the system we are proposing.

The hon. Member for Wallasey said that people will be discouraged from seeking regular treatment because they will have to pay more for less extensive courses of treatment. I agree that that is the position, but I do not believe it will have the consequence she said. The initial examination is still free. The people who already attend their dentists regularly appreciate the value of regular checks. I do not see any reason to suppose that they will be discouraged by the possibility of paying a little more than previously to ensure that their teeth are kept in good order. On the other hand, patients who require more treatment certainly do not need any kind of monetary disincentive. They do not need to be put off by any fear of escalating cost.

It is not true to say, as some Conservative Members seem to imply, that only people who neglect their teeth need extensive treatment. The patient may have a defect in general health, or there may be a defect in the treatment that is given for a medical condition. Either situation can give rise to caries or gum conditions which require extensive dental treatment. Unlike the scheme introduced by the Conservative Government, the charges embodied in the Regulations will ensure that many unfortunate people, through no fault of their own in many cases, do not have to bear a disproportionate burden of charges. I believe that that is an important improvement.

Mr. Nigel Spearing (Newham, South)

I appreciate the point that my hon. Friend is making about the scheme, but as regards what he said earlier about not being able to compel dentists to work within the National Health Service, is he aware that in East London, where there is a great deal of call upon dental services and where dental facilities are not as extensive as they should be, many dentists who are faced with patients requiring extensive treatment are refusing to take them under the NHS? Those patients are thereby forced to pay very much higher fees than those which my hon. Friend is quoting under the regulations.

Mr. Meacher

I know that my hon. Friend has taken a close and enduring in? terest in these matters in the East End of London. However, the fees that are paid to dentists are reviewed and updated regularly on the recommendation of the Dental Rates Study Group. That body consists of representatives of the dental profession, including practising dentists, and members of the Health Department in equal numbers under an independent chairman. I believe that my hon. Friend will agree that dentists have an important say in what is decided. Therefore, it is difficult to argue that fees should not properly represent what dentists or their representatives believe to be necessary for certain courses of treatment.

The fees that are arrived at—this may be one of the sources of complaint—are an average for a particular item. There may be an element of swings and roundabouts because extra time and cost may be involved in difficult cases which is not necessarily proportionately remunerated. But that has to be seen against the cases which are less time consuming and less costly than the average, which are equally well remunerated. I do not think that there is a case for saying that that is a reason for there not being a suitable level of care in the East End. The matter has to be tackled in other ways and we are in close consultation with the British Dental Association in seeking to improve the situation.

I turn to the optical side of the Regulations. The Regulations provide for three flat-rate charges: a single charge of £2.25 per lens for single-vision lenses—the most popular—instead of the variety of charges ranging from £.1.20 to £3.20 per lens under the previous scheme; and two rates of £4.25 and £5 for bifocal lenses, depending on the type of lens. These compare with previous charges ranging from £2.45 to £3.50 per lens. Here again, we are introducing flat-rate charges for spectacle lenses in place of the Conservative cost-related charges because the latter lose most heavily on points in the most serious eyesight problems.

There is no charge for a sight test or a dental examination, and some items of dental treatment—for example, arrest of bleeding and repairs to dentures—continue to be free.

I turn to exemptions and remissions from charges. I have already said that people up to the age of 21 are entirely exempt. I emphasise that many patients —not only children but those on low incomes, expectant mothers and women who have given birth to a child within the previous 12 months—are wholly exempt from charges. In about 60 per cent. of courses of dental treatment no charges at all are paid by the patient.

In introducing the new charges, we have made a special effort to protect those most in need. The increases in supplementary benefit rates and the doubling of the earnings disregard from £2 to £4, both of which came into effect last November, will ensure that more patients will pay no charges at all or will qualify for help with their charges. To increase even further the numbers who will get this help, we have raised from £1.50 to £2.50 the margin, known as the tolerance margin, above the supplementary benefit level which is taken into account when assessing whether a person can afford to pay charges.

Finally, we have announced that we intend to exempt altogether from optical charges a group of people with special visual needs, namely the registered blind and partially-sighted, many of whom can be helped by spectacles. This exemption cannot take effect immediately because it needs legislation, but I assure the House that we are working out the necessary procedures, in consultation with the profession and others involved, and the necessary legislation will be introduced as soon as possible.

Mr. Penhaligon rose —

Mr. Meacher

I am about to come to the point that the hon. Gentleman mentioned dealing with toughened lenses. These lenses are available under the general ophthalmic services on the payment of an extra charge of about £1 or £2 per lens, depending on type. But if people have a clinical need for such lenses, they can obtain them free of extra charge under a hospital or school eye service. I am referring to the case where there is a clinical need rather than a preference not based on clinical need.

Mr. Penhaligon

I find it difficult to understand the difference. My optician tells me that the clinical reason of which he takes account in deciding whether children should have spectacles with toughened lenses that in childlike play glasses break and there is a strong clinical danger involving substantial damage to eyesight. If the hon. Gentleman does not regard that as a clinical reason, will he say what is? Indeed, in such circumstances could not every child claim toughened glasses?

Mr. Meacher

If the doctor believes that they are clinically necessary and if they are prescribed under the hospital or school eye service, there is exemption from any increase in charge. I hope that those observations meet the hon. Gentleman's point.

Mrs. Chalker

I should like to raise one matter which bears particularly on the observations of the hon. Member for Truro (Mr. Penhaligon). Has the Department examined the saving which could be made by the provision of 80 per cent. hydroscopic lenses in place of the toughened lenses which are obviously dangerous for some children but which are probably better than the normal type of lens? Hydroscopic lenses would cut out the problem and would probably be cheaper. What has the Department done?

Mr. Meacher

The hon. Lady did not warn me that she would ask me about hydroscopic lenses. I shall be only too pleased to make inquiries of the Department as to how far we have examined whether it would be cost-effective to have hydroscopic lenses as opposed to toughened lenses. I assure the hon. Lady that I shall write to her.

In making these charges we have also announced other, long overdue, improvements in the ophthalmic services which I am sure the House will welcome. They are improvements for which the increased revenue from the charges will help to pay.

First of all, as my right hon. Friend the Secretary of State told the House last November, we want to improve the range of spectacle frames which are available under the National Health Service so that patients have a real choice between National Health Service frames and private frames. At present over 50 per cent. of persons obtaining lenses under the National Health Service have them fitted into new private frames, often at considerable expense. This has been for a long time a weakness of the service and we are now taking action to try to remedy it. My right hon. Friend has invited the industry and the profession to discuss together how we can provide a range of attractive, modern frames at reasonable cost under National Health Service arrangements for people who do not want, or cannot afford, to pay high prices privately for attractive good quality frames. I am glad that the hon. Member for Reading, South believes, as we do, that this is a valuable and important initiative.

Secondly, we are making some small but important improvements in the services for children. We propose to add the most popular plastics adult frame to the range of frames which can be supplied free to children. At present the only frames available to children free are wire or wire-ended frames. I am sure that all hon. Members will agree that a great deal of distress is caused to children who feel self-conscious in such frames but whose parents in many cases cannot afford to buy the more attractive frames. We are discussing the timing of necessary adjustments in production with the industry. However, I hope that the frame will be available free to children by the end of this year.

We are also proposing to provide children who have very poor sight needing strong correction with free plastics lenses as an alternative to glass. I think this point will interest the hon. Member for Truro. Glass lenses which incorporate powerful corrections can be very heavy and uncomfortable—these are the so-called pebble lenses. Plastics lenses can provide the same correction but without the disadvantage of weight. We are discussing with the industry how quickly the necessary adjustments in production can be made so that these can be supplied free to children.

In addition, we have removed, as from 1st January this year, the charge made for supplying under the hospital eye service contact lenses to children who have a clinical need for them. A clinical need is a necessary qualification to impose but it should not in any way deprive children who have a real need of them.

Much as we deplore the necessity to levy any charges for National Health Service treatment, a substantial rise in costs could not be contained within the Health Service budget and we, therefore, had to find a means of making these charges in such a way as to distribute them more fairly.

The revised system of charging has been welcomed by the optical profession as a fairer and simpler system of levying charges on patients and of reducing administrative work. The dental profession, which was opposed to the previous cost-related system, has given a cautious welcome to the revised system.

I am convinced that the charges we have introduced, together with the extra provision which I have briefly sketched to protect those on low incomes, will not place an unduly high burden on any patient or group of patients. I believe that people will understand the need in our present economic situation for these charges and that, where they face higher charges for the care of their eyes and teeth, they will be prepared to pay the small increases we feel constrained to impose.

On that basis, I commend the Regulations to the House.

Dr. Vaughan

I beg to ask leave to withdraw the motion.

Motion, by leave, withdrawn.