GENERAL OPHTHALMIC SERVICES AND OPTICAL APPLIANCES

HC Deb 14 April 1988 vol 131 cc397-431

Mr. Robin Cook

I beg to move amendment No. 13, in page 10, line 26, leave out subsections (1) and (2).

Mr. Deputy Speaker (Mr. Harold Walker)

With this it will be convenient to consider the following: Government amendments Nos. 31 and 33.

Amendment No. 14, in page 12, line 44, leave out subsection (4).

Government amendments Nos. 32 and 34.

Mr. Cook

Amendment No. 13 seeks to remove from the Bill the provisions for charges for the eyesight test. There is a degree of common ground between this debate and the debate that we have just concluded about charges for dental examination. I shall take as read the position on the general principles. [Interruption.] I have had occasion to mention that the Tea Rooms in this building are provided for people to gossip and that the Chamber is where we debate important matters. I wonder whether you, Mr. Deputy Speaker, would draw that to the attention of hon. Members.

Mr. Deputy Speaker

The hon. Gentleman is quite correct. Will hon. Members who wish to make conversation do it elsewhere. and will those who remain in the Chamber allow the hon. Gentleman to move his amendment?

Mr. Cook

I am obliged to you, Mr. Deputy Speaker.

There is much common ground between this debate and the one that we have just concluded. I shall take as read the general principles that underlie both debates. The clause provides for another reduction in health services which are free at the time of use. For that reason. it is objectionable. The clause also provides a charge that will discourage people from attending for a screening process. It is being put forward by a Government who proclaim their commitment to preventive medicine. It is impossible to square that paradox.

I shall not rehearse the debate on the general reasons for rejecting the clause. Instead, I shall concentrate on the specific and substantial damage that the measure will cause. First, it is misleading to describe an eyesight test merely as an eyesight test. It involves a full eye examination: an examination of the back of the eye for systemic disease as well as for eyesight. Indeed, the objectives of the examination are laid down in regulations issued by the DHSS. They prescribe the diseases that have to be looked for.

In the previous debate I asked the Secretary of State what evidence had emerged since Second Reading that would support the case that the Government are making for charges. I have to say to the Minister for Health, who I understand is to respond to the debate, that evidence has emerged since Second Reading that is appropriate and relevant to the clause, but it buttresses the powerful case against introducing a charge for such tests.

The first piece of evidence, and perhaps the most powerful, is provided by the survey carried out by the British College of Optometrists. It carried out a survey of 1,500 optometrists in the first week of January this year. That is a massive survey and it covered an enormous sample 70,000 eye examinations. From that survey it emerged that in the five working days of that week 6.1 per cent. of those examined were referred to a general practitioner or hospital for further examination for a medical condition. A total of 2.5 per cent. of examinations resulted in a notification to a general practitioner of a medical condition which the optometrists believed should be reported. In other words, 8.6 per cent. of the sample revealed some sort of medical condition, not immediately related to eyesight, that was worthy of further medical investigation.

To put that figure into perspective we should bear in mind that 12 million eye examinations take place each year. If 8.6 per cent. of those examinations require referral, that means that over 1 million people are referred to their doctor or hospital for a further medical investigation as a result of the routine screening.

Some of the medical conditions discovered during eye examinations are serious. The two most common to emerge in the survey were cataracts and glaucoma. Both those conditions can result in total blindness. One can be operated upon and the other can be treated, but both can be irreversible if left untreated for too long. It is an interesting fact that the majority of cases of glaucoma are detected not by GPs but by optometrists using the routine NHS eye examination.

It is perverse to suggest that that screening operation is likely to be done better by GPs who remain free; or who remain free for as long as the hon. Member for Pembroke (Mr. Bennett) is content to allow them to do so. It is not the case at present that GPs carry out that screening better than optometrists, and it is not likely to be the case in the future, as, by and large, GPs do not have the same experience as optometrists and are unlikely to have the equipment that is available to optometrists. The examination is vital and can result in the identification of serious medical conditions.

The question that remains is whether the charges in this case will deter people from coming forward for examination and preventive screening. I believe that they will. On this occasion I am happy to say that I have substantial and influential supporters for my contention that charges for eye examination will deter people from coming forward.

First, I should like to pray in aid the Prime Minister. She wrote a letter in June 1980 to an optometrist in London concerning the then proposal by the Government to charge for eye examinations. That proposal was abandoned at the time. The letter stated: The Government have decided to drop this proposal in response to strong representations that such a charge in a service that has a preventive function would be wrong in principle and could deter patients from seeking professional advice. Those are the words of the Prime Minister, the senior Minister of the Government, who now, eight years later, are coming forward with a charge for that very examination.

The question that I have to ask the Minister—I hope that he will be able to answer it—is why did the Prime Minister consider that charges for eye examinations in 1980 would be a deterrent, when in 1988 we are told that they will not be a deterrent?

A suggestion was made by a spokesperson from Downing street which was quoted in the newspaper that revealed the Prime Minister's letter. It said: Most people are better off nowadays. If people spend so much on luxuries, surely they can afford £10 for an eye test. Let us examine that proposition and see whether it convinces us. I believe that the charges in this case will be an even greater deterrent than the charge for dental examinations. They will be a greater deterrent for three reasons. First, such examinations are likely to be more expensive. Optometrists are currently paid £9.30 for every eye examination. If they are to recoup that income in full, they will have to set a charge of about £9 or £10. Therefore, the charge will be substantially greater than that currently proposed for dental examinations.

Secondly, the client group to whom the examination is most relevant is the elderly. As one grows old, one's eyes degenerate. The optometrists survey to which I referred earlier discovered that half of all referrals were people over the age of 60. Yet the exemptions for people who have an income too low to pay are drawn in such a limited fashion that, of the 9 million pensioners in Britain, 6.5 million will not qualify for exemption. Those 6.5 million will have to find the full £10 for the examination, although they may well be the people who have just lost £10 of housing benefit as a result of the changes that we have seen this month.

Thirdly, those who require eye examinations are likely to require them periodically. As one gets older and one's eyes start to fail, one needs to have one's spectacles adjusted regularly. Such people should have their eyes tested regularly to ensure that their spectacles are appropriate for the condition of their eyes. The elderly, who are least likely to be able to afford the £10 charge, are in the invidious position of having to go more often and pay that charge.

Diabetics are another group of people who ought to go regularly for an eye examination. To their credit, officials at the DHSS are seeking to encourage greater screening for diabetic retinopathy. This condition can result in blindness among diabetics. It requires regular examination to ensure that retinopathy is not developing from the diabetic condition. Diabetics are not exempt from the £10 charge. They will have to pay that charge every time they present themselves for examination. There is every reason why every hon. Member would wish a diabetic to attend for a full eye examination as often as possible because with that condition, as with others, sight can be retained by treatment, but that treatment can be successful only if there is an early enough intervention.

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I stress that the decision whether to go for that examination will inevitably be taken by people who have no idea at the time how important that examination might be to them. Of course, any member of the public, however poor, who believed that the examination could result in his or her sight being saved would scrape together, borrow,, find, beg or steal the £10 to pay for that examination, but: it will not appear that way to many people. Many of them will not be aware until too late that, by passing up the chance of an examination because they did not want to pay £10, they have seriously jeopardised their eyesight—perhaps worse.

My hon. Friend the Member for Fife, Central (Mr. McLeish)—who will seek to catch your eye, Mr. Deputy Speaker, in the course of this debate—has with him the details of a constituent who developed a problem with her eyes, went along for a full eye examination and, as a result. was referred immediately to the local hospital and was treated within days for secondary cancer from breast cancer. She had no idea, as she considered whether she would go for an eye examination, that her life was at risk and would be saved by that examination. Indeed, she has, said that she is doubtful whether she would have gone for the examination at that time had she been obliged to pay £10 for it.

How many more people will respond perfectly rationally to the price signal, will not present themselves for an examination and will suffer the tragedy of discovering when they do eventually go for an examination that it is too late for their life or too late for their sight?

There is an irony here, and it is that the Government are expecting individuals to show prudence by investing, and investing early, in an eye examination and spending a substantial sum as a preventive health measure. They expect individuals who may not be in a position to make an informed decision to make that prudent investment. Yet the Government themselves are not prepared to show a similar prudence by investing in a free screening facility that is excellent value and of proven quality.

I want to conclude by looking at what good value it is. It is reckoned that the cost of blindness to the state is some £3,500 per person per annum. That figure was last used by Professor Yudkin in the British Medical Journal. That is a substantial sum per annum. I hope that my hon. Friends will forgive me if I put a cash figure on such a deep personal tragedy as the loss of sight, with all that that implies for the loss of witness of life and the life that then has to be lived in darkness, but that may be the best way to get through to the Treasury Bench.

Taking the cost of screening as £9.30 per patient, we can calculate that the total cost of screening 1,000 patients would be £9,300. If the survey to which I referred at the beginning of this speech provides an accurate guide—and it was certainly a very comprehensive, large-scale survey—the examination of 1,000 patients would produce 60 patients to be referred to doctors or hospitals for conditions such as glaucoma, cataract and retina—

Mr. Galbraith

Retinopathy.

Mr. Cook

I am most grateful. I knew that my hon.

Friend would be a great asset in this debate. I rest on his guidance. Possibly he could check Hansard for me when I have concluded my speech.

Of those 60 cases, many of them with serious conditions that threaten blindness, it is far too modest to suspect that one in 10 would have their sight preserved as a result of that referral to medical attention. If only six were saved from going blind as a result of that examination, the annual saving to the state would be £21,000—over double the cost of paying for the screening of the 1,000 patients in the first place. It is a bargain. Only a Government obsessed with counting the petty cash of public expenditure would be prepared to put such a bargain at risk. This is the last chance that the House of Commons has to save the Government from their own folly. Many hon. Gentlemen on the Government Back Benches know that it is folly. It needs only a sufficient number of them to show the vision and courage to join us in saving the Government from their own folly and saving an excellent free Health Service for our constituents.

Dame Jill Knight (Birmingham, Edgbaston)

It will be no surprise to my hon. and right hon. Friends on the Front Bench that I feel impelled to speak in this debate. Indeed, I have travelled many thousands of miles to do so. I rise particularly to support amendment No. 13.

I can understand the need to find more money for the Health Service, even if it is to be moved to be spent in a different part of the Health Service. There are many needs, and I acknowledge them all and would wish money to be spent. So I can understand the Government's view that they should find more money for the Health Service. But the proposition now before us will cost the Health Service far more that it will save. I can understand the Government's view that primary medical care, on which they are to spend a lot of these dubious savings, as I understand it, and preventive medicine, are of great importance. But clause 10 as it stands will be a powerful instrument against early diagnosis of a number of diseases, and early diagnosis is surely the core of preventive medicine.

I can understand the soundness of the economic theory that people who can afford to pay for medical aids should be asked to do so, but such people are already paying for glasses and other appliances, such as contact lenses, that they may need. We are dealing not with the principle of their paying for something that they need but with whether they should pay for the check to find out whether they need it. It has always been a fundamental concept of the National Health Service that medical examinations must be free. If those examinations indicate that some appliance, such as glasses, contact lenses or dentures, as we were discussing earlier, are necessary for the patient, fair enough; we have conceded that they should be paid for. Most people who originally thought, happily and with misty eyes, looking through rose-coloured spectacles, that we could make health service free have accepted that if appliances are needed they must be paid for. But the argument advanced in the earlier debate by my hon. Friend the Member for Pembroke (Mr. Bennett) was absolutely shot to pieces by hon. Members on both sides of the House, because if we once say that the principle of free testing for anything is to be breached, what is the reason for stopping anywhere? That is what worries us.

I have no doubt whatsoever that a very substantial number of people will he deterred from having their eyes tested. On the Government's figures, a quarter of pensioners will be eligible for free tests. That leaves three quarters who are not eligible. I have to admit that I have never accepted the theory that every gentleman over 65 or lady over 60 is automatically a pauper; there are some who are very wealthy, but I do not think that three quarters of pensioners fall into the category. Many are on a very difficult line between managing and not managing and for them that £10—and we know that it has to be at least £10—is going to be a very powerful deterrent. And, as the hon. Member for Livingston (Mr. Cook) said, this comes just at the time when they need to have their eyes examined more often than at any other time in their life. They will find it very difficult to work out where the £10 is to come from out of their budget. After all, 78 per cent. of people between the ages of 78 and 85 have major eye diseases and obviously need to have their eyes tested very regularly. I am worried about those pensioners.

I am also worried about the parents of growing children. The children will be safeguarded, as they should be, but I am talking about the parents themselves. I have read all the debates and nothing I have seen has convinced me that I am wrong when I say that parents will put the needs of their children above paying for their own eye tests. I would have done it myself. We all would, if we were short of money when our children were growing up. A parent will say, "I may not need to have my eyes tested. They may be all right. It will cost £10 and Johnny needs a new winter coat." That is where the money will go. The parents will not go to have their eyes checked and early signs of the onslaught of such things as heart disease, cancer and diabetes will be missed.

It is all right for hon. Members. We are in receipt of a salary and we do not mind paying. We will pay even though we do not like the principle of the free test being eroded. I am making a plea not for us but for the people who will find it extremely difficult to pay. Because the early signs of some diseases will he missed, the whole operation will cost far more than it will save in the long run because it is much more expensive to treat these things at a later stage.

Nothing I have yet heard convinces me that I am wrong when I warn about the implications of the clause for ophthalmic departments in hospitals. This is serious. A person will go to his doctor and say "I am having headaches." The doctor will tell the patient that his eyes should be tested and that he can go to the high street and pay the optometrist £10 or £11, or he can go to the hospital and have it done for nothing. It stands to reason that people who find it difficult to get the money together will go to the hospital. There is no way that the Government can tell doctors that they are not to send these patients to hospital. That is not on the cards. It cannot be done. People have a right to have their eyes tested in hospital.

Again I come to the point about the extra cost of the proposal. Whereas the Government have been paying optometrists £10 to test a person's eyes, if the person goes to a London hospital it will cost at least £35 for each test. I am using a conservative estimate. Some people have given me higher figures, but at the moment in London the Government pay £10 to the optometrist and will pay £35 at least to the hospital. Outside London the cost is slightly less. As I understand it, it is in excess of £27 or £28. That is the lowest figure I have heard. I am trying to be fair, but that means that we are bound to pay more in the long run.

Again, the most conservative estimate of the current waiting list for care in the eye department of a hospital is nine months. If this goes through, I warn the House that we shall all get shoals of letters from constituents complaining that they have to wait two or three years to have an eye test. Crowding in hospitals has led the people in charge of some hospital eye departments to write to some of us already. Their worries about the extra people who will come to their departments are severe. We should understand this.

I read with interest some of the speeches made in Committee. On 16 February my right hon. Friend the Minister for Health said: Regular checks of, for example, blood pressure or urine samples arc a far more reliable way of diagnosing the conditions—especially diabetes …—than is the occasional eye test. In any event,"— he said cheerfully— people go to their opticians much less frequently, if at all, than they go to their doctors."—[Official Report, Standing Committee A, 16 February 1988; c. 733.] I wonder whether that is so. I was interested to see that my right hon. Friend was challenged to produce figures but I did not see any figures.

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If a person goes for an eye test, something positive is done. Many of the people who go to their doctors and who, I am sure, are in the lists of patient attendances may be going simply to have their inoculations updated. That counts as a visit to the doctor. So do a host of other things. Many people need glasses from the time they are children. We all know children who have to wear glasses. Those people have to go regularly to the optician throughout their life. Do they really go more often to the doctor than to the optician? I have tried to remember, and I think that the only time that I have been to my doctor in the last 20 years has been to have a jab, whereas I have been to the optician to have my eyes tested far more often. People who wear glasses for reading or for distance vision have to go regularly to the optician.

My right hon. Friend's statement was mirrored by my hon. Friend the Parliamentary Under-Secretary of State for Health and Social Security in a most important contribution: We would not seek to deny that opticians may detect signs of diabetes or hypertension during the sight test,"— that is magnanimous because they do it all the time— but primary responsibility for the diagnosis and treatment of all medical conditions rests with the patient's GP. The GP has a better opportunity to detect such conditions than the optician has. Doctors normally see about three quarters of the patients on their list within a 12-month period. I wonder whether those are the same patients or whether some of them have gone along to have jabs, as I did.

It stretches my credulity to impossible lengths to imagine that if someone takes a child with, for example, measles to the doctor there will automatically be a test for diabetes. What doctor takes a urine sample for a wrenched ankle, a broken arm, a tummy upset or flu? There will be many complaints from general practitioners if they have to carry out blood and urine tests on patients in those categories. It is unrealistic to think that doctors would do that.

Later in Committee, my hon. Friend the Parliamentary Under-Secretary of State said: We wish to use our funds to encourage GPs to do that kind of screening more effectively in future."—[Official Report, Standing Committee A, 16 February 1988; c. 751–752.] The GP should not be asked to do all this screening at the same time as he is dealing with a condition which has nothing to do with eyes. The optometrist, who has trained for three or four years, and sometimes more, is looking at the eyes alone. Because he knows what he is doing he can detect early signs of trouble. The doctor will not do that if he is examining another part of the patient's body.

The idea that doctors should test eyes should be exploded here and now. It is different if the doctor is an ophthalmic medical practitioner, but the ordinary GP knows less about eyes than the trained optometrist. That may come as a shock and surprise to the Government, but it is true. The ordinary GP has not specialised in eyes because he has many other parts of the body to look after. If the Government suggest to the British Medical Association that all GPs should carry out this screening free instead of it being done by optometrists, there will be a loud outcry. Doctors are not trained to do it. If they are going to do the same job as optometrists they will have to train, and to buy a great deal of very expensive equipment. I gather that it costs at least between £3,000 and £4,000. Doctors do not have that equipment in surgeries at present. If a doctor is told that he must test eyes it will be no more practical than the suggeston that charges will have to be made for hospital eye checks. It is not realistic to suggest that.

I resent, on behalf of trained optometrists, the suggestion that they do a really rather unimportant job. They provide us with a cheap and very cost-effective means of doing a very good job on eyes. We should not write them down. After all, only about five years ago, the Government introduced the rule that optometrists should do refractions and give the prescription to the patient. who could then trot off down the road to a boutique and get some snazzy glasses at reasonable cost. At one stroke, one means of an optician earning money was cut off.

Here we have cut off his other source of income. The Government will say, "We are not stopping him asking for money." But suppose that patients do not turn up or a prescription is taken elsewhere, or, as happens in very many cases, the test does not reveal any need for spectacles? Who will pay then? I think it is unrealistic to say, first, that an optician may or may not get his money from spectacles, and then to say that he may get money from patients, but not from the Government, to do his job of testing eyes.

Clearly, the Government do not want to have late diagnosis of disease when it could be done early. Obviously, the Government do not want to pour out more money on the Health Service, yet get a worse service for it. And surely the Government are not intending to flood hospitals with patients who could be dealt with perfectly well elsewhere, for a great deal less money. I cannot believe that the Government need to place new money worries on people who already have problems making ends meet. Those who need to have regular tests will have problems.

In the previous debate, the hon. Member for Pembroke said that £3 was the cost of a few cigarettes. We are talking about at least £10, so I wonder what new figures we shall hear. But let nobody in the House be in doubt but that people will find it very difficult to pay to have their eyes tested. I do not believe that my right hon. Friends are guilty of all these things: of intending to flood hospitals, or to pour out money only to get a worse service. Nor do I believe that they are trying to place money worries on people. Yet that is exactly what they are doing. All those points will be covered by clause 10, unless it is amended.

I cannot quite understand why this matter has not been thought through, or why difficulties about its implementation have not been foreseen. Should the clause be accepted, we shall have a great deal of trouble on our hands. I shall be first in the Lobby to vote for amendment No. 13 tonight.

Mr. Barry Jones

I am glad to follow the hon. Member for Birmingham, Edgbaston (Dame J. Knight). The hon. Lady's well-informed speech was supported by considerable experience, and has been of much help to the House in considering this serious matter.

I should like to follow the hon. Lady by drawing to the attention of hon. and right hon. Members a letter that I have received from a consultant physician at Chester royal infirmary. The hospital, just the other side of the Welsh border, cares for many of my constituents. The consultant says: While I welcome many of the initiatives, for example, retirement of GPs at the age of 70, I am on the other hand very concerned about the plans for introduction of a charge for an NHS sight test with opticians. He went on: It was reported in The Times on 26 November 1987 that charges for dental examinations and sight tests would raise £170 million for 'development of the Health Service' and the 'promotion of better health'. Such a statement is a strange paradox when the major thrust of the White Paper is towards preventive medicine to provide better health care. He says: Eye disease due to diabetes has to be detected before development of symptoms…to enable provision of effective treatment. Strenuous efforts are being made to provide such screening and yet the hospital service can only cope with, at best, around 50 per cent. of such patients at risk of losing their vision. Most general practitioners declare that they do not have the necessary expertise to carry out such a task.

That was a central point of the hon. Member for Edgbaston's contribution. The consultant emphasised it strongly. He continued: Opticians are therefore ideally placed to carry out this task. It was therefore unfortunate that on the morning of 25 November 1987 I was invited to speak to the local optical committee and received their enthusiastic support for opticians in the area in carrying out screening for diabetic eye disease. Later the very same day such plans were effectively shattered by the proposed introduction of a charge for sight testing. He goes on to say: Hopefully such charges will not be introduced but if this should happen I would like to make a plea for an exemption from a sight testing charge for patients with diabetes. Obviously this will result in other patients with as yet undiagnosed conditions…for instance glaucoma and high blood pressure, going undetected with inevitable serious consequences on occasions. That consultant is not embroiled in the party political scene, but he felt so strongly that he made this case to me by letter, which I have also put to Ministers.

One principle is undeniable. Free sight testing is a cheap and effective method of preventive medicine. If a charge is introduced, I believe that the White Paper's emphasis on preventive health care will be undermined, as other hon. Members have said in relation to dental charges. The Government's stance in the White Paper will be contradicted. The proposed measure will not help any of my constituents.

I say to the Secretary of State and his Ministers that their proposals to put a charge on eye tests is a serious error of judgment. I also advise them that it will damage the Government politically. It puts them in a very unfavourable light at a time when they are struggling on various political fronts. The measure debated today is far from helpful, even in the interests of the long-term life of the Government. It is also morally wrong to put a charge on eye tests a month after massive Budget handouts were given to the richest in our society. This is an unjust proposal and I hope that the Government will think again.

Mr. Sims

In the course of our earlier debate, Mr. Deputy Speaker, several of my hon. Friends said that they would not seek to catch your eye in this debate because they felt that the arguments were much the same. I apologise for rising again, but I hope that I shall not be unduly repetitious. Indeed, some of the arguments are much the same, except that in this instance they are rather stronger than those put forward in the case of dental health.

As the hon. Member for Alyn and Deeside (Mr. Jones) said, the thrust of the Government's health policy is prevention. Indeed, the White Paper is specifically entitled, "Promoting Better Health", and the third of the Government's six objectives laid out in the foreword to the documents reads: to promote health and prevent illness. The proposals to make charges for dental and eye checks seem incompatible with those admirable aims.

I agree with the hon. Member for Alyn and Deeside that the proposals seem politically inept. The controversy that they have aroused has diverted attention from the many good points in the White Paper and the Bill. It is unfortunate that we have been diverted by those two issues.

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The value of an eye test is not disputed. Anyone who read the material provided to us by the British College of Ophthalmic Opticians (Optometrists) will have learned what is involved in an eye test from the, examination of the skin surrounding the eye to the eye surface and the retina. If hon. Members had had the opportunity, as I have, of seeing a detailed examination being carried out by the college, they would have been most impressed, as I was, by its scope and detail and what it can detect. There is ample evidence that a wide range of problems which merit reference to a specialist can be revealed by a test—not only glaucoma and cataract, but symptoms of other problems such as diabetes and hypertension.

As a result of an eye test, it was discovered that a member of my family was suffering from hypertension, which is what you, Mr. Speaker, and I would call high blood pressure. The condition was treated and is under control, but had it not been revealed by the test the consequences might have been serious.

My right hon. Friend the Minister will argue that by withdrawing free tests we are saving money which can be spent elsewhere. I suspect that he will also point out that we are not imposing a charge in the Bill but are simply enabling optometrists to levy one if they wish. Various figures have been suggested; £10 is a popular one. I had my eyes tested only a month or two ago and I spent 30 or 40 minutes with a well-qualified gentleman who used expensive and sophisticated equipment. At the end of the examination I said to him, "Have I had £10-worth?", to which he replied, "You have had about £25-worth," and I believe that he is right.

Whatever the figure, the question is: will such a charge be a deterrent? As I said earlier, any charge, particularly of this sort of magnitude, is bound to deter, especially elderly people on smal incomes—the very people who most need a test.

Would money be saved by this measure? In the short term it would, but in the long term certainly not. The extra cost to the NHS of treating some of the conditions to which I have referred which will have been allowed to develop but which could have been detected earlier by an eye test will be enormous and far greater than for dental matters.

I shall not embarrass the Minister by voicing my assessment of his qualities, but he is wrong on this issue. I shall vote for amendment No. 13 to remove this power from the Bill. It will undoubtedly be said by the media and in the Whips' Office that I have voted against the Government. Perhaps in response I can read a brief quotation: Our policies rest on six principles: First, we will give greater emphasis to the prevention of avoidable illness and the promotion of good health—to make the NHS more truly a health service and not merely a sickness service. My hon. Friends will recognise those words from our party's election manifesto, on which the Minister, I and others fought and won the general election. I supported that policy then, and I shall support it tonight with my vote.

Mr. D. N. Campbell-Savours (Workington)

I feel sad about what is happening in this Chamber tonight. The condition of glaucoma appears to be genetically transmitted within my family, so it helps to concentrate my mind on precisely what we are debating here this evening. When my grandmother died it was not from that condition, but it went with her to the grave. I remember well her final years and what it meant in my family, and I cannot understand why the Government wish to press on in this way.

We on the Labour Benches cannot claim any monopoly of compassion and in the context of objectively debating these matters it would be wrong to do so. I cannot understand what thought processes go through Ministers' minds when they conclude that this is in the public interest and, indeed, would safeguard the position of those who may ultimately find that they have this condition.

As my hon. Friend the Member for Linlithgow (Mr. Dalyell) said to me earlier, this goes against everything that he has ever stood for, and I understand exactly what he means. I sense that many Conservative Members who, recognising that none of us can claim a monopoly of compassion, also wish to say that tonight, but they may feel from a sense of loyalty that they are required to vote with the Government. Yet they are not in the Chamber and will not hear this debate. They will walk into the Lobby and support the Government. The Minister knows the antagonism that the measure is creating and the strong feelings that many of us have and must contain.

Some weeks ago I wrote to the Minister responsible, Lord Skelmersdale. Indeed, I wrote to the Secretary of State the other day and added a footnote in my hand, saying that this was wrong and that he misunderstood what the debate was about. My letter to Lord Skelmersdale included a letter from a consultant at the West Cumberland hospital, and the Minister replied, trying to reassure me and the consultant of the merit of the Government's position. I sent the consultant ophthalmic surgeon, Mr. Cubey, the Minister's letter and Mr. Cubey replied: I am writing again so soon because I am sure that you will be interested to know that already within three days of having received your letter enclosing Lord Skelmersdale's views, I am able to refute those views categorically by a concrete example. I have examined for the first time today a 73 year old man who is a constituent of yours. He had not seen an optician for many years but felt that he should perhaps have some reading glasses and therefore consulted an optician just two weeks ago. The optician found in him signs of early glaucoma of which the patient was totally unaware and which were totally unrelated to his reasons for seeking the optician's help. The optician advised the man's General Practitioner that he should be referred to Hospital, and I saw him at the Workington Infirmary this morning. I confirmed that he has early glaucoma and I have started him on treatment aimed at preserving his sight. I asked the patient whether, if he had thought that he would have to pay a fee of £10 for his sight test by the optician"— I presume that that is if he were not going in for glasses— he would have been deterred from consulting the optician. His reply was unequivocal. He said that in those circumstances he would not have consulted the optician.

That is an admission that someone would not have consulted an optician because of the charge. The assumption made was that the charge would be £10. I have discussed this with my hon. Friends. Indeed, the hon. Member for Chislehurst (Mr. Sims) referred to a completely different figure. We are now talking not about £10 but about £20, £25 or even £30. Does the Minister accept that if such charges are introduced they will act as a disincentive?

The letter continues: It is therefore clear that in those circumstances his glaucoma would have gone undetected for a considerable time"—

that is an assumption; it might not be true, but I think that it could be in this context— with irretrievable damage to his sight.

That person is a 73-year-old man.

The letter continues: I asked the patient if he would agree to me writing to you about the details of his case".

The letter goes on to comment on matters of personal detail and then states: I have quoted this case in some detail in order to demonstrate the false assumptions made by Lord Skelmersdale. It is clear from this case, and this could be multipled many times over in this constituency alone, that Mr. Pitts Crick's fears about the detection of glaucoma are not groundless. The 'primary purpose of the NHS sight test' may indeed have always been 'to establish if a person needed glasses and if so to what prescription', but an essential purpose of it also is the detection of eye diseases or abnormalities—indeed opticians expose themselves to litigation if they fail to detect these. It may well be 'that the Government is doing nothing to change the way sight tests are actually conducted', but the proposed restriction of free NHS sight testing will reduce the number of sight tests conducted and hence the number of cases in which for example early glaucoma is detected. Lord Skelmersdale apparently believes that it 'need not be so' that people would be 'deterred from seeking sight tests on cost grounds'. Here is one clear example of such deterrence. People on low incomes may be deterred by ignorance or by the complexities of having to claim exemption from the sight testing fee. The recommendations that 'anybody with health worries should in any case consult their family doctor' misses the point altogether, which is that glaucoma, for example, is symptomless until quite advanced, and therefore the sufferer has no cause for concern about it and no indication that he should consult his family doctor until an optician recommends this as a result of his NHS sight test. A consultant ophthalmic surgeon is telling me that what is being done is wrong and is pointing to the dangers. Surely that must influence ministerial judgment.

I turn to another aspect of the matter. I understand that a court case is going on. I believe that it relates to the British Ophthalmic Lens Manufacturers' and Distributors' Association. I have not done my homework in this area, but I have been informed of it tonight. I understand that it has brought some action, which may be sub judice so I cannot talk about the merits—but perhaps I am wrong—about the right of persons who sell spectacles to sell them without a full eye test. I know that there are shops around the country—I am told that there is one near my constituency in Whitehaven—where a shopkeeper sells spectacles without a formal eye test. It seems that a person enters the shop, looks at a card on the wall and then, based on the identification of certain letters, is able to establish what kind of spectacles are required, and proceeds to purchase them.

7.45 pm

I advise the Minister that persons such as the gentleman to whom Mr. Cubey referred in his letter could enter such a shop—perhaps the Minister could clarify this because I should like to know what the position is—

The Minister for Health (Mr. Tony Newton)

rose—

Mr. Campbell-Savours

Perhaps I could finish the point.—and buy his spectacles without having undergone a full eye test, thus slipping through the net for establishing whether glaucoma exists. If that is the case, Ministers must make it clear during tonight's debate.

Mr. Newton

As the hon. Gentleman will realise, I am not aware at the moment of a court case such as he has described, but as he has suggested that there may be such a case, I must obviously choose my words cautiously. I understand that the provisions in the legislation that introduced the voucher scheme were that spectacles can only be provided against a recent prescription, by which is meant a prescription which would entail an eye examination less than two years old.

Mr. Hayes

Perhaps I can assist the hon. Gentleman. I am not aware of any court case but I have been lobbied and know that many hon. Members of all parties have been lobbied by a company whose name I shall not mention, which wants to sell glasses in shops without a proper eye test. I feel that that is dangerous.

Mr. Campbell-Savours

I am sure that the Department's officials will follow up what I am saying tonight to find out whether what I have said has any foundation. I was informed of this just one hour ago by the principal optician in West Cumberland who told me of the existence of this retailer. Perhaps there is a case in the European court—it might not be—but he has referred to an action in some court. I am sure that advice is now being taken from civil servants. The matter should be clarified during tonight's debate.

The second issue that I want to raise is the question of what pensioners will do. As I understand it, the hon. Member for Birmingham, Edgbaston (Dame J. Knight) referred to the fact that three quarters of pensioners would not be entitled to the voucher—

Mr. Newton

In view of what the hon. Gentleman has said, it would be sensible for me to clear up the matter straight away. What I had asked for from my officials was what I said on precisely this point in Committee. I repeat it: The law is that spectacles can be sold against a prescription that is up to two years old. There is scope for argument about whether two years or some other period is right, but there must obviously be some such provision."—[Official Report, Standing Committee A, 11 February 1988; c. 660.]

I then repeated the fact that it is not lawfully possible to sell spectacles other than under those provisions.

Mr. Campbell-Savours

The firm that gave me the information this evening is Philip Heal of Workington. I am sure that officials will wish to follow that up.

As I was saying, three quarters of pensioners would not necessarily be supported in the payment of the charges. Pensioners are a group of people particularly susceptible to the condition of glaucoma. I should have thought that detection of the condition is very much dependent on their regular visits to opticians to secure a test. If the charge is not to be £10, if it is to be perhaps £15, £20 or £25 because opticians would know that they are not likely to be selling spectacles, and if a hospital is some distance from where elderly people live—as is the case in parts of my constituency—and with their problems with the resources that they retain, they may well visit opticians less frequently to secure that test.

Unless the Minister can give an absolute guarantee to the House tonight that pensioners will secure tests as regularly as they have done in recent years, he has absolutely no right to press the provision on the House because not to give that guarantee is to accept that pensioners will become a more exposed group of people.

Finally. I am sure that the Secretary of State is listening to what I am saying and I advise him that I am not speaking out of any sense of unreasonable criticism of his position. Yesterday he had a very difficult day in the House. We all understand why, and we do not necessarily blame him. These are collective decisions taken by the Cabinet, and he had to sell a brief to the Commons, a very difficult brief indeed to sell. But there comes a time in life when one must realise that what one is doing is not necessarily correct. He knows that in the event that this is pushed to a Division tonight he will win—and he will win because people will vote who have not heard this debate and who may well not have considered this matter in as great a depth as many of us over the past few months, nor corresponded as much with others as some of us have done.

The Secretary of State is in a position not to press this tonight. He is in a position to accept the tenor of the debate, based on the expression of very strong opinions on this subject. In the light of what happened yesterday, I ask him genuinely to reconsider the position. We have but minutes before the Division. Unless he makes some concession, this amendment will not go through. If so, the damage will be done and it will be he who is held responsible. I am sure that he would not wish to carry that responsibility for the rest of his political life.

Sir Philip Goodhart (Beckenham)

My hon. Friends the Members for Birmingham, Edgbaston (Dame J. Knight) and for Chislehurst (Mr. Sims) have made powerful speeches with which I wholly agree. I wish to add only two brief points.

The first relates to road safety. There has recently been much discussion about bringing daylight saving time in this country into line with that in Europe, and the Royal Society for the Prevention of Accidents has argued powefully that the extension of daylight saving, so that we have lighter evenings, will prevent thousands of accidents on the roads, since many drivers with slightly defective eyesight find it particularly difficult to see at dusk and become accident-prone. In the interests of road safety, we ought to encourage more drivers to take eye tests more regularly, and anything that prevents this is a small step in the wrong direction.

Secondly, it is plain that my right hon. Friend the Secretary of State for Social Services, for whom I have the greatest admiration, needs some money and some excuse to get off the hook on which he has impaled himself. I believe that the European Court of Human Rights has provided us with both an excuse and some additional funds. We have argued in the past year in front of the European Court that value added tax should not be charged on opticians' dispensing fees. We lost that case and, as a result, some £25 million of extra money will be flowing into the Treasury from opticians.

We did not want that decision from the European Court. We can, in practice, set it aside by reducing, even by eliminating, the charges proposed. I hope that my right hon. Friend will take this excuse and change his mind.

Mr. Ieuan Wyn Jones (Ynys Môn)

My first duty is to congratulate the hon. Lady the Member for Birmingham, Edgbaston (Dame J. Knight) on her considered speech, which she delivered with conviction. The House should ponder carefully what she had to say, and the Government should act on her good advice.

In the few brief minutes that I would like to detain the House, I wish to address my remarks to the effect which these changes, particularly the imposition of eye test charges, will have on pensioners. The Federation of Ophthalmic and Dispensing Opticians estimates that over 6 million pensioners will no longer be eligible for free tests under the National Health Service; and, according to its estimates, that is at least two thirds of all pensioners. As the House has already heard, a recent survey of people over 70 in an inner-city area showed that only 50 per cent. had had their sight tested in the previous two years. What we ought to be doing is persuading more pensioners to attend for tests rather than dissuading them because the tests will have to be paid for.

A survey by the British College of Optometrists shows that over half the referrals for treatment or further investigation were in the over-60 age group, particularly for glaucoma, cataracts and certain other conditions. Elderly people are often insufficiently motivated to seek help, and tend to regard deteriorating eyesight as inevitable. So they need particular encouragement and support.

We know that it is the elderly in our society who place the greatest demand on our Health Service. The over-65 age group and particularly now the increasing number of over-75s need more medical treatment proportionately than any other age group. Advances in medicine have enabled people to live longer but we have not really begun to cope with the resulting increase in demand on resources.

Hon. Members on both sides agree that we should treat our elderly people with honour, with respect and with compassion, so that they can enjoy their twilight years without the added burden of worrying about the cost of their health.

The Government will no doubt ask, as did the hon. Member for Pembroke (Mr. Bennett) in the earlier debate on dental charges, what is a few pounds for a test? Pensioners have fared badly in recent years, and I would like to give an example. A fairly typical pensioner in my constituency will have modest savings; she will be on a state pension; she will have a heart condition; and she will have failing eyesight. If the hon. Member for Pembroke were present for this part of the debate, I would tell him that she would be insulted if anyone were to say that she touched drink or sullied her lips with a cigarette, and she thinks that videos are luxuries for rich people. So we are talking about ordinary pensioners.

In 1987, the local health authority in the county of Gwynedd, because of pressure on the ambulance service, stopped transporting patients to routine hospital clinics. So my constituent, who lives on her own 20 miles from the district hospital, had to cancel her heart test because she could not afford the taxi fares to attend the local hospital, and there is insufficient public transport in our area. Earlier this month that constituent also lost her entitlement to housing benefit, so immediately became worse off to the tune of £7 per week. If this Bill is enacted, she will budget her income and find that she cannot afford the eye test that she desperately needs.

What the Government must consider is the cumulative effect of these changes in health provision and housing benefit. It is not simply a case of a £10 test for eyes or a £3 test for teeth: it is the cumulative effect, the punishing effect, on their budgets. I am sure that right hon. and hon. Members in all parts of the House will support me when I ask the Government to reconsider this cumulative effect of their policies on not only my constituents but the constituents of every hon. Member. I have illustrated the reality of living as a pensioner on a tight budget. That is why I and other hon. Members appeal to the Government for a change of heart on this issue.

8 pm

Mr. Peter Fry (Wellingborough)

I have not yet intervened during the debate, although I did so on Second Reading when my right hon. Friend the Secretary of State was speaking.

This matter was eloquently raised by my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight). It has caused me and many Conservative Members considerable concern. The case has been well made about the problems of people being deterred from having their eyes tested. I do not want, therefore, to go over that argument again. I shall do what the Secretary of State asked us to do in the previous debate about charges for dental checks—put the proposal in context. First, I shall put it into its financial context.

In the last debate, my hon. Friend the Member for Great Yarmouth (Mr. Carttiss) asked why charges were necessary. We all know why they are necessary—my right hon. and hon. Friends on the Front Bench could not get money from the Treasury to make the increases that they wanted in the family practitioner service. The only way in which they could obtain an agreement was to introduce charges. We know the realities of power and how they work, but that does not make it right. If every £1 milllion that were spent would endanger the economic well-being of the country, I could understand that argument, but we know that the reverse is the case. There is amply money to provide for what the Government want to do with the family practitioner service without making these charges.

The great danger is that when the Bill is enacted it will be remembered not for the hundreds of millions of pounds that have been put into the family practitioner service but as the Act that introduced charges for eyes tests. That is the wrong king of epitaph for the Bill.

The second matter that I should like to discuss follows the speech of the hon. Member for Ynys Môn (Mr. Jones). There is a danger that the Government have completely misunderstood the problems of many pensioners. I am talking not about pensioners on income support or those who pay income tax, but about the considerable number of pensioners who are in between. That section of our elderly population are being kicked and kicked again at present. They have to pay the extra gas and electricity price increases and the water rates and contribute to their rates. Now they will have to pay £10 to have their eyes tested. That is the context in which this proposal should be judged.

I do not think that my right hon. Friend the Secretary of State is inhumane, and I have the greatest admiration for him. However, he must realise that this proposal, put in the context that I have just outlined, is a dangerous one, which will do great harm and cause much suffering.

Far from furthering the Government's reputation as a Government who care about the nation's health, the Bill will be seen cynically as the one that introduced charges for people who could not afford to pay for eye tests.

As the proposal does not make much financial sense—it has been generally agreed that its long-term costs are likely to be higher than the short-term savings—and as we are seeking to hit again that section of the community that is the most defenceless, and given the political effect of what the Government have done, they should think again. Unless my right hon. Friend the Minister of State can give some heavy assurances, I shall be joining my hon. Friends in the Opposition Lobby.

Mr. Dalyell

It is my experience that Governments should always be aware of the long-term consequences of what they are doing when their supporters who know most about a particular subject decide to speak out against their decisions.

For many years, some of us have listened to the hon. Member for Birmingham, Edgbaston (Dame J. Knight), who, if she will forgive me for saying so, has a deep personal interest in this subject and knows much about it. When she makes such a moving and well-informed speech, please let us appeal to Ministers at least to go to the Chief Secretary to the Treasury and say, "This is the collective view of a serious House of Commons; can you not do something about it?" I was glad that the Chief Secretary to the Treasury was in the Chamber earlier.

I shall ask one question, as I did in the last debate, on dental charges. I am conscious that perhaps I asked not so much the wrong question as the right question wrongly worded. The Secretary of State treated me courteously and I have no complaints. I asked whether the chief medical officer had endorsed the Government's view on dental charges. Further, I should like to ask a different question. Have Sir Donald Acheson and Dr. I. S. Macdonald, who is the chief medical officer in Scotland, given medical advice on this subject? If so, what was the precise nature of the medical advice that they gave? I see that the Secretary of State is saying something to his right hon. Friend the Minister of State, but the House is entitled to hear the factual medical evidence. This matter is not the same as an argument with civil servants. The chief medical officer, as a technical, professional and independent representative, is surely entitled to have his advice made known to hon. Members who are interested; it is a different matter whether it is accepted.

I want to know what has changed. I am grateful to my hon. Friend the Member for Livingston (Mr. Cook) for recollecting some assurances that the right hon. Member for Sutton Coldfield (Mr. Fowler), the then Secretary of State for Social Services, gave. He said: we also believe that the access to a free sight test is important in detecting serious eye disease."—[Official Report, 20 December 1983; Vol. 51, c. 295.]

I am entitled to ask what has changed. That former Conservative Secretary of State took the same view as every Labour and Conservative Minister has since 1945, and he made those remarks in Parliament, in public. What precisely has changed to make the Government alter their view? What has Sir Donald Acheson, in his capacity as a doctor and medical adviser, said? The House is entitled to know.

Mr. Hayes

The hon. Member for Linlithgow (Mr. Dalyell) is so right. What I, my hon. Friends and my constituents cannot understand is that since 1980 the Government's stated policy from the Dispatch Box has been that it would be completely wrong in principle to abolish or remove exemptions for the free sight test. What has changed? The House should be told.

We all know that all that has changed are the bilateral negotiations between the DHSS and the Treasury. Normally I would not wish to intrude on private grief, but this is not private grief, because 6.5 million pensioners will have to pay. Those pensioners are not on income support, and they will not he assisted. We know that pensioners and elderly people must have their eyes tested regularly, because their eyes are changing all the time.

What about diabetics and people with glaucoma? Diabetes is the largest single cause of blindness in people of working age in the United Kingdom, yet we know that 70 per cent. of that blindness could be prevented if only—this is the key—it is diagnosed early. The same applies to glaucoma sufferers. Glaucoma, as the hon. Member for Workington (Mr. Campbell-Savours) movingly told us, causes blindness and death among many. Sixty per cent. of that blindness and suffering could be prevented. The Health and Medicines Bill is a watershed in primary health care, but what are we doing? The answer is the very thing that will act as a deterrent to primary health care and deter people from going to their optometrists and opticians.

This is not only a stupid decision; it is a wrong one. Will any of my hon. Friends support the Government tonight? Will anyone stand up and say that this is a marvellous idea and endorse it wholeheartedly, going through the Division Lobby with a spring in his step? Of course they will not, because they know in their heart of hearts what the reality is. The electorate forgive the Government quite a bit. They forgive us for messing around with their taxes, their jobs and even their rates, but if we start messing about with their health and their eyesight, there will not be much forgiveness for the Government.

I urge my right hon. Friend to think carefully about this decision. Those of my hon. Friends and I who will vote against the proposal will not defeat the Government tonight, but I sincerely hope that we shall give a clear sign elsewhere.

Mr. Henry McLeish (Fife, Central)

During my brief time in the House few issues have seemed to transcend political differences. There are ideological differences about the market, but this is not a discussion about the market—it is about the rights and wrongs of a specific proposal and the impact it will have on millions of people throughout the country, regardless of how they vote. More importantly, it will have an impact on their health.

This charge goes to the heart of preventive health care. Many eloquent speeches by Conservative Members this evening have identified the principles at stake and shown clearly that, if there is a necessity to save money, it will be swamped by the needs for health care provision of people who will not receive this excellent service from opticians when they need it and before certain diseases develop to the point at which much greater and costlier health care is required.

Already this week specific cases have been used—especially yesterday in the social security debate—to highlight what are often distressing practical points. Today, my hon. Friend the Member for Livingston (Mr. Cook) referred to a letter that I had received from one of my constituents. When we deal with subjects that are sensitive and emotional, two or three lines from a letter will often more adequately sum up a case than endless speeches from either Government or Opposition Members.

The letter comes from a Mrs. Celia Ralph, who lives in my constituency: Dear Mr. McLeish, I would like my name to be added to those who are opposing charges being made for eye tests. I count myself very fortunate that I can, in fact, write this letter to you to-day. In mid-July '87 my eyesight changed dramatically. My own doctor could pick up no change in the eye, and he then was going off for a two week holiday. Being quite concerned, and not knowing where to go next, I consulted my optician, who realised that something was terribly wrong. Next day I saw a specialist at the Victoria hospital who diagnosed secondary tumours from breast cancer on both eyes. This is seemingly quite a rare occurrence and all of my doctors at the Western General in Edinburgh had nothing but praise for my optician. I've had radio-therapy and chemo-therapy since, which fortunately has stopped the growth meantime. The question to be asked is, would I have gone to my optician so quickly, if at all, if I had to find £10 for the examination. My visit to him saved not only my eyesight, but my life.

8.15 pm

Many hon. Members on both sides have said tonight that this is a matter of right and wrong, and few issues come down to that. I earnestly appeal to the Minister to take this matter seriously. It is not an ideological issue that we can kick back and forth. This Chamber is a combative forum, and we use it as such to best advantage, but this is a night for quiet reflection on a serious issue. A consensus has emerged from the debate and I sincerely hope that it will be reflected in the Lobbies.

Mr. David Nicholson (Taunton)

This is the first occasion in my short time in the House on which I have found myself seriously at odds with the Government. My late father-in-law, who had regular eye checks, either as a result of an accident or of incompetence, did not have glaucoma diagnosed early enough to save the sight of one eye. He was a conscientious man who would probably not have been deterred by the charges from having tests, although he was on a low income, but I fear that, as other hon. Members have said, hundreds or thousands of people in our constituencies would be deterred.

I wish to quote from a letter from a constituent who has been a strong supporter of our party for many years. Many people in our constituencies and elsewhere have worked hard for our party for many years, but are appalled by this measure. She says: but for regular eye tests my husband's glaucoma would not have been discovered in its early stages. He had no cause to suspect that anything was wrong.

In previous debates and conversations Ministers have emphasised the need for the revenue from these charges. Whatever concessions my right hon. Friend may produce this evening, he cannot go against that requirement in any significant way. I do not see why new resources for the National Health Service—I am not speaking only of inflation-proofing—must come from this source. The British economy is not now, thank God, in the hands of the IMF. We are not in the position of 1976, or even of 1980, when we were over-spent, over-borrowed and over-taxed.

I am something of an iconoclast about the minutiæ of economic theology, but just assuming—and I do not—that the Treasury needs the money, I suggest two ways of meeting the requirement. I do not believe that my right hon. Friend the Minister can make the concessions this evening, but if, as I suspect, the clause runs into trouble in the Upper House, this will give him time to prepare.

One suggestion is a rather crude solution; nevertheless, I commend it for consideration. If Ministers are convinced that opticians need not pass on these charges, why not prohibit them from doing so? At the very least, will my right hon. Friend give a pledge that he will closely monitor opticians' practice, and if, either generally or in areas such as rural areas in which competition is low, they charge £10 or so, will he take powers to prevent that? That would help to diminish my opposition to this measure.

The second alternative was suggested to me by my hon. Friend the Member for Mid-Kent (Mr. Rowe). It is that all holders of current driving licences should be obliged to have a sight test every three years, for which they would be charged the going rate. That would achieve three things. First, there would probably be more sight-testing among such people than there is now, which would be good for preventive medicine and the Treasury's income. Secondly, it would be good for road safety. Thirdly, people in households who own a car could generally be considered—I appreciate that there will be rough justice for some—able to pay. All others, particularly the elderly whose income, health or eyesight did not permit car driving, would have the eye tests free, as they do now.

The clause is symbolic of two tendencies which I fear and regret in present politics. First, there is the view that new resources—new resources in real terms—for the NHS can or should come from the extension of charges. My hon. Friend the Member for Great Yarmouth (Mr. Carttiss) referred to this, and in the previous debate my hon. Friend the Member for Pembroke (Mr. Bennett) obliged us by saying that he believed that there should be charges for visits to GPs. I would never say never to that, but we need carefully to consider going down that route. There was no consideration of or consultation on this measure before it was announced last autumn.

Secondly, almost without intending it, and indeed almost without expecting it, in the past few weeks my party has drifted into a temporarily regressive fiscal regime. I refer to the combined effect of the Budget and some of the social security measures, especially housing benefit, which came into effect on Monday. The elderly, many of whom out of tradition and loyalty are our supporters, are distressed by this temporary situation. I say "temporary" because I believe that my right hon. Friends the Chancellor and the Secretary of State can put those matters right.

This measure is symbolic of that approach, which is why I cannot support it. I regret having to disregard the advice which, no doubt, my right hon. Friend the Minister will offer, but although the voice at the end of the debate will be the gentle and reasonable voice of my right hon. Friend, the hands which have introduced such a discordant measure into this otherwise excellent Bill—a measure that militates against the preventive medicine which the rest of the Bill promotes—have been the hairy old hands of the Treasury.

Mr. Richard Holt (Langbaurgh)

We have had an excellent debate, although I have listened in vain for any words from any part of the House in support of the Government's proposals. I make my short contribution from a special and privileged position in that I am a diabetic and, as such, I speak for many thousands of people who can and will be put at risk if this piece of legislation is passed.

The Government have made a mistake. It is a good Government who can recognise that they have made a mistake and withdraw it before it is too late. In the five years in which I have been a Member I have never spoken or voted against the Government, but this evening I shall, because I feel strongly that diabetics are being done a disservice by the Government's proposals.

It is possible, just possible, that my right hon. Friend the Minister will say that he will make a concession to diabetics, but I put it to him that that is rather like closing the stable door after the horse has bolted. More often than not a person discovers that he is a diabetic as a consequence of his eye tests rather than the other way round. If a person is deflected from having an eye test he does not find out that he is a diabetic until perhaps it is a little too far down the road.

I am lucky; diabetes was detected in good time, so it will not materially affect me during the rest of my life. But many people are not in that lucky position. If they must make—this point has been eloquently put by hon. Members—the choice between buying a pair of shoes for their children and having an eye test, which cannot cost less than £10 and almost certainly will cost a great deal more, they may suffer diabetes with all the attendant consequences.

I am concerned at the principle which the Government have announced and introduced in this way. Yesterday we had another excellent debate on cervical smears. How long will it be before the Government decide that it is a good idea to charge ladies for having cervical smears? When the Government do that, where do we end?

The Government should listen to those who are their most loyal and best supporters on these Back Benches and should not proceed with this piece of nonsense legislation, which will not do the reputation of the Government, the Minister or the Conservative party any good. I urge those Conservative Members who have not heard the whole of the debate not to go slavishly into the Division Lobby to support the Government. I do not regard this as a political issue. It is a conscience issue which should have been given a free vote. I hope that hon. Members will join me in the Opposition Lobby.

Mr. Churchill (Davyhulme)

I and other Conservative Members expressed our grave concern at this proposal when it came before the House on Second Reading in the hope that my right hon. Friend the Secretary of State would see his way to reconsider his ill-advised proposals, which we all realised did not originate from him or from within his Department.

My right hon. Friend the Secretary of State has admitted in a parliamentary reply to me only this week that he can make no estimate of the number of people who are likely no longer to have eye tests because of the imposition of these charges. He has assured the House that in his judgment it will not be a significant number, but none of us can possibly know what will be the drop in take-up of eye tests.

In a matter as serious as this—many of my hon. Friends have explained this to the House and I touched on it on Second Reading—we are talking not just of people's eyesight but of the many diseases that can be detected in time, allowing positive action to be taken to protect the health and sometimes the lives of individuals. I am not prepared to see my constituents' health and lives gambled with in this way. The way in which the Government have tried to bulldoze this measure through is unacceptable, taking no account, as it does, of the strong representations made to them by their hon. Friends.

Mr. Dalyell

The hon. Gentleman said that the proposals did not come from DHSS Ministers. Some of us think that it is unlikely that they came from Treasury Ministers. It is not the Treasury's nature specifically to say, "You shall have such and such measures on eye tests." The Treasury does not operate in that way. From where did the proposals come?

Mr. Churchill

I am afraid that I cannot agree with the hon. Gentleman. I am inclined to think that the Treasury takes a close interest in the budgets of spending Departments. This measure has nothing to do with health but everything to do with the penny-pinching attitude enforced by the Treasury on my right hon. Friend the Secretary of State, and, I regret, accepted by him. It is a mean-spirited measure which is unworthy of the Government. With great regret, because there is so much in the Bill that I applaud, I feel impelled to vote against this measure.

Mr. Newton

I do not think that in response to the question asked by the hon. Member for Linlithgow (Mr. Dalyell) I can add anything to what my right hon. Friend the Secretary of State said in the previous debate on dental charges.

I want to remind the House of the basic position on the Government's proposal. It is not a matter, as the hon. Member for Peckham (Ms. Harman) sought to imply in a debate yesterday, of seeking to abolish NHS sight tests, any more than we abolished help with spectacles some two years ago. The proposal is to confine that test in much the same way as help with spectacle vouchers, in a scheme which I believe is widely recognised to have been successful, to certain groups, including those on low incomes, and to use that money—I say this without any sense of shame—for other purposes in developing what we believe to be more significant aspects of our primary care services, with an even more important prevention role. I shall return to that later.

No less than one third of the population—one person in three—would remain entitled to NHS tests. They would include all children, all members of families on family credit, all those on income support and all those who are registered blind or partially sighted. One in three of the population would remain entitled.

Sir Raymond Gower (Vale of Glamorgan)

Can my right hon. Friend explain the distinction between the exemptions in this case and exemptions in the case of prescription? Would it not take a lot of the sting out of the proposals and answer much of the criticism if those exemptions were extended to eyesight tests?

8.30 pm

Mr. Newton

The distinction goes back a very long way, to the arrangements introduced in relation to spectacles and prescriptions by the Labour Government in 1951 when charges were initially introduced into the Health Service.

It has also been acknowledged—this picks up a point raised by my hon. Friend the Member for Davyhulme (Mr. Churchill) and a number of other hon. Members—that there is no intention to impose a particular charge for tests for those who will no longer be entitled to an NHS test. The hon. Member for Livingston (Mr. Cook) fairly used the figure of £9.30, which is paid to some ophthalmic opticians, although there are others who, for rather curious historical reasons, receive £10. The £10 figure is simply intended to reflect what the DHSS currently pays for a sight test carried out by some of those who do sight tests.

I accept the point made by my hon. Friend the Member for Davyhulme and a number of other hon. Members that we cannot by definition know what, if any, the charge would be for private sight tests in future, because that would be for the market to determine. However, in the light of our experience of the market for spectacles, following the ending of free NHS spectacles and the introduction of vouchers, it seems to me to be overwhelmingly likely that the competition will keep any charge to a modest level.

I am strengthened in that view by the fact that any regular reader of the optical press will find advertisements that offer to pay ophthalmic opticians more for conducting sight tests than the DHSS will pay. One such advertisement offers a fee per capita in excess of £10 per sight test. Another, which relates to Tyne and Wear, Northumberland and County Durham, offers two optometrists a salary package in excess of £35,000, which can include a fully furnished luxury flat, company car, pension and private health insurance, coupled with an excellent working environment in modern, well-equipped practices. A profession that can widely offer such salary packages and offer to pay people for doing sight tests more than they will be reimbursed by the DHSS must contain scope for a considerable amount of downward competitive pressure on some of its activities.

Mr. Churchill

Is my right hon. Friend suggesting that the extravagant salaries and perks to which he has referred are now to be borne largely by pensioners and others who do not qualify for the exemption? Is it not even now possible for the Government to reconsider a blanket exemption for pensioners from the charges, as they are the ones who have to go back again and again for sight tests?

Mr. Newton

I shall say something more about pensioners in a moment or two.

First, however, I acknowledge that much of the debate has turned on the question whether there will be a significant deterrent effect for that part of the population—I emphasise again that it will not be those on the lowest incomes—who would be expected to pay any charge that might be levied. I accept, as I have throughout our debates on the proposals, that that is not a point that I could, or would, dismiss out of hand.

Apart from anything else, it cannot be a matter of certainty; it has to be a matter of judgment based on experience. However, we have highly relevant experience in the form of what has happened in the market for spectacles. The hon. Member for Livingston pressed me to explain why there had been a change in the Government's position of eight years ago. One of the things that has significantly changed since then is that we have introduced a different policy in respect of the NHS spectacles market which has proved to have had a significantly successful effect on the optical market, and we have sought to build in part on that experience.

Mr. Robin Cook

May I press the Minister on the point fairly and pertinently raised by my hon. Friend the Member for Linlithgow (Mr. Dalyell)? My hon. Friend reminded the House that a previous Secretary of State said five years ago that the Government believe that the access to a free sight test is important in detecting serious eye disease."—[Official Report, 20 December 1983; Vol. 51, c. 295.] Will the Minister make it clear to the House whether the medical advice from his chief medical officer varied from the advice received five years ago? Has the chief medical officer of health revised his advice on the basis of experience in spectacles?

Mr. Newton

I cannot add to what my right hon. Friend the Secretary of State said in that respect. In any event, I shall gladly undertake to write to the hon. Gentleman, but I am not in a position, apart from anything else, to be sure of the precise basis on which my right hon. Friend the Secretary of State for Employment, then the Secretary of State for Social Services, made those remarks eight—or was it five?—years ago.

Dame Jill Knight

With the greatest reluctance, I must press my right hon. Friend, because this is a matter of supreme importance, to say whether the advice has changed, or whether the situation has changed. Why has the measure been introduced?

Mr. Newton

I hope and believe that I have already answered that question by reference to the change that was carried through the House which led to the introduction of the NHS spectacle voucher scheme and the ending of the old NHS spectacle regime. That change, which was completed in 1986, has given us significant new experience of the operation of competition in that market and has left us better placed to assess the consequences of the changes that we propose.

Mr. Cormack

My right hon. Friend is replying with his customary courtesy. However, can I press him on this? Is the Government's best and highest medical advice that charging will not be a deterrent and that it will be in everyone's best interests? There should be a simple answer to that question, and my right hon. Friend ought to be able to ascertain that information from a certain quarter during his reply.

Mr. Newton

My right hon. Friend the Secretary of State made clear the chief medical officer's attitude to the proposals in the White Paper as a whole, which seek to develop our primary care services as a whole and which the Government argue will contribute to a significant improvement to the health of the nation as a whole. It is as a whole that it is right for the policies to be considered.

There is one highly significant piece of evidence from our experience of the scheme that has operated in relation to spectacles and spectacle vouchers since July 1986 which enables us to make a judgment about the possible deterrent effects referred to in the debate. According to a survey conducted by the economists advisory group for one of the optical bodies of those who are entitled to vouchers for their spectacles—by definition broadly the same groups as will continue to be entitled to NHS sight tests, including those on the lowest incomes—some three quarters willingly pay significantly more than £10 on average above the voucher values for their spectacles.

When the survey was conducted, the lowest voucher value was just over £14. At that time, people generally paid more than £15 extra on top of that for their spectacles and the sums ranged as high as £20 and more for some of the higher spectacle voucher values. People have willingly been paying significantly more for their spectacles, in addition to the voucher values, than any sum that has been mentioned as a possible charge for eye testing.

Mr. Terence Higgins (Worthing)

My right hon. Friend relies heavily on the comparison with the situation in relation to spectacles, but if we rely on the forces of competition there will be real dangers. At present, the expression "eye test" is rather vague. Much of the debate has centred on the detection of glaucoma and so on. I understand that at present many eye tests do not cover that aspect, because the opticians involved are not capable of doing so. If we rely on the forces of competition, it is likely that the test will consist purely of the eye test, without the extensive medical coverage that is required. Is there not a danger that, as the price is driven down, the quality of the test will deteriorate?

Mr. Newton

I hope that I am not doing my right hon. Friend an injustice, but I think that he may have missed my speech yesterday, when the House agreed to insert new clause 15 with the precise purpose of allowing the Government to take powers to determine the content of the eye test to ensure that an eye examination remains part of the test. In fact, somebody has challenged the need for such an examination to be carried out under the present regime, so the validity of the present situation has been called into question. We have made it clear that we intend to ensure by regulation that the test includes the eye examination to which my right hon. Friend the Member for Worthing (Mr. Higgins) attaches importance.

Mr. Higgins

I understand that at present the eye test does not always include that kind of check, because some opticians do not have the necessary equipment.

Mr. Newton

I shall deal with that point in my comments about diabetics. My right hon. Friend is right in saying that there is a difference of view about what a full examination entails and that at present not all opticians have the necessary equipment to carry out what is known as tonometry, with the result that the necessary pressure tests are not always carried out. That is the present situation. The professional requirements do not necessarily entail carrying out such tests, but I shall return to that point.

I will deal with some of the specific concerns against the background of my judgment that, on the figures that I have given, the alleged deterrent effect is most unlikely to occur. However, I accept that that must be a matter of judgment against the background of experience, and I do not intend to use that judgment as a means of avoiding considerations of the specific concerns expressed in the debate.

With regard to low incomes, I have already said that people on income support or family credit will remain entitled to a free NHS sight test. That group will include, we estimate, a quarter of all pensioners. Indeed, the number will have increased as a result of recent changes in the social security system and in particular the higher pensioner's premium. In low-paid working families, more than 750,000 adults in such families will continue to be entitled to free sight tests. That number is estimated to have grown by nearly 500,000—in other words, it has more that doubled—as a result of the change from family income supplement to family credit. Those are important and significant figures.

In the light of the points made in earlier discussions and in today's debate, we intend to introduce arrangements to provide help for those with incomes just above those qualifying levels. The precise arrangements will need to be worked out, and if necessary we shall seek to amend the Bill in another place to achieve that purpose.

Mr. Fry

How many more pensioners are likely to be covered by the additional relief that my right hon. Friend has just announced?

Mr. Newton

It will be some tens of thousands. As we have not yet been able to work out the details, and as the calculation will involve some complexity in the light of the new arrangements, I cannot give more detail than that.

8.45 pm

We share the concern about glaucoma that has been expressed by Members in all parts of the House. Everyone wishes glaucoma to be detected at a stage when it can be effectively treated. At present, when an optician detects signs of glaucoma, the patient is referred to the family doctor. In almost all cases, confirmation of the diagnosis and subsequent mangement and care are provided by the hospital eye service. That will remain the position. As the debate has made clear, however, the process is broadly opportunistic and covers only people who visit an optician, usually because of some problem with their eyes. By definition, therefore, the symptomless glaucomas which have given most cause for concern in the debate are least likely to he picked up by what is an accidental rather than a systematic screening process.

Where the eye examination involves only ophthoalmoscopy, as my right hon. Friend the Member for Worthing pointed out, the condition may not be detected at the earliest possible stage under the present system. Tonometry and visual field tests can provide earlier detection, but are not always undertaken by opticians. One of the ways in which we shall seek to carry things forward in the light of the resource changes proposed in the White Paper and the Bill is to discuss with the profession which tests should be included in the definition of the eye test with the aim of achieving further improvements in the testing process. I believe that that will help the concerns of the House.

We have also been discussing how to tackle the problem of identifying those at higher risk of suffering glaucoma. As there is a strong hereditary element, people over 40 who are children, brothers or sisters of people with glaucoma are at increased risk of themselves developing the condition. We are therefore considering whether and how—I believe that it should be possible to move in this direction, although it will not be as easy as I should like—if necessary by using additional resources, arrangements can be devised to ensure that, whenever glaucoma is identified in a patient, positive steps are taken to ensure that members of the family who may be at risk are identified and their attention drawn to the need for an eye test. I believe that that would do more to improve real screening for glaucoma in good time than anything in the present arrangements.

As I have said, almost all those who already have or are found to have glaucoma are treated by the hospital eye service, although there may be circumstances in which the doctors managing the case will wish to involve an optician. Free sight tests will therefore be available for patients with glaucoma who are referred to an optician by the doctor.

Diabetes has been mentioned as a special area of concern in perhaps more speeches than any other single issue. There are really two separate issues here. Until I heard certain comments in the debate, I thought that it was common ground that sight testing was neither a sensible nor an effective means of screening for diabetes. In Committee, my hon. Friend the Under-Secretary of State quoted the director of a regional retina service as saying: it is exceptionally rare for diabetes to be detected by the observation of retinopathy in a person who is otherwise not known to be suffering from the disease. The hon. Member for Strathkelvin and Bearsden (Mr. Galbraith), with his own particular medical expertise, intervened in my hon. Friend's speech to say: We have already accepted that the method for diagnosing diabetes and hypertension is not fundoscopic examination of the eye."—[Official Report, Standing Committee A, 16 February 1988; c. 751–2.]

Mr. Galbraith

We also accept that it was a useful addition. It was not a primary method of screening or of diagnosis. Secondly, a regular check-up for diabetics is important in order to look for the retinopathy.

Mr. Newton

I want to say something about that as well. But in relation to retinopathy and hypertension, general practitioners should play a more active role in screening their patients for such conditions, and they should make good arrangements—for example, through regular diabetic or hypertension clinics, which many good general practitioners already do—for their continuing care. That is precisely one of the objectives that we are pursuing in the discussions now taking place with the medical profession about the restructuring of its remuneration and allowances, using the additional resources which the Bill will enable us to make available. I have no doubt that that represents a more effective use of those resources than the maintenance of universal NHS eye tests.

The second issue is the need for regular screening of the eyes of diabetic people, however diagnosed for diabetic retinopathy. The importance of that has already been acknowledged by the Government in the three-year study that is currently being undertaken, and that is due to end next year, to evaluate the most cost-effective way of screening for that condition. We shall, of course, consider what further steps may be appropriate in the light of its results.

Meanwhile, we have listened carefully to what has been said during the discussion on the Bill, including by many of my hon. Friends and others tonight. We recognise that diabetics have a special need for regular eye checks for the detection of retinopathy. Diabetes itself is usually managed by the patient's family doctor or by a clinic if that is desirable. However, some doctors may wish to refer their patients to an optician specifically for those regular eye checks. We wish to support that practice, so we shall make arrangements in the regulations which will provide for free sight tests for diabetics who are referred for an eye check by their GP or clinic. That could potentially benefit some 750,000 people a year.

I hope that those of my right hon. and hon. Friends and others who have spoken in the debate will think that the steps that we have taken in relation to people on low incomes, those with glaucoma and diabetics, constitute a proper and reasonable response to the points that they have raised. They will together reduce the savings which would otherwise have been expected from the measure by some £7 million to £8 million, and, as I have said, extend by at least 750,000 those entitled to NHS sight tests.

I recognise that those steps cannot entirely meet the views of those who argue against the proposals, simply because we are talking about examinations rather than treatment. But to them I have to say that, whether expenditure on health is labelled as prevention, treatment or cure, it is important that we use it to the best effect. Our proposals to redirect some part of the expenditure in this area from its present purpose to others, and in particular to the systematic development of the quality, scope and preventative nature of our family doctor services, will enable us to do more, not less, to promote the heath of the nation.

Mr. Robin Cook

Eight Conservative Back Benchers have spoken in the course of the debate. As it happens, that is exactly the same number as in the previous debate. Those of my hon. Friends who were present at the end of the previous debate will recall that the scoreboard was five out of eight against the Government's proposals and two out of the eight in support of it.

I have to report that, having kept my scoreboard throughout this debate, of the eight Conservative Back Benchers who have spoken, all eight were against the proposal. There was not a speech in the entire debate, until the Minister for Health rose to speak at the Dispatch Box, in support of the proposal for charging for the eye examination. There has not been an intervention in any speech in the course of the debate in support of charges for the eye examination.

This parliamentary debate has been important because it has exposed the fact that this particular proposal cannot be sustained and is supported only by the Minister who came to the Dispatch Box to defend it. Nobody else came to the Chamber to support the proposal tonight. That demonstrates the importance of the Report stage in the examination of Bills. If parliamentary consideration and examination mean anything, this proposal, after the examination and debate that it has received tonight, should be thrown out.

I want to say a few words about what the Minister said in reply to the debate. The intervention in the Minister's speech by his right hon. Friend the Member for Worthing (Mr. Higgins) was well-merited, in that the first half of the Minister's speech based the Government's proposal on their experience with the charges and competition which they have introduced in the spectacles market. That was wholly at variance with the gravamen of the debate that preceded the Minister's reply. The gravamen of that debate was about people who had suffered from serious systematic diseases such as glaucoma, cataracts and diabetes, which is almost irrelevant to whether they require eye tests to determine whether they need spectacles.

To the suggestion that competition may bring down charges, I have to say that it is possible. It is possible that as a result of competition not every optometrist will charge £9.30. It is also possible that, as a result of competition, prices will go up. In America there is competition for this type of eye examination and the prices are very high indeed. Indeed, a Conservative Back Bencher spelt out what remarkably good value the eye examination is for £9.30, with half an hour's time of a highly-qualified technician using extremely expensive equipment. If they were to put a charge on their service that represented the full market cost of that half hour, they would be charging well above £9.30.

Yes, it is possible that competition could bring down charges. Let us suppose that competition is so intense and successful that it halves the charge. We would still be talking about an eye examination charge of £5. Who in this Chamber is prepared to say that that will not be a deterrent to some people who are on the margins? Moreover, it will only halve the charge at the expense of lower income to optometrists from eye examinations. That will have two consequences.

The first consequence is that the optometrist service will contract. It will be centralised in the areas of urban population. I warn Conservative Members that it is their constituents rather than ours who will be likely to suffer most from that withdrawal of services from centres of urban populations.

Secondly, it will inevitably drive optometrists—indeed, the Minister came near to saying that this was the intention of the competition—to look more and more for their income and profit to the sale of spectacles rather than to eye examiniations and the provision of a full examination of the inner eye.

Do hon. Members believe that in that competitive environment in which optometrists are more and more obliged to look for commercial sale of their spectacles that we shall have optometrists who are prepared to take the time, and with the experience and qualifications, to detect the kind of rare case referred to by my hon. Friend the Member for Fife, Central (Mr. McLeish), in which a woman with secondary cancer was diagnosed because she presented herself for an eye examination and whose life was therefore saved?

I am well aware that the House wishes to move to a Division, but I want to return to the telling intervention of my hon. Friend the Member for Linlithgow (Mr. Dalyell). He asked what had been the medical advice offered to the Government by the chief medical officer. We can certainly hear what the advice has been from the House tonight. Every hon. Member who has spoken in the debate has expressed concern about the medical consequences of the charge; the medical consequences of the deterrent effect of that fee being introduced. I find it very difficult indeed to credit that the medical advice that the Government may have received from the chief medical officer could have varied from the advice that the Minister has heard in the House tonight. The Minister said that he relied upon what the Secretary of State said in response to the earlier debate. In response to the earlier debate the Secretary of State said that the chief medical officer had endorsed the White Paper as a whole.

All Opposition Members, at any rate, have experience of putting our names to composite resolutions. We know what that means. Inevitably on every occasion one swallows something that one would dearly have liked to leave out. The question remains: what was the chief medical officer's advice in respect of the charges for eye examinations? What advice did he tender to Ministers on whether such a charge would deter people from turning up? What advice did he offer them on the one screening method which currently produces three times as many diagnoses of glaucoma as any other screening arrangement? The Minister said that he would write to me telling me what that advice was. Unfortunately, that letter will arrive after the Division tonight.

There is a way round that predicament. Frankly, if the Minister was listening to the debate tonight, and if Treasury Ministers were interested in taking the temper of the House of Commons, the response of the Minister would be clear. He would accept the amendment and withdraw the proposal. If the Minister can justify the proposal in a way in which he has been unable to justify it tonight, he can always reintroduce it in the other place. If he is going to say that we must wait until another day to find out what was the medical advice on which the proposal was based, I have to say to him that no self-respecting House of Commons can tolerate that offer. We shall, therefore, press the amendment to a Division and we hope that all hon. Members who have heard the debate and who share our deep trouble and concern about the consequences of the proposal will join us in the Lobby tonight.

Question put, That the amendment be made:—

The House divided: Ayes 206, Noes 280.

Division No. 259]	[9.00 pm
AYES
Abbott, Ms Diane	Churchill, Mr
Adams, Allen (Paisley N)	Clarke, Tom (Monklands W)
Allen, Graham	Clay, Bob
Archer, Rt Hon Peter	Clelland, David
Armstrong, Hilary	Clwyd, Mrs Ann
Ashley, Rt Hon Jack	Cohen, Harry
Banks, Tony (Newham NW)	Cook, Frank (Stockton N)
Barnes, Mrs Rosie (Greenwich)	Cook, Robin (Livingston)
Barron, Kevin	Coombs, Simon (Swindon)
Battle, John	Corbett, Robin
Beckett, Margaret	Corbyn, Jeremy
Bell, Stuart	Cormack, Patrick
Benn, Rt Hon Tony	Cox, Tom
Bennett, A. F. (D'nt'n & R'dish)	Cummings, John
Bermingham, Gerald	Dalyell, Tam
Bidwell, Sydney	Darling, Alistair
Blair, Tony	Davies, Rt Hon Denzil (Llanelli)
Boyes, Roland	Davies, Ron (Caerphilly)
Bradley, Keith	Davis, David (Boothferry)
Bray, Dr Jeremy	Davis, Terry (B'ham Hodge H'l)
Brown, Gordon (D'mline E)	Day, Stephen
Brown, Nicholas (Newcastle E)	Dewar, Donald
Brown, Ron (Edinburgh Leith)	Dixon, Don
Bruce, Malcolm (Gordon)	Dobson, Frank
Buchan, Norman	Doran, Frank
Buckley, George J.	Duffy, A. E. P.
Caborn, Richard	Dunnachie, Jimmy
Campbell, Menzies (Fife NE)	Dunwoody, Hon Mrs Gwyneth
Campbell-Savours, D. N.	Eadie, Alexander
Canavan, Dennis	Eastham, Ken
Carttiss, Michael	Ewing, Mrs Margaret (Moray)
Cartwright, John	Fatchett, Derek
Chapman, Sydney	Fearn, Ronald

Field, Frank (Birkenhead)	Marek, Dr John
Fields, Terry (L'pool B G'n)	Marshall, David (Shettleston)
Fisher, Mark	Marshall, Jim (Leicester S)
Flannery, Martin	Martin, Michael J. (Springburn)
Flynn, Paul	Martlew, Eric
Foot, Rt Hon Michael	Maxwell-Hyslop, Robin
Foster, Derek	Meacher, Michael
Fraser, John	Michie, Bill (Sheffield Heeley)
Fry, Peter	Millan, Rt Hon Bruce
Fyfe, Maria	Mitchell, Austin (G't Grimsby)
Galbraith, Sam	Molyneaux, Rt Hon James
Galloway, George	Moonie, Dr Lewis
Garrett, John (Norwich South)	Morgan, Rhodri
George, Bruce	Morley, Elliott
Godman, Dr Norman A.	Morris, Rt Hon J. (Aberavon)
Golding, Mrs Llin	Mowlam, Marjorie
Goodhart, Sir Philip	Mullin, Chris
Graham, Thomas	Murphy, Paul
Grant, Bernie (Tottenham)	Oakes, Rt Hon Gordon
Griffiths, Nigel (Edinburgh S)	O'Brien, William
Griffiths, Win (Bridgend)	O'Neill, Martin
Grocott, Bruce	Parry, Robert
Hardy, Peter	Patchett, Terry
Harman, Ms Harriet	Peacock, Mrs Elizabeth
Hawkins, Christopher	Pendry, Tom
Hayes, Jerry	Pike, Peter L.
Hayhoe, Rt Hon Sir Barney	Powell, Ray (Ogmore)
Heffer, Eric S.	Prescott, John
Henderson, Doug	Quin, Ms Joyce
Hicks, Robert (Cornwall SE)	Radice, Giles
Hinchliffe, David	Randall, Stuart
Hogg, N. (C'nauld & Kilsyth)	Redmond, Martin
Holt, Richard	Rees, Rt Hon Merlyn
Home Robertson, John	Reid, Dr John
Hood, Jimmy	Richardson, Jo
Howarth, George (Knowsley N)	Roberts, Allan (Bootle)
Howells, Geraint	Robertson, George
Hoyle, Doug	Robinson, Geoffrey
Hughes, John (Coventry NE)	Rogers, Allan
Hughes, Robert (Aberdeen N)	Rooker, Jeff
Hughes, Simon (Southwark)	Ross, Ernie (Dundee W)
Hunt, John (Ravensbourne)	Rowlands, Ted
Illsley, Eric	Ruddock, Joan
John, Brynmor	Sedgemore, Brian
Jones, Barry (Alyn & Deeside)	Sheerman, Barry
Jones, Ieuan (Ynys Môn)	Sheldon, Rt Hon Robert
Jones, Martyn (Clwyd S W)	Shore, Rt Hon Peter
Kennedy, Charles	Sims, Roger
Kilfedder, James	Skinner, Dennis
Kirkwood, Archy	Smith, Andrew (Oxford E)
Knight, Dame Jill (Edgbaston)	Smith, C. (Isl'ton & F'bury)
Knox, David	Soley, Clive
Latham, Michael	Spearing, Nigel
Leadbitter, Ted	Steinberg, Gerry
Leighton, Ron	Stott, Roger
Lewis, Terry	Taylor, Matthew (Truro)
Litherland, Robert	Turner, Dennis
Livsey, Richard	Vaz, Keith
Lloyd, Tony (Stretford)	Wall, Pat
Lofthouse, Geoffrey	Walley, Joan
Loyden, Eddie	Wardell, Gareth (Gower)
McAllion, John	Wareing, Robert N.
McAvoy, Thomas	Welsh, Andrew (Angus E)
McCusker, Harold	Williams, Rt Hon Alan
McFall, John	Williams, Alan W. (Carm'then)
McKelvey, William	Winnick, David
McLeish, Henry	Worthington, Tony
McNamara, Kevin	Young, David (Bolton SE)
McTaggart, Bob
Madden, Max	Tellers for the Ayes:
Madel, David	Mr. Frank Haynes and
Mahon, Mrs Alice	Mr. Allen McKay.

NOES
Aitken, Jonathan	Amos, Alan
Alexander, Richard	Arbuthnot, James
Alison, Rt Hon Michael	Arnold, Jacques (Gravesham)
Allason, Rupert	Arnold, Tom (Hazel Grove)
Amery, Rt Hon Julian	Ashby, David
Amess, David	Aspinwall, Jack

Atkinson, David	Gower, Sir Raymond
Baker, Nicholas (Dorset N)	Grant, Sir Anthony (CambsSW)
Baldry, Tony	Greenway, John (Ryedale)
Banks, Robert (Harrogate)	Griffiths, Sir Eldon (Bury St E')
Batiste, Spencer	Griffiths, Peter (Portsmouth N)
Bellingham, Henry	Grist, Ian
Bennett, Nicholas (Pembroke)	Ground, Patrick
Biggs-Davison, Sir John	Grylls, Michael
Blackburn, Dr John G.	Gummer, Rt Hon John Selwyn
Blaker, Rt Hon Sir Peter	Hamilton, Hon Archie (Epsom)
Body, Sir Richard	Hamilton, Neil (Tatton)
Bonsor, Sir Nicholas	Hampson, Dr Keith
Boswell, Tim	Hanley, Jeremy
Bottomley, Peter	Hargreaves, A. (B'ham H'll Gr')
Bowden, A (Brighton K'pto'n)	Hargreaves, Ken (Hyndburn)
Bowden, Gerald (Dulwich)	Harris, David
Bowis, John	Hayward, Robert
Boyson, Rt Hon Dr Sir Rhodes	Heathcoat-Amory, David
Braine, Rt Hon Sir Bernard	Heddle, John
Brandon-Bravo, Martin	Heseltine, Rt Hon Michael
Brazier, Julian	Hind, Kenneth
Bright, Graham	Hogg, Hon Douglas (Gr'th'm)
Brittan, Rt Hon Leon	Hordern, Sir Peter
Brooke, Rt Hon Peter	Howard, Michael
Brown, Michael (Brigg & Cl't's)	Howarth, Alan (Strat'd-on-A)
Bruce, Ian (Dorset South)	Howarth, G. (Cannock & B'wd)
Buck, Sir Antony	Howell, Ralph (North Norfolk)
Burns, Simon	Hughes, Robert G. (Harrow W)
Burt, Alistair	Hunt, David (Wirral W)
Butcher, John	Irvine, Michael
Butler, Chris	Irving, Charles
Carlisle, John, (Luton N)	Jack, Michael
Carlisle, Kenneth (Lincoln)	Jackson, Robert
Carrington, Matthew	Janman, Tim
Cash, William	Jessel, Toby
Chalker, Rt Hon Mrs Lynda	Johnson Smith, Sir Geoffrey
Channon, Rt Hon Paul	Jones, Gwilym (Cardiff N)
Chope, Christopher	Jones, Robert B (Herts W)
Clark, Dr Michael (Rochford)	Key, Robert
Clark, Sir W. (Croydon S)	King, Roger (B'ham N'thfield)
Clarke, Rt Hon K. (Rushcliffe)	King, Rt Hon Tom (Bridgwater)
Colvin, Michael	Kirkhope, Timothy
Conway, Derek	Knapman, Roger
Coombs, Anthony (Wyre F'rest)	Knight, Greg (Derby North)
Cope, John	Knowles, Michael
Couchman, James	Lamont, Rt Hon Norman
Cran, James	Lang, Ian
Currie, Mrs Edwina	Lawrence, Ivan
Curry, David	Lee, John (Pendle)
Davies, Q. (Stamf'd & Spald'g)	Lightbown, David
Devlin, Tim	Lilley, Peter
Dickens, Geoffrey	Lloyd, Sir Ian (Havant)
Dorrell, Stephen	Lloyd, Peter (Fareham)
Douglas-Hamilton, Lord James	Lord, Michael
Dover, Den	Luce, Rt Hon Richard
Dunn, Bob	Lyell, Sir Nicholas
Durant, Tony	McCrindle, Robert
Eggar, Tim	Macfarlane, Sir Neil
Evans, David (Welwyn Hatf'd)	MacGregor, Rt Hon John
Evennett, David	MacKay, Andrew (E Berkshire)
Fallon, Michael	Maclean, David
Farr, Sir John	McLoughlin, Patrick
Favell, Tony	McNair-Wilson, M. (Newbury)
Fookes, Miss Janet	McNair-Wilson, P. (New Forest)
Forman, Nigel	Major, Rt Hon John
Forsyth, Michael (Stirling)	Malins, Humfrey
Forth, Eric	Mans, Keith
Fowler, Rt Hon Norman	Maples, John
Fox, Sir Marcus	Marlow, Tony
Franks, Cecil	Marshall, John (Hendon S)
Freeman, Roger	Martin, David (Portsmouth S)
Gale, Roger	Mates, Michael
Garel-Jones, Tristan	Maude, Hon Francis
Gill, Christopher	Mawhinney, Dr Brian
Glyn, Dr Alan	Mayhew, Rt Hon Sir Patrick
Goodlad, Alastair	Mellor, David
Goodson-Wickes, Dr Charles	Meyer, Sir Anthony
Gorman, Mrs Teresa	Miller, Hal
Gorst, John	Mills, Iain
Gow, Ian	Mitchell, Andrew (Gedling)

Mitchell, David (Hants NW)	Soames, Hon Nicholas
Moate, Roger	Spicer, Sir Jim (Dorset W)
Monro, Sir Hector	Spicer, Michael (S Worcs)
Moore, Rt Hon John	Squire, Robin
Morris, M (N'hampton S)	Stanbrook, Ivor
Morrison, Hon Sir Charles	Stanley, Rt Hon John
Morrison, Hon P (Chester)	Stern, Michael
Moss, Malcolm	Stevens, Lewis
Moynihan, Hon Colin	Stewart, Allan (Eastwood)
Neale, Gerrard	Stewart, Ian (Hertfordshire N)
Needham, Richard	Stokes, John
Nelson, Anthony	Sumberg, David
Neubert, Michael	Summerson, Hugo
Newton, Rt Hon Tony	Tapsell, Sir Peter
Nicholls, Patrick	Taylor, Ian (Esher)
Nicholson, Emma (Devon West)	Taylor, John M (Solihull)
Onslow, Rt Hon Cranley	Taylor, Teddy (S'end E)
Oppenheim, Phillip	Tebbit, Rt Hon Norman
Page, Richard	Temple-Morris, Peter
Paice, James	Thompson, D. (Calder Valley)
Parkinson, Rt Hon Cecil	Thompson, Patrick (Norwich N)
Patnick, Irvine	Thornton, Malcolm
Patten, Chris (Bath)	Thurnham, Peter
Patten, John (Oxford W)	Townsend, Cyril D. (B'heath)
Pattie, Rt Hon Sir Geoffrey	Tracey, Richard
Pawsey, James	Tredinnick, David
Porter, David (Waveney)	Trippier, David
Portillo, Michael	Trotter, Neville
Price, Sir David	Twinn, Dr Ian
Raffan, Keith	Vaughan, Sir Gerard
Raison, Rt Hon Timothy	Viggers, Peter
Redwood, John	Waddington, Rt Hon David
Renton, Tim	Wakeham, Rt Hon John
Rhodes James, Robert	Waldegrave, Hon William
Riddick, Graham	Walden, George
Ridley, Rt Hon Nicholas	Walker, Bill (T'side North)
Rifkind, Rt Hon Malcolm	Walker, Rt Hon P. (W'cester)
Roberts, Wyn (Conwy)	Walters, Dennis
Roe, Mrs Marion	Ward, John
Rossi, Sir Hugh	Wardle, Charles (Bexhill)
Rost, Peter	Wells, Bowen
Rowe, Andrew	Wheeler, John
Rumbold, Mrs Angela	Whitney, Ray
Ryder, Richard	Widdecombe, Ann
Sackville, Hon Tom	Wiggin, Jerry
Sainsbury, Hon Tim	Wilshire, David
Sayeed, Jonathan	Wolfson, Mark
Scott, Nicholas	Wood, Timothy
Shaw, David (Dover)	Woodcock, Mike
Shaw, Sir Giles (Pudsey)	Yeo, Tim
Shaw, Sir Michael (Scarb')	Young, Sir George (Acton)
Shephard, Mrs G. (Norfolk SW)	Younger, Rt Hon George
Shepherd, Richard (Aldridge)
Skeet, Sir Trevor	Tellers for the Noes:
Smith, Sir Dudley (Warwick)	Mr. Robert Boscawen and
Smith, Tim (Beaconsfield)	Mr. Mark Lennox-Boyd.

Question accordingly negatived.

Mr. Fearn

I beg to move amendment No. 66, in page 11, line 37, at end insert— '( ) Subsection (4)(b) shall apply, in the case of a person suffering from a prescribed medical condition, both to the inspection or course of treatment during which the condition is diagnosed and to subsequent inspections and courses of treatment while the condition continues to be diagnosed or suspected'.

Madam Deputy Speaker (Miss Betty Boothroyd)

With this it will be convenient to take amendment No. 76, in page 14, line 6, at end insert— '( ) Subsection (1C)(b) shall apply, in the case of a person suffering from a prescribed medical condition, both to the inspection or course of treatment during which the condition is diagnosed and to subsequent inspections and courses of treatment while the condition continues to be diagnosed or suspected'.

Mr. Fearn

These amendments are designed to ensure that patients with prescribed medical conditions are not charged for examinations for the entire period during which they suffer from those conditions. Thus, the whole procedure, or series of procedures, when the condition is first diagnosed is exempted from any charge and this exemption continues until the end of the episode of care during which the patient is finally cleared of any suspicion of still suffering from the condition. Unless this interpretation is made clear and is entrenched, the promotion of good health will be put at risk.

Again, as with dental charges, we take particular exception to the proposal to charge for eye examinations and we have voted against it, but, as the Opposition amendment failed a few moments ago, we shall expect support for the view that our interpretation of the period of exemption from charges as set out in amendments Nos. 66 and 76 is the correct one.

9.15 pm

Mr. Newton

Our understanding of the effect of the amendment is that a prescribed medical condition is one of the criteria which may be used to define eligibility for NHS sight tests. The amendment would ensure that the sight test at which the prescribed condition was found and subsequent tests were NHS tests.

The only comment that I can make on this slightly arcane point is that there is already power to extend NHS tests to those suffering from prescribed medical conditions. In my previous speech I said something about diabetics. The amendment would simply provide that the test at which the condition was found could also be an NHS test. However, if the person is having a test, it seems likely that he has not been deterred by the private fee.

I said earlier that we would make changes in the arrangements for diabetics and those at risk from glaucoma. I shall examine what the hon. Gentleman has said against what is on the Amendment Paper. If it turns out that we need a provision of the kind proposed in the amendment, I shall be prepared to consider it later. I am not at present persuaded, partly because I think that there is confusion about the purpose and purport of the amendment.

Mr. Fearn

It would appear from what I hear that the Minister accepts the general theme that I have put forward. Therefore, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendments made: No. 31, in page 12, line 12, leave out 'The services provided under this section' and insert 'Regulations shall define the services for the provision of which arrangements under this section are to be made and the services so defined'. No. 32, in page 14, line 29, leave out 'The services provided under this section' and insert 'Regulations shall define the services for the provision of which arrangements under this section are to be made and the services so defined'.

No. 33, in page 12, line 35, leave out 'subsection' and insert 'section'.

No. 34, in page 14, line 41. leave out 'subsection' and insert 'section'.—[Mr. Newton.]