§ Lords amendment: No. 22, in page 13, line 18, leave out subsection (1).
§ Mr. Kenneth Clarke
I beg to move, That this House doth disagree with the Lords in the said amendment.
§ Mr. Speaker
With this it will be convenient to take the following:
I remind the House that privilege is involved in these amendments.
- Amendments (a) to (f) to Lords amendment No. 22.
- Lords amendment No. 23.
- Amendments (a) and (b) to Lords amendment No. 22.
- Lords amendment No. 26.
- Amendments (a) to (f) to Lords amendment No. 26.
§ Mr. Clarke
Lords amendment No. 22 deals with the question of whether we should introduce charges for eye tests as a contribution towards the Health Service's rising expenditure.
We have just had a rather closer vote than those to which we are accustomed—[Interruption.]
§ Mr. Speaker
Order. Right hon. and hon. Members who remain beyond the Bar must be quiet or should enter the Chamber.
§ Mr. Clarke
There is a certain degree of excitement in the House, and we have just had a very rousing winding-up speech from my hon. and learned Friend the Minister of State, Department of Health. We have had some exchanges with our own right hon. and hon. Friends as well as with Opposition Members on exactly what the divisions are about this evening.
We are engaged in a very serious matter that has considerable consequences for the Health Service. I listened to a good part of the last debate. I heard, for example, my hon. Friend the Member for Reading, East (Sir G. Vaughan), a distinguished former Minister of Health and a personal friend of mine, speak extremely eloquently about the problems of oral cancer. He touched on the subject of eyesight and spoke also about glaucoma. 922 I accept entirely the sincerity with which he spoke. I also know that he realises that both my hon. and learned Friend the Minister of State and myself are equally concerned about the problems of oral cancer and glaucoma.—[Interruption.] Of course we are. The suggestion that we are oblivious to those matters has arisen. In the previous debate, there was a difference between us as to whether a £3.15 charge every six months will deter anybody from examinations that might in a few cases give rise to the discovery of oral cancer.
What also runs behind this debate are the finances of the National Health Service for next year. What happens as one progresses in a debate of this kind is that everyone rather warms to his theme. Certainly I find myself warming to my theme and becoming ever more convinced of my case. I suspect that some of my right hon. and hon. Friends and Opposition Members are growing ever more convinced of theirs.
The House has just given us a rather close run thing that might have cost the Health Service £50 million in the coming year. I find it ironic and perverse that on a day when we have provided over £2 billion more for the Health Service over and above last year's spending, and over and above last year's settlement, the Labour party is voting to take funds out of the Health Service and to try to knibble away at that increased expenditure. My hon. and learned Friend was quite correct in saying in the previous debate that hon. Members on both sides of the House spoke of £50 million as though it were a small sum, although at least one of my hon. Friends was talking about more than the complete budget of his district health authority. Both my hon. and learned Friend the Minister and I gave examples of the kind of treatment that can be provided out of such sums.
I respect the sincerity of hon. Members of both sides, but they are not addressing themselves to the fact that by voting as they do they are denying patients throughout the country the prospect of treatment. In this debate, no doubt I shall be told that we are—[Interruption.]
§ Mr. Speaker
Order. I ask hon. Members not to address remarks to me, or to anyone else, from a sedentary position.
§ Mr. Clarke
The hon. Member says, "Get to the business." I am getting to the business of the £70 million against which he is about to vote and which will deprive people in Workington and elsewhere of an expansion in services that might otherwise take place. That is highly relevant to the next debate, and he and others should bear it in mind.
I make no apologies for reminding the House of that background. It is against that background that I shall listen again to the arguments that will be adduced about the possibility of undetected glaucoma if we do not vote against the prospect of the most prosperous 60 per cent. of the population—those who do not fall into the exempt categories—facing a horrendous bill of up to £10 every two or three years. [Interruption.] Yes, I am angry, because we are facing—[Interruption.] The Labour party is again 923 being irresponsible about health charges. If the House becomes irresponsible, we shall be £70 million light for the Health Service and treatment expansion next year.
§ Mr. Clarke
I may give way in a bit, but I will not be interrupted from a sitting position by the hon. Member for Workington and then give way to him two minutes later.
The issue in this debate will turn on whether people will be deterred from going to the optician and cases of glaucoma will not be detected if we introduce the charges that we are suggesting for the sight test. That is the nub of the debate. Before we launch into long descriptions of the consequence for eye disease, we must first ask how many people, if any, will be deterred from going to the optician by the prospect—and it is no more than a prospect—that many opticians will charge £10 or thereabouts.
I said when I spoke about dental charges that we had heard the argument about deterrence year in and year out for more than 10 years, every time we raised the charges. We have had exactly the same experience with the optical services. But, as many hon. Members will remember, we had a more serious debate about optical services about four years ago when we took the dispensing service out of the NHS and introduced the voucher scheme. We made significant changes in the way in which the NHS was financed.
At that time exactly the same arguments were adduced. We were told that there would be undetected disease and sight problems. I recall those debates quite well. I have seen briefing quoting some of the comments that I made in that debate. I have re-read the debate. The then spokesman for the Labour party, the hon. Member for Oldham, West (Mr. Meacher), said on 20 December 1983:The result for the public will be eye strain and headaches at best. At worst it will be the inability to see clearly so that they are at risk in their work, a hazard in the road or otherwise may injure themselves".—[Official Report, 20 December 1983; Vol. 51, c. 306.]We heard all the stories of glaucoma, we heard about bus drivers driving into lamp posts and how the price of spectacles would soar as we privatised the service.
The evidence supports the arguments which I used before and which go to the root of the debate. We have heard this cry of wolf before. It did not happen. The changes that we made did not result in fewer visits to the optician. In fact, competition made spectacle prices more reasonable and the choice to the consumer was extended. According to the most recent survey that I have, the United Kingdom's retail sale of spectacles increased by about 10 per cent. in the first two years alone— from 1984 to 1986.
Therefore, all those arguments proved to be false. Greater use is being made of the optical services than was made before we made the changes which were opposed on precisely the same grounds as our proposals are being opposed today at a threatened cost to the National Health Service of £70 million.
§ Mr. Ian Bruce (Dorset, South)
Does my right hon. and learned Friend realise that this House did away with free eye tests before? Before we had the National Health Service, opticians gave free eye tests. At the moment the 924 taxpayer pays for eye tests. Does my right hon. and learned Friend agree that we are likely to get free eye tests again because of economic and commercial pressures?
§ Mr. Clarke
I agree with my hon. Friend. I shall turn tohis point in a moment.
The people who campaign against us now campaigned against us four years ago. They are better off than they were then, although at the time they feared that they would be made poorer. The public are making more use of the optical services than they did then.
We are now discussing the idea that the six out of 10 of the population who are not exempt will be deterred by having to pay £10, typically about every two or three years. I shall not rehearse all the arguments I used about dental examinations as to why I think that that is contrary to common sense as well as the evidence.
I keep being challenged, "Who in the profession agrees with you?" I have never found that large numbers of turkeys rush forward before Christmas, but I have found some support from sensible journals. I propose to assist the House by reading from the column known as Nemo which, as hon. Members who follow optical matters will know, appears in Optician of 1 January 1988. It deals directly with the core of the debate—whether people will go to the optician with less frequency because of the charges. I shall read from Nemo because I have been challenged to produce support from people within optics —having found one, I shall read it— [Interruption.] As my hon. Friend the Member for Dorset, South (Mr. Bruce) said, if the House agrees with their Lordships, opticians expect to continue to be paid by the taxpayer for a service which otherwise they would provide free. There is no doubt as to who the beneficiaries will be if we agree with their Lordships in the amendment.
Optician said:if it is to have any effect in the place where it matters, the case against the Government's proposals needs to be presented in well reasoned and dispassionate terms, avoiding as far as possible dire predictions and the sort of sweeping and unsubstantiated allegations normally resorted to on such occasions. What reason is there for supposing that to ask people to pay for something previously provided free will cause them to lose interest in the particular goods or services, particularly where their health is concerned? To incline to this view is surely to underestimate the intelligence and sense of responsibility of the man in the street.The audience of this journalist are opticians.
Is it really asking too much to require persons in work or who are otherwise able to pay, to fork out, say, £10 for a sight test every two years? Let us retain a sense of proportion; this represents no more than the cost of a couple of modest rounds of drinks, or a single restaurant meal.Contrary to what the pundits would have us believe, one tends to learn more from the experience of history. Those who are old enough, for example, will recall how the imposition of the first NHS charges in the early 1950s was interpreted by the Cassandras as the death knell for opticians. The reality, of course, was that people still had need of spectacles—and have demonstrated their willingness to pay for them to an ever-increasing extent over the years.The end of NHS dispensing in 1985"—
§ Mr. Clarke
Of course I am reading—I am quoting. The hon. Member last emerged in the Chamber to chant in a similar way at one of my hon. Friends. I trust that he will not continue to do that throughout the debate. I have already told one of his hon. Friends that a lot of money forthe Health Service is at stake.
The end of NHS dispensing in 1985"—
§ Mr. Clarke
—the ending of their sales monopoly. On this evidence there seems little to fear regarding the public's longterm willingness—
§ Dame Jill Knight
On a point of order, Mr. Speaker. Is my right hon. and learned Friend not perfectly entitled to read a quotation if that is what he wants to do? I for one am anxious to hear what he says.
§ Mr. Clarke
I am grateful to my hon. Friend. She and I address ourselves seriously to this issue. I do not think that people outside will be very pleased to hear that we are talking about this sum of money for health care against a background of din from the hon. Member for Falkirk, West (Mr. Canavan), who has just joined us.
I have quoted Optician, setting out in reasonable terms, which I shall not attempt to repeat or embellish, the underlying case of people who follow the affairs of the optical world much more than most hon. Members and 926 their fears on costs. We must ask whether opticians will impose a charge which will deter the six out of 10 of the population who are not exempt from charges.
How much will opticians charge? One proposition is that they will continue to charge what they at present charge the NHS, which is about £10. The Bill would end the provision of an NHS test for non-exempt people. Opticians will charge what they decide to charge. If the Government are successful in this Division, it will be for opticians to determine what, if anything, is charged to their customers or patients.
Much of the debate, in this and the other place, has been founded on the proposition that all opticians will continue to charge the equivalent of the NHS fee that they now get for the free sight test which they offer to everyone. Some of my hon. Friends who know just as much about the optical profession as I do disagree with me. This is a matter of opinion and judgment. I do not believe that all opticians will maintain a charge for a sight test which is equivalent to the present NHS fee that they receive, for the same reason that the cost of spectacles did not soar when we withdrew NHS glasses four years ago. Competition —a legitimate activity for professional people, as for others—will oblige opticians to offer a charge for optical tests—if they charge at all.
I ask the House to consider the other argument against me. I know that I shall hear this point: "No, we have asked all the opticians and they all say that they will carry on charging what they get at the moment from the NHS. That will deter the clientele. We shall sit around and watch the eye disease develop which would otherwise have been detected." Does that mean that these commercial men—all professional men are business men as well as qualified people—will solemnly all set the same fee, at a level which deters customers from coming over the threshold of their shops? They will all sit around watching their incomes drop as fewer patients come in— [Interruption.']
§ Mr. Clarke
Before my hon. Friend again starts telling me that this is peanuts— about four and a half times the budget of his health authority—let me say that I have history on my side. I told the House four years ago that I did not believe those people then, and I was right. Frankly, I do not believe them now.
§ Mr. Robert McCrindle (Brentwood and Ongar)
My right hon. and learned Friend is spending a good deal of time in likening the proposed charges to past examples. Does he agree that there is a fundamental difference in one area to which he has not so far directed his attention? Those of us who are concerned about the Government's proposal are not just concentrating on the poor, as perhaps we did in the past. We are looking at people who, for no other reason than that they are over a certain age, begin to develop sight defects. If there is a deterrent to those people—a large number of whom will not fall within the category of poor—and they do not seek an eye test, the savings on which my right hon. and learned Friend concentrates will be swamped by the additional resources that will have to be devoted to diseases if and when they arise.
§ Mr. Clarke
I respect my hon. Friend's views. He is returning to the key of the argument. He asserts, contrary 927 to what I have just said, that these charges will continue to be levied, despite the competitive pressures on opticians—
§ Mr. Clarke
I do not think that the right hon. Gentleman spoke when we last talked about opticians, four years ago.
My hon. Friend the Member for Brentwood and Ongar (Mr. McCrindle) is entitled to disagree with me. He disagrees with my instinct, my opinion, that opticians will not maintain eye test charges for very long. If they do not maintain eye test charges, my hon. Friend's fears will be ill-founded, as he will concede. He says that, if opticians maintain some eye test charges, that will deter the elderly in particular. I am sure that he agrees that not all pensioners fall into the poor category, but I agree that the older one becomes, the more one is prone to glaucoma.
I concede that I may be wrong in my opinion that the charge for the eye test will steadily disappear, but that is my strong personal opinion. Let us imagine that some charges are maintained at anything up to about £10, which is what opticians get for the NHS test now. We can then examine what I first anticipated would happen. Every couple of years or so, people might face the prospect of having to go to the opticians. At the moment, people who go to opticians usually expect to pay for their spectacles, if they are not exempt. They are right to do so. The reason why people usually go to the opticians is that they are not seeing as well as they used to, or need to have their prescriptions updated. Three out of four people who go for a sight test wind up acquiring spectacles. And they pay for them. The charges they pay for the glasses are considerably higher than any possible deterrent arising from these charges.
We have found since privatisation that people are not deterred, as I have already said, by the prospect of going through the voucher scheme or paying for themselves. NHS voucher customers who qualify for help have in practice been willing to pay more than their vouchers for the spectacles of their preference. Even though such people are, by definition, of modest means, it is not surprising that they are willing to top up their NHS vouchers to pay for what is not a huge or recurrent item of expenditure. Most pay now; most will in future.
§ Dr. Keith Hampson (Leeds, North-West)
Does my right hon. and learned Friend agree that the competitive pressure on opticians will depend entirely on where they are—that is, on whether they are in major town centres or small towns?
Does my right hon. and learned Friend accept that this is not a matter of creating a further disincentive to those who already use eye tests? Every Government Minister accepts and preaches that there is not enough take-up of screening of all kinds, and that we should encourage more take-up.
In the context of the remarks made earlier this evening by my hon. and learned Friend the Minister of State, what is the real difference between screening for cancer and screening for eye ailments and other diseases?
§ Mr. Clarke
I shall deal first with the argument that competition may not occur everywhere. My hon. Friend the Member for Boothferry (Mr. Davis) pointed out in 928 conversation with me that competitive pressures may not exist in rural areas. But, even in rural areas, I cannot believe that opticians will be too far away from other opticians for such pressures not to exist. Although they may have a slightly protected market, they will not sustain their position if it is clear to their rural customers that in nearby towns such as Leeds or Hull there are no charges for a test. [Interruption.] Already one can see those little signs in the windows of opticians' premises saying, "Free NHS tests here". I do not criticise opticians for that: it is a way of getting customers across the threshold to sell them spectacles, if it turns out on examination that they need a prescription.
Secondly, my hon. Friend mentioned screening tests. My hon. and learned Friend the Minister of State was right to challenge the direct comparison with full-blooded screening. We are not talking about cervical cancer or breast cancer screening. Both those tests are expressly designed to show whether the first signs of a particular condition are present. We are discussing average patients going for eye tests to see whether they need spectacles, or going to the dentist to see whether they need treatment —[Interruption.] What I have said is correct. [Interruption.]
§ Mr. Speaker
Order. Hon. Members will have an opportunity to participate later in the debate, but not by intervening in this way.
§ Mr. Clarke
What happens—and neither I nor my hon. and learned Friend denies this—is that it gives an opportunity to someone who is examining for a particular purpose to detect the first signs of other diseases. However, it is not a specific screening test. The idea that eye tests were invented for the purpose of detecting glaucoma is nonsense. This Government introduced and financed breast cancer screening to detect avoidable disease and breast cancer in women. The eye tests merely offer an opportunity for people to detect glaucoma.
Of course, we must not take risks. Most of my hon. Friends and Opposition Members have listened patiently while I have explained why I do not agree that patients will be deterred, nor even convinced, that the charges will be maintained. My hon. Friend the Member for Leeds, North-West (Dr. Hampson) and others ask, "Why take the risk?" My hon. Friend is obviously worried about the risk of glaucoma going undetected if my judgment, based on experience of optical charges, turns out to be wrong. This measure has been through this House several times and I and my hon. Friends have gone to great lengths to cover that risk. I have already said that it is my opinion that no great risk exists and that people will not be deterred from having eye tests.
I began my speech by saying that I am no more anxious to have avoidable disease in this country than is my hon. Friend the Member for Reading, East or any other hon. Member. At earlier stages we have made concessions that provide a free NHS eye test for those groups most at risk. Glaucoma is estimated to affect about 1 to 2 per cent. of those over the age of 40, a proportion of whom do not wear glasses. There is a much higher risk among particular people as there is a hereditary element in the condition of glaucoma. People of 40 or over who are the siblings and children of the glaucoma patient are at 10 times greater risk of developing the condition than those who are not so related. That is why my right hon. Friend the Chancellor 929 of the Duchy of Lancaster, then the Minister for Health, proposed to retain the free NHS eye test for that group, which is most at risk.
We have already proposed to retain the free test for those suffering from diabetes. Contrary to what I believe to be necessary, there have been concessions, in case we are proved to be wrong, to cover that section of the population most at risk. Yet, having gone to such lengths, hon. Members now say, "No, there must be a free eye test for everyone in this Chamber and everyone in the high income groups, including those in the higher tax bands, in case the opticians continue to charge."
I believe that the practical effect of these proposals is that the opticians will continue to have an income from the NHS that they would not otherwise get. Most important, the NHS—on the night of the day when my right hon. Friend has given a great deal more money to it—will have to take £70 million out of its planned expenditure if this amendment is not carried.
§ Mr. Hayes
I am sort of grateful to my right hon. and learned Friend. He said that he was taking a risk—it is more like backing a whippet with a wooden leg. Some 70 per cent. of optometrists' income comes from the sight test. What will happen to the other 30 per cent.? It will be loaded on to the price of spectacles and contact lenses.
§ Mr. Clarke
I invite my hon. Friend to raise the subject of optometrists' incomes in his speech, and I shall deal with it when I reply to the debate. That is what I think to be at risk if their Lordships' decision is overturned by this House. I think that the most competitive optometrists, the best opticians, those who continue to build on the success of the past four years when there has been a growth in spectacle sales, will do very well.
§ Mr. Clarke
My hon. Friend obviously knows some less competitive optometrists who rather like the idea that the NHS should continue to pay them £10 a time for everybody who comes through the door to whom they give a sight test. If he wishes to pursue that argument further —which he did not set out in his Evening Standard argument—my hon. and learned Friend the Minister of State will be only too anxious to give him as good as he gets in the course of the exchange.
§ 11 pm
§ Sir Giles Shaw
Will my right hon. and learned Friend clarify the position of a glaucoma test in the NHS testing procedure? Is there no requirement for such a test to be conducted when a person goes for a normal NHS sight test? Is there any way in which it can be enforced so that when we have—if my right hon. Friend's argument is persuasive—a £10 charge for it, at least the public will know that the test for that disease will be a part of the NHS eye test?
§ Mr. Clarke
My hon. Friend raises a serious point. I believe that the bulk of responsible optometrists and 930 opticians give a full sight test—[Interruption.]—and we have the powers to specify the extent to which the patients and customers are tested. We shall look at the necessity to use them if we find that people are giving quick sight tests and not screening for glaucoma. [Interruption.] Labour Members are disappointed by that, it seems. They have come to life again, their Scottish hon. Friend the Member for Falkirk, West (Mr. Canavan) having gone back to where he came from prior to joining us for our discussion. What I said is important and is relevant to the detection and treatment of glaucoma.
Most of the arguments that we are about to hear in this debate, I anticipate— though I shall listen, as ever, with an open mind—will not touch on the detection and treatment of glaucoma. If some passion is to enter the debate, let us ensure that in making a judgment in the next hour or two we do not put at risk £70 million which I and my hon. Friends want to put to use in the NHS, including in the optical services.
Rebellion requires more courage and conviction than routine opposition. Tonight Labour Members are indulging in routine opposition. When my hon. and learned Friend the Minister of State teased them about whether they would like to see the end of all health charges, a big cheer came from them. Apparently they are saying that they would abolish all health charges. That would mean huge expenditure for no benefit to the patients. It also means that they are committing themselves to a policy which, as we know perfectly well, they would never implement if they ever got to power.
If we succeed in overturning this Lords amendment, I do not believe that any future Labour Government will ever withdraw this charge for the optical examination or will bring it back—because I do not think there will be a charge —for the sake of paying the opticians a fee, which by then will have disappeared or be very cheap indeed by the forces of competition.
Labour Members are being opportunistic. They are taking advantage of an occasion when my hon. Friends are concerned about eye disease. There are serious issues at stake, such as the future of the Health Service, its expanded services next year and keeping the full benefit of the £2.2 billion that we have put in. I ask my right hon. and hon. Friends to vote to ensure that we keep the full benefit of all that extra money.
§ Mr. Robin Cook
It would be churlish of me to begin without congratulating the Secretary of State on having found one medical view in support of his proposal, albeit one who felt compelled to write anonymously.
The right hon. and learned Gentleman said that he believed that he was absolutely right those were his words—in the views he expressed in the House on 20 December 1983, when we last debated this matter. Let me remind the Secretary of State of what he said in the speech in which his remarks were "absolutely right". He said:We are keeping in the NHS what should be kept there—free sight tests for everyone, regardless of need."—[Official Report, 20 December 1983; Vol. 51, c. 362.]
§ Mr. Kenneth Clarke
I am glad that the hon. Gentleman has got round to the House of Commons brief; I trust that he has also looked at the copy of Hansard from which that quotation is taken. Before he comes to the quotations from my right hon. Friend the then Secretary of State for Social Services, I would point out that when the quotations are taken in context it is clear that we were describing the then 931 measure and the then measure kept the eye test in the National Health Service. The charge for it was not at issue in the explanation of the deregulation. [Interruption.] The hon. Gentleman has not read Hansard. [Interruption.] I am merely asking hon. Members to stop quoting selectively. If the hon. Gentleman reads the debates in March 1983 he will find that the hon. Member for Holborn and St. Pancras (Mr. Dobson) helpfully intervened to underline the point that I made in Committee. I described the arrangements as being in place for the time being, and my remarks are on record. There is no inconsistency in what we are saying today.
§ Mr. Cook
It was as well that we let the Secretary of State intervene, and continue for as long as he did. I listened with great care to his concluding remarks. He said that he had made it clear—of course, he is quite right—that his commitment to free sight tests was "for the time being". Those are precisely the words that he used earlier when he said that this Government had no plans to introduce charges for cervical cancer smears, breast cancer examinations or visits to the doctor. That, too, was "for the time being." We now have a clear definition of what "for the time being" means: it is a period of four to five years at the outside.
The Secretary of State is perfectly entitled to change his mind. It is open to any hon. Member to do so. However, I put it to him that some people who heard what he said in the debate in 1983 have not changed their minds and believe that free sight testing ought to remain in the NHS. If I may say so—as one colleague to another—the Secretary of State is not entitled to get angry with those who have not changed their mind with the same facility as he has. There are serious and deeply held views on sight tests on both sides of the House and those views will not be changed by a display of ill temper.
All the arguments of principle in the previous debate can be carried forward into this second debate. The House will he relieved to hear that I do not propose to repeat those arguments. However, I firmly believe that the case against charges applies with even greater force to the eye test.
There are two reasons for that. The first is the nature of the examination. In preparation for the debate, I went for an eye examination. Some hon. Members may know that, having observed photographs which perhaps do not show me at my best. Any hon. Member who has been through the test must know that it is misleading to describe it as a sight test. It is a full examination of the eye. The eye is the one part of the body behind which one can look without cutting it open. It is a window through which one can see not just the ocular system but the circulatory system and the immediately adjacent part of the brain. That has been admitted by the Secretary of State and the Government, who have tabled an amendment seeking to exempt those suspected of suffering from glaucoma and diabetes. That is a very clear indication of the fact that the eye examination is an effective way of screening for those very serious diseases.
Other diseases may also be detected. Twice as many cases of hypertension as cases of diabetes are detected through the eye examination. Since the debate began a year ago, when the Government first floated their proposals, my hon. Friends the Members for Aberdeen, South (Mr. Doran), for Fife, Central (Mr. McLeish) and for Wigan (Mr. Stott) have all been visited by constituents 932 who have made it plain that their lives had been saved by a routine eye examination in which a serious tumour requiring urgent operation had been detected. It is not an isolated and rare occurrence; one in 12 eye examinations results in a medical referral. That is 1 million cases a year. To put it another way, three out of four cases of glaucoma are first detected during eye examinations. Those matters are not in dispute. The Green Paper said that sight tests can identify health problems as well as a need for spectacles. Therefore, it is important that skilled sight testing should remain readily available. That is important.
As I understand the Government's case, they do not deny the importance and the significance of the eye examination. What the Secretary of State has argued is that, yes, eye examinations are important, but nobody will be deterred if we take away the fee that we pay to optometrists and they in turn introduce a charge. I find it curious that a Government as committed as this Government are to market forces—in all other areas holding that the price signal is effective—should in the solitary case of health charges suspend the law of market economics and say that the price signal does not deter. It is nonsense on stilts for them to sustain that no one would be deterred by "a tenner a test".
I listened with interest to the Secretary of State when he talked about how much the test would cost. I believe that he would agree that one could fairly sum up his comments by saying that, after this measure has been passed, we shall have no control over what the charge might be. We are abandoning the charge to the optometrists. In a sense, this debate is even worse than the previous one, because at least then we knew how much the charge would be. On this occasion, the Secretary of State maintains that the charge could be less than £10. Equally, it could be more than £10. I am bound to say that every optometrist I have met during the past year has made the obvious and simple observation that he is likely to have fewer people coming forward and, if he is to sustain the same amount of income, he will have to charge more than £10 a test.
We now have evidence—which was not available on Report—of what happens when the fee is withdrawn and it is left to the market to decide. It is sufficiently dramatic to justify a retrial. That evidence comes from the state of Alberta. In August 1987 the state eliminated free eye tests by withdrawing them from state insurance. The result was so disastrous that it brought back free eye tests within 11 months. Lord Skelmersdale was unfortunately caught adrift when the other place debated this measure, and he was unwise enough to say that the report of things going wrong in Alberta was merely anecdotal. He was unaware that in the same month in which he referred to those difficulties as being anecdotal the government of Alberta had been so convinced by the reality of its experience that it was bringing back free sight tests. The abolition of free sight tests in Alberta did not reduce examination charges, but resulted in charging by optometrists. It is claimed that abolition produced a drop of 30 per cent. in the number of people presenting themselves for eye examination. Another consequence was that there was a sharp increase in the number of people being referred to eye hospitals for a more expensive eye examination.
That brings me to the second reason why on this issue the case against charges is stronger. The Secretary of State repeatedly told us that he was doing this for the money and, to be fair to him, he made no bones about that. In that spirit of candour, I will respond by saying that he will 933 get more money by charging for dental examination, but, in so doing, he will cause great damage to the teeth of the people of this nation—damage which is not worth £49 million. I accept that he will get the money from dental examination fees. I do not believe for one moment that he will find himself in pocket as a result of abolishing free eye tests. He will not get any money from this perverse measure and I will give two reasons why that is so.
§ Mr. Michael Grylls (Surrey, North-West)
The House is listening carefully to the hon. Gentleman's arguments. I am certainly trying to do so. Is it not wrong to talk about "free" eye tests? Surely what we are arguing about—this is a perfectly reasonable argument—are eye tests that are provided by the generality of taxpayers—they are certainly not free—and eye tests provided by a free and competitive market. Is it not our experience in most aspects of life that the operation of a free market where there has never been one before, which is what there will be if this measure is agreed, will serve the public better?
§ Mr. Cook
I have some sympathy with the hon. Gentleman's point. Ultimately the eye test is not free. Ultimately it has to be paid for by somebody. At present, it is paid for by the taxpayer. What I find curious about the Secretary of State's argument is that he seemed to have invented the free sight test for which the taxpayer would not pay and nor would anybody else. Plainly, that does not stand to reason. The Secretary of State cannot save £90 million unless somebody else pays for it.
I predict, with confidence, that the Secretary of State will not save that sum, for two reasons. The first is a short-term reason. Our eye hospitals will be swamped by references from general practitioners who will no longer be able to refer their patients to optometrists for free examinations. They will be able to secure free tests for their patients only by referring them to an eye hospital. That is what many general practitioners will do. The Secretary of State has come up with a proposal which gives everybody an incentive to go for their eye examination to the one place where it costs the right hon. and learned Gentleman the most to pay for it and to avoid the optometrist round the corner, where it would cost him least to pay for it.
The long-term reason why I do not believe that there will be any savings from this proposal is even more disturbing. As a result of the removal of the free sight test there will be a growing burden on the Health Service from people with serious medical conditions which will not now be detected until they are at an advanced stage.
It is possible to extrapolate from the experience of Alberta what that could mean for primary care in Britain. There are 12 million eye examinations in Britain every year; 70 per cent. will now be liable for a charge—that is 8.5 million. If 30 per cent. of those cases in Britain are deterred by a charge—as happened in Alberta—2.5 million people will not go for an eye examination. If the instances of glaucoma among that 2.5 million is the same as that for the population as a whole, we will miss 10,000 cases of glaucoma annually. We may miss another 10,000 cases of diabetic retinopathy. Glaucoma cannot be reversed. It can be arrested, but when it has proceeded to too advanced a stage, it cannot be reversed. When it is found too late, the sufferers are going blind. 934 That is not just a personal tragedy for the people concerned. If I may put it in terms to which the Treasury can relate, it will also be expensive for the NHS. Every blind person costs the state £3,500 per year in added services. The annual cost for 10,000 cases of glaucoma which are not detected in time would wipe out half the savings that the Secretary of State hopes to achieve by abolishing the free sight test. He is not making a saving. He is taking on an expensive commitment to future care. The truth is that the free eye test is not a burden; it is a bargain. Only those who can see only the bottom line on costs or those who overlook the importance of the sound principle that preventive screening should be free can overlook the excellent cost benefit that the free eye test represents.
I come now to the heart of the matter. In the past few days, we have seen high drama on whether the Secretary of State will succeed in facing down his hon. Friends the Members for Birmingham, Edgbaston (Dame J. Knight) and for Harlow (Mr. Hayes). Twice in one night the Secretary of State has taken on not only the Opposition but a large wing of his Back Benches. It is inconceivable that any man so urbane and well-rounded as the Secretary of State would go to all this trouble for the modest sum that he hopes to save. It is impossible that a man of his intelligence even believes that he will save any money from this proposal.
No Minister goes to all that trouble over such a doubtful prospect, but he may go to it for the sake of principle. I fear that the reason why the Secretary of State is taking on all-comers over this issue is the principle that, if the House swallows this proposal, it will swallow the principle of charges for any form of primary care treatment. All that is left is to decide what comes next—charges for a visit to the doctor, for cervical smears and for breast screening.
I end by coming to the point where Opposition Members differ from the dissenters on the Conservative Back Benches. We agree with them in opposing the proposal because it will be deeply damaging to the nation's health, but we also oppose it on grounds of principle, because we are committed to a Health Service open to all and free at the time people need it. It is in defence of that principle that we shall vote against the Government.
§ Mr. John Marshall
Much of what we have heard today has been predictable. Whenever the Labour party is in opposition and Health Service charges are mentioned, Labour Members have a knee-jerk reaction. In 1964, the Labour party promised to abolish prescription charges. By 1970, prescription charges had not been abolished, but were higher than they were in 1964. In 1974, the Labour party campaigned on a promise of abolishing prescription charges. By 1979, they still existed. I am willing to wager that, whatever they have said tonight, Labour Members will campaign in election after election promising to abolish these charges and then doing nothing about it, if they ever, by some mischance, find themselves in government. They have led the country down that path before, making promises and then not keeping them, and that is what they would do about these charges.
Much of the discussion about these charges is pure synthetic indignation. A charge of £10 to be met every second year is equivalent to giving up two cigarettes a week; how much better it would be for people's health if they gave up the whole lot rather than just two a week. Can people really say that no one can afford a charge of £10 935 every second year when the average industrial wage is £224? When I asked the Liberal party spokesman, the hon. Member for Southport (Mr. Fearn), about this, he said that there were people below the average industrial wage. Of course there are, but those who are poor and those with low incomes will not be paying prescription charges.
§ Mr. Marshall
No, I shall not give way. I promised to be brief and I shall be.
We are discussing a charge that will raise £70 million at a time when this country spends £2,458 million a year on betting and gaming. Are we saying that a society that can afford to spend that amount of money on betting and gaming cannot afford to spend £70 million on eye tests?
We are told that the charge will definitely be £10. We even had the absurd suggestion from the hon. Member for Livingston (Mr. Cook) that, because some people might not have a test, the opticians' reaction would be to put up the price, but he confessed to some doubts about market economics. I can assure him that there is no market place in the world where the supplier of a service reacts to a reduced demand by putting up the price. If he were to take a first-year course in elementary economics, he would be told that a reduction in demand leads to a reduction in price. Wherever one goes in our towns and cities, one sees competition among opticians in the main high streets. I am willing to wager that, when these charges are introduced, we shall find an optician in every town offering a free National Health eye test. As soon as one optician takes that step, the optician down the road will take it. Competition will ensure that the £10 charge will not increase, as Labour Members suggest, but decrease.
We must consider the proposed charges as part of a package that will lead to better primary health care and a better Health Service. We must ask ourselves whether it is right that those who can afford to pay a modest charge should receive a free service.
§ Mr. Fry
My hon. Friend is saying that those who can afford to pay should pay. I have much sympathy for that view, but has he considered the position of pensioners who do not pay income tax and receive no benefit from the state apart from their basic state pension? They will not be able to afford a charge of £10. What will be their position?
§ Mr. Marshall
My right hon. and learned Friend the Secretary of State made it clear this afternoon that someone who is in receipt of the basic pension will be in a better position than my hon. Friend imagines. Those who take a Rip Van Winkle view of life, suggesting that every pensioner has merely a basic pension and that there should be free eye tests for all those of pensionable age, are suggesting that Sir Robin Day, for example, should be given the right to enjoy a free eye test. What would people do to try to get on "Any Questions" on a Thursday night? It is surely not a correct sense of social priority to seek to provide free eye tests for Sir Robin Day at the expense of the general body of taxpayers, many of whom earn much less than he does. It is much better to target those who can afford to pay so that the Health Service can be improved. Do we want a better Health Service? Of course we do. That is why I shall support the Government and vote for the charges.
§ Mr. Ian McCartney (Makerfield)
For the past three hours I have been worried by the patronising, almost self-congratulatory and arrogant way in which the Secretary of State, the Minister of State and their supporters have dealt with the key principle of preventive medicine. The argument on principle is not confined to the proposed charges, and I welcome the fact that there is common agreement on both sides of the House that these charges foreshadow what the Government have set out in a secret manifesto that they will seek to implement during their present term of office or during the next one if, God help us, they win the next general election.
I shall deal with the issue in a way that is different from the one that has been followed by those who have preceded me. We have heard politicians arguing eloquently along the lines that are set out in prepared briefs. I shall advance an argument from the other side of the wall. I have had personal experience of the results that stem from the inability to receive preventive medicine in time to prevent blindness.
During the 1970s, when visited the House to see my father, who was then the hon. Member for Dumbarton, Central, I took ill. I was sent to Moorfields eye hospital, where it was found that I was suffering from Eels disease. For the following two years I was entirely blind in my left eye. I could see nothing apart from the light and colour that was visible through my right eye. Eels disease is especially nasty when it is contracted by men and women in middle age and pensionable age.
I was struck down with Eels disease in my mid-20s. Over two years I underwent 19 operations at Moorfields, some of which were of an extensive and complicated nature, using the latest laser techniques and other surgical procedures. I owe my sight to the "qualities" of the professors at that hospital and to the dedicated skill of those engaged in the prevention of eye disease and the restoration of the ability to see for those in my position —the magic of seeing again.
I received my sight back at some personal cost as a result of the social effects of my illness. There were also costs to the state and to my family. I had 19 complicated operations, the last three of which were of a type that Professor Hill had not tried before. Yet he carried them out in an attempt to restore my sight. Thousands of pounds were invested in that programme of operations by Professor Hill and the Moorfields eye hospital. I was not unique at the hospital. It was full of people suffering from permanent blindness, going blind or seeking treatment to restore sight as a result of the lack of preventive medicine in the community.
I suffered social effects as a result of my illness. For two years I was unemployable. For six months I was unable to hold my three-year-old son because even the smallest shake could cause a haemorrhage in the eye. Such haemorrhages are part and parcel of Eels disease. Eels disease and invitreous haemorrhages are caused by infestation of the eye which causes substantial and serious blood clots, many of which are inoperable. For the middle aged and pensioners who are afflicted that usually means the end of sight and the removal of the eye or, in some cases where both eyes are affected, it could mean total blindness.
The effects of such illnesses are not restricted to loss of employment and the cost to the state and the family that 937 that involves. Those illnesses also cause social problems in the family. They bring pressure on a family as it must come to terms with the fact that one central, important member of the family must accept the possibility of total blindness. The family must accept that the person concerned may be unable to work and have a career. The family might suffer a loss of income. Those factors have social consequences for the family. My family was no different from many families which suffer from blindness. I live with those consequences today in terms of my former marriage as the family could not stick together because of the nature of the illness and the pressures that it brought on the family.
When the Minister talks about vested interests, it is important to know what we are talking about. My vested interest and that of hon. Members on both sides of the House lies in the belief in the prevention of disease and illness because of their social and financial costs to the state. The doctors and professors whom the Minister attacked so glibly a moment ago left at their own expense within hours of the Bhopal disaster to go to India to try to prevent mass blindness among the people of that stricken town. The professionals have a vested interest in their own position and in the well-being of their patients and the community in which the patients reside.
One of the major arguments in the debate is about communities and preventive medicine. I am a child of the National Health Service. I was born in a steel and coal community in 1951. I have early recollections of the workings of the service. I was among the first generation to be born under the NHS. I saw the effects of inoculation, eye tests and screening as part of eye tests. I remember as a child that 50, 60 or 70 of us at a time lined up to take the tests in a working-class community. Preventive medicine is important to the community as an attempt to prevent disease and to ensure that the community is properly served in terms of facilities for all people.
The Government talk about cost-effectiveness and in my short contribution so far I have talked about how my illness affected me and my family. The Government argue that cost-effectiveness is irrelevant. My illness has resulted in a net loss to the community, both in terms of the cost to Health Service in trying to put right the damage to my eyes and the cost to the Exchequer of social security and sickness payments. It makes no sense to impose such a small charge and put at risk so many individuals in the community.
If the Government are really looking for a trade-off for this small amount of money, why not trade off some of the tax cuts that so many hon. Members voted for only a few short months ago? What about a trade-off with the assisted places scheme for educational attainment, the money that has been pumped into city technology colleges at the expense of the rest of the education service, or even half the money from the wholesale sale of the royal ordnance factories at a third of their market value? If the Minister is really interested in a trade-off, trade off those items, not the health and sight of many thousands of potential victims in Britain.
I know that many hon. Members wish to speak and, like me, have waited a number of hours to participate. I hope that when the Minister replies in his histrionic way he will not return to the blackmail of today's Autumn Statement. The House should be supreme in the 938 decision-making of this country and it should not be subservient to anybody, whether it be the Chancellor of the Exchequer or the Prime Minister. If the House decides not to impose these charges, the Government have a duty to come back here and put into the nation's budget the resources to provide that service.
Unless that is the case we are well on the way to having an elective dictatorship. That is another fundamental argument. Tonight the Government have been arrogant enough to name hospitals in the constituencies of those hon. Members who have argued persuasively against the Government. No stone has been left unturned by the Secretary of State in trying to denigrate the profession, or individual hon. Members who have argued against the Government's principles.
That leads me to suggest that it is not simply one or two additional charges that are at stake but the concept of who pays for preventive medicine in Britain. Therefore, in voting against this we are voting not just against the charge but against the whole concept of the market philosophy of this stinking Secretary of State—[HON. MEMBERS: "Withdraw."]—who is prepared to put at risk the sight of so many people for a few pounds. Hon. Members might shout. They have never understood the blackness of blindness and what it does to the individual or his family. I would never wish it on anyone. I can only say that I can stand here because I have been lucky. The opportunities given me by Moorfields eye hospital and the skill of its professors, nurses and doctors have enabled me to have my sight back. The tragedy is that for thousands that will not be the case. The Government's proposals mean that for many more blindness will be a reality.
§ Dame Jill Knight
I can assure the House and my right hon. and hon. Friends that there are infinitely better and calmer arguments in favour of retaining the Lords amendment than we have heard in the last few moments. I had thought that the financial advantages to the Government and the NHS of regular health checks were obvious. One reason why some of us are so concerned is that we do not believe that the Government have their sums right on this matter. The earlier that disease can be diagnosed, the cheaper and easier it is to treat and the greater the likelihood that the treatment will cure.
Preventive medicine means having a health check which discovers a disease at an early stage and then having something done about it. Some of us find it strange that the Government say that they will not do this, but will instead spend the money on preventive medicine. We truly believe that eye tests come under the heading of preventive medicine. This is the fence at the top of the cliff rather than the ambulance at the bottom of it. Everyone knows that that is more sensible and infinitely cheaper.
Since the Health Service began there have been many necessary changes, and I am not bothered which party introduced them. The fact remains that charges have been imposed for prescriptions and for various appliances as time has gone by. I entirely agree with that. It seems right and sensible that an individual, having been given a free test and discovering that a requirement exists—whether it be for spectacles, bridge work or whatever—should pay something towards the cost if he can afford to do so.
This debate is a fight to keep tests free and thus encourage people to take them regularly. That principle has never wavered in 40 years of the National Health Service. Other aspects have changed but never that. Tests 939 have always been free, and as a result of that rule thousands of people have had their sight and even their lives saved.
The early signs of many serious diseases reveal themselves in eye tests. I shall not rehearse them all because right hon. and hon. Members are well aware of what those diseases are. Almost 1 million people per year are referred for hospital treatment by optometrists who have discovered something wrong during testing. I understand that that number was the subject of some ridicule by one of my right hon. Friends, who said that not all of the 1 million people referred annually by optometrists ultimately needed treatment. Nevertheless, every single one of them was referred because it was thought that they should have a blood test or be checked for heart disease. The accuracy of an optician's referral is substantially higher than that of the general practitioner.
Earlier today, my right hon. and learned Friend the Secretary of State commented on radio or television—and as I did not hear the broadcast myself, I ask him to correct me if I am wrong—that opticians do not test for glaucoma, or that the eye test does not include a test for that condition. I do not know whether that is correct, but I assure my right hon. and learned Friend and all other right hon. and hon. Members that any person seen by a trained optometrist who is judged to be in an at-risk category will be checked. A child being given an eye test will not be checked, but that is no reason to say that the contribution made by opticians is not important.
I turn to one of the Department's own publications, "Health Trends", which points out that 72.5 per cent. of all glaucoma referrals to hospitals are made by opticians, while 23.7 per cent. are by general practitioners. That surely illustrates the value of the opticians' contribution, and the fact that they have saved the sight of many of their patients.
§ Mr. Peter Thurnham (Bolton, North-East)
I refer my hon. Friend to a letter that appeared in The Times yesterday from two consultant surgeons at Moorfields Eye hospital, who in referring to glaucoma commented:There is no evidence that early diagnosis necessarily halts the progress of the disease, which in any case only leads to visual disability in a small minority of cases.
§ Dame Jill Knight
My hon. Friend would have been wiser to read The Times today as well, because his point was answered in a letter to it. The two gentlemen who wrote the letter are, I understand, retired and no longer work in that hospital. It is possible to produce this quote and that quote; all that I can say is that the quote that I gave is from the DHSS itself. The figure is accurate and, I should have thought, one that the whole House could accept.
I hope that the House agrees that regular health checks are a good thing and should be encouraged. The Government's case is that charges will not discourage. We heard earlier this evening that checks by dentists showed a drop when extra charges were brought in. Charges have never been made for eye tests, so how can we judge at this stage whether demand will go up or down? What is interesting, however, is that some ophthalmic opticians in the United Kingdom still have figures showing a dramatic increase in eye examinations when they became free in 1947. I know that that is not a complete answer, but if 940 many more people took advantage of the free eye test when it came in, surely it is reasonable to suppose that the reverse may well happen.
Charges for eye tests in Alberta, Canada—as the hon. Member for Livingston (Mr. Cook) mentioned—were brought in very recently. Incidentally, they were levelled only at those between the ages of 19 and 63: people of pensionable age were not charged. But the drop in demand of 30 or 40 per cent. was so worrying for the Government that they took only 11 months to reverse their decision. My hon. Friends and I ask the Government to listen to what we are saying, because they too may have to reverse their decision if the vote goes the wrong way this evening.
There is no doubt in my mind that there will be a drop in demand, and my view is shared by all the professional organisations—including the British Medical Association, which cannot be said to have a financial or fiscal interest. My right hon. and learned Friend says that most people can afford to pay something for a test, and that those who cannot afford it will not have to pay. It is true that under my right hon. Friend the Prime Minister, Britain is more prosperous than ever before, and many more people have money in their pockets. But the House must not fall into the trap of imagining that everyone outside this building finds it as easy as we inside it do to put his hands on £12 or £15—for I warn hon. Members that the price of an eye test will be somewhere between those sums.
§ Mr. Bennett
Surely if people are deterred by the £10 or £12 that my hon. Friend says will be charged they will be equally deterred from buying spectacles if they need them; but she is not advocating free spectacles.
§ Dame Jill Knight
I do not think that point worth answering. I am saying that the cost of a test for people outside the House will be difficult to meet. Besides, no one has yet pointed out tonight that spectacles will be much more expensive because the Government have been forced to put VAT on them for the first time. Not only will people have to pay for their eye tests, but they will have to pay much more for their glasses.
I am extremely concerned at everything that I have heard this evening about pensioners. It is simply not good enough to say that as a country we spend so much on beer, so much on tobacco and so much on gambling. Not everybody spends money on beer, gambling or tobacco. Many people write to me and come to see me in my surgery about some of the more recent changes, such as those to housing benefit, saying, "I do not gamble, I do not smoke and I do not drink, yet I am finding it a hard job to manage."
I am very troubled about pensioners. Of course my right hon. and learned Friend is quite right to say that not all pensioners are poor. But we should not disregard those who are poor because they are more at risk than anyone else. After pensionable age, eyes are more likely to become diseased, so pensioners are in real need of regular care. Undoubtedly some early diagnoses will be missed, and it will be more expensive. Furthermore, members of the public are well aware that they are entitled to free eye tests in hospitals and many will go there. Like the dentist mentioned by my hon. Friend the Member for Great Yarmouth (Mr. Carttiss), many doctors know when their 941 patients are hard up and some will refer them to hospitals. The silly thing is that it costs the Government nearly three times as much to have an eye test done in the ophthalmic department of an eye hospital than they currently pay to an optometrist in the high street. It costs about £28 outside London and £30 in London, whereas they are paying the opticians £10. Where is the economic sense in that?
My right hon. and learned Friend and some other hon. Members think that optometrists will provide tests free. That is absolutely ludicrous. Why should they do that? Those men and women are professionals who have studied and trained for four or five years. It is like telling a doctor, "You can give your professional services free. Nobody will pay you for your professional services and you can make your money from bandages." That is ridiculous. Why should professional men and women who have studied and worked in their profession be expected to provide their services free?
Furthermore, the Government have already taken steps to ensure that when a patient has had the refraction, he must be given a prescription so that he or she can buy glasses elsewhere. The patient is free to go to the boutique down the road. An optometrist will not be able to say to a patient, "I have tested your eyes. You will buy your glasses here, won't you?" I have a letter from the Parliamentary Under-Secretary of State saying:Opticians will be prohibited from offering sight tests on condition that any spectacles required are purchased from their business.The Minister has already knocked one leg off the optician by saying that he can do a refraction and the patient can walk out, so he has done the test free. How can the optician keep his doors open? Furthermore, 25 per cent. to 30 per cent. of people who have an eye test are found not to need glasses. So there are two groups of people who walk out of the opticians, and the optician is paid not a penny. How will he pay his rent, his rates and his receptionist? It is an extraordinary argument.
Finally, is it fair that people who need glasses should subsidise those who do not need glasses? That is what will happen. If the optician is expected to provide free eye tests, he will have to put more money on the glasses that he is able to supply. That does not seem to be fair.
I know that the Government did not wish to put VAT on spectacles but it will greatly increase the cost. Why cannot the money brought in from VAT be used to keep the test free? Tonight we are talking about the breach of a principle that we have held to since the very beginning of the National Health Service. For the first time we are breaching a rule that was introduced for a very good reason.
It appears that the Government have already agreed that ready made spectacles should be available without a prescription. If ever I heard of a way in which to ensure that people do not get their eyes tested, that is it. People will have to pay quite a lot for the eyesight test and more for their glasses, so they may decide to get a ready made pair from Woolworth's.
§ Madam Deputy Speaker (Miss Betty Boothroyd)
Order. The hon. Lady is coming to a conclusion, but it is extremely rude of hon. Members to have loud conversations during her speech.
§ Dame Jill Knight
I am indeed finishing. I am worried by that final deterrent to getting a test. The free test is important to the Health Service, important to the economy and important to health. I shall go into the Lobby in support of that principle.
§ Mr. Loyden
The House may have had some sympathy for the Secretary of State at the beginning of the debate as he had to argue an indefensible case, but he did not tell us what merit the Government's proposals have. He has dealt with the issue in a cavalier fashion. When hon. Members have illustrated the dangers of doing away with an important facet of preventive medicine, he has used an argument based on the financing of the NHS.
Like my hon. Friend the Member for Makerfield (Mr. McCartney), I have an interest in glaucoma although, unlike him, I did not know that I had an eye disease. I went for an eye test and was referred by the optometrist to the local eye hospital where glaucoma was diagnosed. I did not know what it was. The same probably goes for about 80 per cent. of the population. I had to go home and read the dictionary. It was rather old and said that glaucoma is a disease of the eye which can result in bursting and total blindness.
Thanks to advances in that segment of the Health Service, that is no longer the case, but early detection is essential if the disease is to be arrested. I sometimes think that the Secretary of State does not understand what it all means. If he does, he is acting in the worst tradition of a Secretary of State responsible for the Health Service. Having listened to the debate, any Secretary of State could not but be persuaded to change his mind.
The argument in favour of the free test has been won tonight. Conservative Members who have listened cannot fail to oppose the Government's proposal. The Secretary of State ought also to bear in mind the fact that people who cannot find the £10 or so that is to be charged are likely to go to eye hospitals such as the one I attend fairly regularly. If the right hon. and learned Gentleman goes to those hospitals, he will realise that cuts in the NHS have meant that people in St. Paul's eye hospital in Liverpool spend between three and five hours in waiting rooms waiting for attention, diagnosis and treatment. If people are deprived of eye tests by opticians, those waiting times will increase as general practitioners refer their patients to hospitals if disease is suspected. This will add to, rather than reduce, the costs of the NHS.
The Secretary of State presented a facile argument to the House. He is doing a disservice to the Health Service by denying people the right to access to a part of preventive medicine. I said earlier that I was dissatisfied with the rate at which the Health Service was moving towards prevention. The Under-Secretary, who allegedly supports preventive medicine, should vote against these measures.
All the aspects which are considered to be an advantage of the Health Service and a part of preventive medicine contribute greatly to people's well-being and health. No Secretary of State has the right to increase the risk of undetected glaucoma and other diseases as this Secretary of State is doing. He is increasing the possibility that a person will end up in hospital for a major operation when 943 his condition could have been detected early and that he will be required to attend the hospital once every six or nine months for treatment.
This is damning evidence of the way in which the Government have treated the National Health Service and further evidence of their aim to change or dismantle it. Every charge that is made is a further erosion of the NHS. Every charge for screening, which is part of preventive medicine, erodes the nature and value of the Health Service and the benefits that have accrued from it. The whole House should reject the flimsy arguments put for the proposals. The Secretary of State has not made out a case on medical grounds. He has referred constantly to market forces. He talks about people going for eye tests merely because they require spectacles. Surely that is the whole point. Of course, they go for spectacles, and then they find out that something is wrong. They are referred to a hospital and treatment takes place. By his decision, the Secretary of State will deprive people of access to a part of preventive medicine. We should condemn him outright for that.
A further chance is being given to Conservative Members. The Opposition cannot defeat the Government and carry the amendments, but Conservative Members should go into the Division Lobby and do exactly that.
§ Mr. David Shaw (Dover)
I support the Government on the issue of introducing charges for those who can afford to pay. My reasoning is similar to that which led the Conservative Opposition to support the Labour Government in 1951, when Labour first imposed charges on spectacles and dentures. Labour's Health Minister gave four criteria for introducing charges. The first criterion was that more money should be made available to the NHS. That is exactly the argument which we put forward—there should be more money for use within the Health Service. In 1951, the Labour Government were worried about whether the elderly were getting proper treatment under the Health Service. The Labour Government were concerned about hospital services and waiting lists and whether the hospitals were getting enough money. That is precisely what this proposal is about. It was as true then as it is now.
The Labour Minister went on to say that the charges were useful because they could be imposed in such a way that they would have virtually no effect on seriously ill people. That is also true today. The charges were not costly to collect—then or now. The Labour Minister also said that the charges were useful for deterring abuse, not that there was much abuse of the tests. The same applies today.
I have one reason for saying that the charges are sensible that did not occur to the Minister in 1951: fairness. About 21 million people will be exempt from these charges, which could not be said of the Labour proposals in 1951, or of any subsequent Labour proposals.
The proposals are reasonable because only those who can afford to pay will have to. It is interesting to read in Hansard what Labour Members said in 1951. Nye Bevan described the charges as a mutilation of the NHS. Many other Labour Members suggested that the charges were the end of the Health Service. The Labour Health Minister suggested that the debate was getting out of proportion. It has not changed much since then. Meanwhile, the NHS has gone from strength to strength, the forebodings of Nye 944 Bevan and the warnings of many other Labour Members notwithstanding. It has done so especially under Conservative Governments such as this one.
It is worth noting that almost all the Labour Members who spoke against the charges in the House in 1951 voted for them in the Lobby afterwards.
§ Mr. Elliot Morley (Glanford and Scunthorpe)
What charges for testing for the identification of the early stages of diseases have any Labour Government brought in?
§ Mr. Shaw
The principle of charging is exactly the same now as in 1951, when the Labour Government introduced charges. Hugh Gaitskell introduced them on the four criteria I outlined earlier, and on the basis that they represented better use of NHS money. That is the key. The eyesight test does not, in itself, improve people's sight. Taking action, having treatment and wearing glasses do that. Government action to increase the use of spectacles has done far more for improving people's eyesight than anything else.
In 1984 the Labour party fought like mad against the introduction of privatisation and competition in providing spectacles and eyesight testing. Now, more spectacles are sold than before, more people go for tests, and the public are more aware of the efficiency of the private sector. That is why I believe, with my right hon. and learned Friend, that the private sector would absorb the charges over time. It will want to expand to its business. It is in its interests to attract more people for testing.
This measure, given the concessions made by the Government for glaucoma and diabetes sufferers, is fair and correct. The Labour party is dishonest about imposing charges. Many of the founder supporters of the NHS supported the Government who brought in charges in 1951. We now have a better service, whose costs people appreciate better. Many of the fears expressed in 1951 and 1984 have proved unfounded. I have no hesitation in supporting the Government; the Lords amendment should be rejected.
§ Mr. Fearn
Much of what I said in the earlier debate applies to the introduction of charges for eye tests. I repeat what I said last December: the proposed charges for eye tests make a mockery of the Government's announced intention to improve preventive health care.
The original 1986 Green Paper, page 32 item 4, states:Free NHS sight tests and prescriptions are maintained for everyone who needs them. The sight-test can identify health problems as well as a need for spectacles, so it is important that skilled sight-testing should remain readily available.I want to know what the Government consider to be "readily available". A charge of £10 will make it virtually impossible for many parents, young people in their first jobs and those in part-time or low-paid employment, many of them elderly, to avail themselves of any sight test. Once again, the Government appear to be acting against the recommendations of all the professional groups and voluntary organisations with experience in this area, all of which claim that the introduction of a charge for the eye 945 test would negate the aim of the promotion of better health. Patients will be deterred, and eye diseases and other conditions will go undetected.
The financial savings that the Government expect to make have also been challenged. It is expected that more patients will visit their general practitioners who, in turn, will have to refer them to eye hospitals. There is the added cost of the treatment of disease and conditions which, if detected, could be remedied at less expense.
We are not simply discussing finance. It is a question of people's lives and the quality of those lives. Are hon. Members willing to introduce proposals that may lead to unnecessary discomfort, poor vision and, in some cases, loss of sight? Are we content that people who may already be hampered by the disabilities that come with age—and that will eventually affect us all—will be put under further stress because they cannot afford £10 or more for a sight test? Are we willing to introduce a measure that may prevent people with diabetes, blood pressure and other conditions from obtaining an early diagnosis and treatment? If this House is interested in prevention as part of the health care of the nation, it will support the Lords amendment and encourage opticians to give more extensive eye examinations and the population to have more regular checks. That could be as effective as other screening programmes.
There have been suggestions that competition in the sight test market will reduce the cost or even eliminate it. I very much doubt that, as most consumers know that nothing comes free these days. Any freebies such as free estimates are always absorbed into the cost of the product, making it more expensive.
On 20 October the Prime Minister, as reported in the "Parliamentary Health Monitor" of 31 October, said that she thought it reasonable for people to pay a modest charge for something fundamental to their health. I am pleased that she recognises that such tests are important to an individual's health, but I question her assessment of a modest charge. It may be modest to someone like the right hon. Lady who enjoys certain comforts, but £10 is not a modest amount to the many people who have far lower incomes.
I remind the Prime Minister and the Secretary of State that the British people already pay charges for their health care through the system of general taxation—not just income tax, but VAT and other taxes. That means that virtually everybody contributes to his or her health care and, as opinion polls show, would be willing to contribute more through that method.
I hope that many Conservative Members will recognise that the introduction of charges will be harmful to prevention and promotion in health care and to the long-term effectiveness of the system. I hope that they will vote with Opposition Members in support of the Lords amendment. In doing so, they will also be sending a message to thousands of their supporters saying that they really care. That, I doubt.
§ Mr. Hayes
I wish at the outset to deal with the rather unpleasant rumour that an altercation occurred earlier between my hon. and learned Friend the Minister of State and myself. What my hon. and learned Friend said was 946 said in the heat of debate and, I understand—because I have known him as a friend for the last five years—was said in fun. I did not take it personally, nor did he, and I hope the matter can rest there. I sincerely hope that there is no wicked press circulation of any rumour about bad blood between us because I assure the House that there is none.
I shall be brief because many of my hon. Friends wish to speak. A peculiarity of tonight's discussion is that we have been dealing with the subject of preventive medicine. While the Bill may be concerned with preventive medicine, the provisions that we have been debating tonight have nothing to do with that. They have everything to do with money.
A year or so ago my right hon. and learned Friend's predecessor was rolled over by the Chief Secretary to the Treasury who, as we know, is an able and talented Minister with a wonderful way of dealing with ferocious Cabinet Ministers. He invites them into his office and for some reason they roll on the floor and let him tickle their tummies while he takes their wallets. The trouble is that those Cabinet Ministers then expect us to bail them out, and we cannot do that.
The Secretary of State has not been a soft touch. He came to the House today with a very good health package indeed, and all credit to him. But to talk of £140 million as a major sum is utterly ridiculous. It is probably equal to the Foreign Office lunch bill. And as for the £27 million which would exempt the 6.5 million pensioners in question, that is probably equal to the Deputy Leader of the Opposition's lunch bill.
I remind hon. Members that it is easy to score party political points. While we have been talking about those who can afford to pay, according to the Royal National Institute for the Blind, 78 per cent. of the population between 78 and 85 years of age have major eye disease, yet 50 per cent. of pensioners still live on or just above the poverty level. The top 20 per cent. of retired households with more than twice as much income as the 80 per cent. below them pull up the national average, and for far too many pensioners who do not qualify for a sight test any charge will act as a significant deterrent.
My right hon. and learned Friend is saying, in effect, "I will take a risk. I do not know how much it will cost ordinary people and pensioners. It could be £10, £15 or absolutely nothing. We will leave it to market forces." But 70 per cent. of optometrists' incomes come from sight tests. From where will the other 30 per cent. come? Clearly, it will be loaded on to the price of spectacles and contact lenses.
About 6.5 million pensioners are particularly at risk. It is absolute nonsense to pooh-pooh the idea that going to the optician is not total screening, and that has disturbed me in relation to some ministerial statements made this evening. Optometrists can diagnose diabetes, glaucoma and cataracts—diseases that are particularly prevalent among those over the age of 60. People over the age of 60 need to have their eyesight tested regularly. In future the poor devils will not know that they have diabetes or glaucoma or cataracts until it is too late.
We should be trying to encourage people to visit their optometrist, optician and dentist. If a charge of f 10 or £15 is slapped on to the sight test, as I believe will happen, those pensioners just above income support—whom Ministers tell us will not get any support from the state—will have to make a choice between paying their gas or 947 electricity bills—[HoN. MEMBERS: "Don't be silly."] Sadly, some of my hon. Friends are telling me not to be silly. It will be interesting to see how many letters they get from their constituents when it gets colder—perhaps from the same constituents who have been clobbered by the housing benefit changes over the past few months. Some pensioners will have to choose between paying their fuel bills and going to the optometrist to have diagnosed any diseases from which they may be suffering.
This evening we could prevent much pain and suffering, and a great deal of money could be saved for the National Health Service in the long term.
§ Mr. Nicholas Bennett
I have listened carefully to the debate since 5.30 this afternoon. It has become clear that this is a debate about priorities and about deterrence. My hon. Friend the Member for Harlow (Mr. Hayes) is wrong to describe the sum of £ 140 million as trivial. It would pay the total costs of my local health authority six times over, and it would buy two completely new district general hospitals. We must ask ourselves whether we are right to regard expenditure on eye tests for those who can afford them as a priority or whether it would be better to divert that money to other aspects of the Health Service.
The problem goes right back to the beginning of the Health Service in 1948. The other day, I was looking at the minutes of the Labour Cabinet of 13 December 1948. Aneurin Bevan, after only five months—[Interruption.] Hon. Members may not be interested in priorities, but Aneurin Bevan said that Socialism was about the language of priorities. The Labour Cabinet found that in only five months of running the NHS the total cost had risen 30 per cent. above the estimates of July of that year. We have to make difficult decisions about where money should be spent in the Health Service, and I do not believe that it is unreasonable to ask those who can afford it to make a modest contribution towards the cost of their health.
If there is no competition between opticians and if the cost is not subsumed in other charges and through opticians maximising their custom, the charge will still be no more than the equivalent of the cost of five or six pints of beer in the more expensive public houses. It will be equivalent to twice the average weekly spending on tobacco in this country, half the price of a tank of petrol and about three Chinese take-away meals. That is to put the charge in the context of those who can afford it.
We are told that 62 per cent. of people are to pay the charge and 38 per cent. are to be exempt. Sixty-two per cent. is exactly the percentage of the population who own their own homes and it is smaller than the percentage of people who own telephones or cars. Are we really saying that people can afford to own their own homes, cars and telephones, yet that they cannot afford to pay a £10 charge for an eye test? I do not believe that that is a reasonable view to take of how people spend their money.
The argument about deterrence is an arrogant one because it says that working people are so stupid that they are not prepared to spend a small amount of money on looking after their health. I do not believe that that is true. There is no evidence that the increase in prescription charges during the past 10 years has deterred people from taking care of their health. It is a small and useful measure to send money to where it is needed and to ensure that people have a right to make a small contribution towards their health. I support the Government.
§ Mr. David Blunkett (Sheffield, Brightside)
I did not intend to address the House on this issue until the hon. Member for Pembroke (Mr. Bennett) had the audacity to talk about three Chinese take-away meals in the same breath as talking about preventing people losing their sight by having an adequate eye test. I believe that that is deplorable. There are many arguments about whether people would pay to have a test to ensure that they were certain that they would receive adequate medical attention for a problem that they had experienced. We shall not further debate in the House by lowering it to the question whether people will buy consumer goods as opposed to having their eyes tested.
Many people who are worried about a problem—whether it is something that has occurred in old age or something that has come over them while they are young —face the trauma of deciding whether to consult their GP or to have their eyes tested because they are uncertain whether it is a serious matter or a passing phase. As many people have said over the past few weeks, if money can be saved by ensuring that a problem is picked up during its early stages by giving people the opportunity of having their eyes tested easily and cheaply and either being reassured or having action taken at a stage when long term problems can be prevented, no one in the House or in this country should deny that person the right to a free eye test. It does matter what happens to other people around us. We have obligations and responsibilities to help each other —not just those who are deserving and responsible because they do not spend their money on three Chinese meals. What happens to the person living next door and to the person sitting next to us tonight is the responsibility of all of us. If by spending a small amount of money we can prevent the deterioration of a person's sight and money being spent on putting right long-term problems, every hon. Member, whatever his politics or ideology, has an obligation to vote to defeat these charges.
§ Mr. Maxwell-Hyslop
We can sum up the debate by asking two questions. Do we wish to encourage people to have their eyes tested or to discourage them? I think that the question answers itself: we want to encourage them. The evidence for that has not been challenged. Secondly, do we want to lengthen the waiting list for out-patient clinics at ophthalmic hospitals or at the ophthalmic departments of general hospitals, or do we not? The answer to that is clearly and obviously no. On both those bases, therefore, we should vote to sustain their Lordships' amendment.
§ Mr. Thurnham
I speak in support of my right hon. and learned Friend the Secretary of State because we know for a fact that this measure will raise £80 million for the National Health Service and we have to weigh that in the balance with the theory that the charge will be a deterrent. I do not believe that it will be a deterrent, but there is no way that we can prove that. I do not believe that there is such a thing as a "free" test because the tests have to be paid for and the cost recovered in one way or another.
Those who argue that charges are a deterrent in one sense must also accept that they are deterrents in another sense because if the money is not raised from the people who benefit from the test, it will have to be raised from the taxpayer. There is then a deterrent for those who have to 949 earn the income with which to pay the taxes. We know what happens when the Labour party is in power—we have taxes—
§ Mr. Christopher Hawkins (High Peak)
If my hon. Friend really believes his argument, should we not charge people to go to a general practitioner, or charge for cervical smear tests and for breast screening on the ground that that would raise money for the Health Service?
§ Mr. Thurnham
My point is that if we have taxes at the level that the Labour party had when it was in power, we know exactly what happens to the economy. The Labour party was the party that had to cut hospital building. The Conservative party is the party that raises the funds to build the hospitals. In 1977 the International Monetary Fund had to bail the country out. That was when hospitals faced cuts.
It is for those reasons that I support this measure, which will raise more money to enable the hospitals that we need to be built. I have weighed that in the balance with the theory that charges might be a deterrent. I believe that those people who feel that they want a test will go to have that test and they will pay for it because they are benefiting from it. They will pay for it either directly or through charges for their spectacles, if they need them. If anybody is deterred from seeking a test, I imagine that it will be the 25 per cent. who currently go only to find that they do not need spectacles. It is for that reason that I support my right hon. and learned Friend in raising funds by this measure which can do nothing but improve the National Health Service for the public.
§ Mr. John Hunt (Ravensbourne)
I have found tonight's debate a profoundly depressing parliamentary occasion. I am bound to say that I regard the proposal to charge for sight testing, at whatever level that charge is eventually set, as mean and misguided. In spite of the confidence and conviction of my right hon. and learned Friend the Secretary of State that charges will not be a deterrent, I believe that they will serve as a deterrent to those most at risk.
I am sure that it will not have escaped the attention of my right hon. and learned Friend that the opposition to these proposals from this side of the House spans the spectrum of our party. Wets and drys are for once united in a common cause and are speaking with one voice in defence of preventive medicine. That is a point of considerable significance. I am surprised and sorry that, faced with this expression of deep and genuine concern among a wide range of the members of our party, Ministers have shown such a reluctance to respond to those genuine concerns.
I advise my right hon. Friends on the Front Bench that charging for eye tests is destined to do maximum political and social damage with minimum benefit, either to the coffers of the Treasury or to the reputation of our Ministers and our Government.
I know that some of my hon. Friends are especially concerned with the impact of the charges on the lower paid. I would certainly not dismiss that concern, but my special and specific concern tonight is with pensioners and with the impact of the charges upon them. We know—we have been told—that to exempt that category will cost £27 950 million per year. However, I have already told my right hon. and learned Friend that in terms of the Treasury's book-keeping, that is petty cash.
Of course, we all welcome the additional funds for the National Health Service announced by my right hon. Friend the Chancellor this afternoon, but surely that begs the question. If we can find an extra £2 billion for the National Health Service and if we can make massive debt repayments, surely we can find the £27 million that is necessary to exempt the pensioners from this charge? That is the answer to the argument by my hon. Friend the Member for Pembroke (Mr. Bennett) about priorities.
However, it appears that, for the sake of a minimal saving in public expenditure, we are prepared to put at risk the sight of the elderly. This is not crying wolf. Let us make no mistake about it. The elderly are particularly vulnerable and are likely to suffer from the diseases about which we have heard—glaucoma, cataracts and hypertension, all of which can be detected at an early stage by regular sight tests. My hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) has reminded us that almost one million people a year are referred for further medical investigation following an eye test. I understand that more than half of those are over 60. That shows the potential danger of introducing this charge.
We are told that a charge of £10 or £15 will not deter and that the Government object in principle to across-the-board benefits. I can say in answer only that, from my experience, the more wealthy pensioners seek private treatment anyway, but anyone who has regular contact with the elderly knows that, even if they are well off, they fear for the future. They watch every penny and avoid spending money whenever they can. My worry is that, faced with a charge of £10 or more for an eye test, they will keep putting it off. They will make do with their glasses and, in the process, often serious and irreparable damage will be done to their sight.
That is why, even at this late stage, I beg Ministers to think again about this policy. Unless they do, there is no way that I can go into the Lobby with them tonight.
§ Mr. Robert G. Hughes (Harrow, West)
Earlier this evening, the hon. Member for Makerfield (Mr. McCartney) told us of his experience when, in his twenties, he lost his sight. Like every other hon. Member, I listened carefully to what he said, but if I believed that, because of these proposals, the care that he received at Moorfields eye hospital would be withdrawn and the condition that he brought to our attention would not have been brought to anyone's notice, I would not vote for the proposal. However, I do not believe that that is the case. I hope that the hon. Gentleman will accept that, although what he said to the House was harrowing, personal and important, it is not relevant to tonight's debate.
§ Mr. Flannery
The hon. Gentleman, with the best of motives, has completely misjudged the issue. My hon. Friend the Member for Makerfield (Mr. McCartney) was talking about a different matter. We are discussing those people who go to an optician, perhaps for spectacles, and discover that they have glaucoma. My hon. Friend was talking about something peculiar to himself and he obtained the necessary treatment.
§ Mr. Hughes
I shall make clear later my views about that matter. The hon. Gentleman makes an important point and I shall not duck the issue. If he is not satisfied, he can deal with the matter in his speech.
I want to refer to the Health and Social Security Act 1984. My right hon. and learned Friend the Secretary of State has quoted what Opposition spokesmen said at that time. There can be no doubt that the arguments advanced by the Labour party were fundamentally flawed. Opposition Members said that, as a result of the measure, people would go blind and the price of glasses would increase. [Interruption.] If Opposition Members do not believe me, they should read the relevant debates. The hon. Member for Holborn and St. Pancras (Mr. Dobson) said that, as a result of the measure, many people's eyesight would suffer and that the Government's proposals would reduce choice, abandon consumer protection and put up the price of glasses. Nothing could be further from the truth. We know that prices have been reduced in the high streets while consumer choice has increased.
The Labour party was not alone in getting it wrong in 1984. The arguments that were advanced by opticians and the ophthalmic trade at that time and those that they are advancing now are almost identical. They were wrong in 1984, and in my judgment they are wrong now. In 1983, Mr. John Thorpe, on behalf of the Society of Opticians, said:Spectacles may be cheaper, except for those who cannot see.That argument was wrong then and I submit that it is wrong now.
Only two years after the 1984 legislation was enacted, glasses sales increased by 10 per cent. During the same period the number of eye tests increased by over 1 million. The nub of the argument—I take up the point which the hon. Member for Sheffield, Hillsborough (Mr. Flannery) made in his intervention—is whether people will be able to pay the proposed charge, but it is my judgment that the charge will not be levied. The 1984 Act, which revolutionised the industry, has done much to bring greater consumer choice and reduced prices. It has led to many major companies slogging it out in the market place to make sure that they get their share of the market. Those who benefit from their struggle are those who need spectacles. Companies will not want to relinquish their market share and I believe that they will offer free eye tests.
We are talking of a profession that guards its standards carefully, which means that it will offer proper eyesight tests. Anyone who suggests otherwise is insulting the opticians' profession. I believe that the Lords amendment will be rejected and that the proposals of my right hon. and learned Friend the Secretary of State will lead to wider availability of eyesight tests. The Bill will act as an incentive for the public to get their eyes tested, not as a disincentive. [Laughter.] The predictable laughter of Opposition Members is the same ill-informed laughter, with the same ill-informed comments, that we heard from them during our consideration of the 1984 measure. They did not understand the market then. They did not understand what consumers wanted or what was happening. It is clear that they still do not understand the market. If Labour Members want to speak, let them make their own contributions to the debate.
952 I support my right hon. and learned Friend the Secretary of State. When we reflect on this measure, we shall understand that he was right. His judgment is good and it will lead to opticians providing a better service.
§ Mr. Michael Irvine (Ipswich)
The hon. Member for Livingston (Mr. Cook), as he sometimes does, let his guard drop for a moment when he dismissively referred to the £70 million that the proposed charges will save as a "modest sum". That is the kind of cavalier attitude to public expenditure savings which in the long term does real damage to the National Health Service.
Over the years the NHS has suffered considerable capital investment damage through financial indiscipline and a cavalier attitude to public expenditure savings. The fact that the charges will save £70 million is not to be scoffed at. That money will be ploughed back into primary health care and will provide £70 million of extra resources for the NHS.
The hon. Member for Livingston should be aware that the merit of the charges does not stop there. If we provide services for free, be they medical or optical, there will be waste of public resources which could be better used elsewhere.
At that point the debate links up to the very serious matter of whether people who need eye tests will be deterred from taking them because of lack of means. The 36 per cent. who will be exempted are all right, but it is wrong to look at the remaining 64 per cent. simply as a group of affluent people. That is not the case. Certainly many of them are affluent and can well afford to meet the fees. They should certainly meet the fees. However, I acknowledge that there is a not insignificant number of people who are just above the exemption limit for whom there is a risk that the charges will prove a deterrent.
The competitive effect of the charges will come into force here. They will have such an effect because they will introduce market forces into an area where those forces are needed. To date the optical profession has had things too easy. It has had a captive amount of money from the Government for some time. It will now have to compete in the market place. As sure as night follows day it will drop its prices. Some within the profession will offer free optical tests. I confidently forecast that the Government will save £70 million and there will also be the widespread availability of free optical tests. Market forces will come to bear and the charges will have a beneficial effect.
I ask my hon. Friends who are teetering on the brink of rebellion and are not quite sure whether to go over the edge to consider those factors carefully. My hon. Friend the Member for Staffordshire, South (Mr. Cormack), who is in that position, wants to make things clearer.
§ Mr. Patrick Cormack (Staffordshire, South)
Does my hon. Friend think that some of the opticians will give free washing machines—[Interruption.]
§ Mr. Irvine
I would not extrapolate the argument quite that far, but my hon. Friend has got the general thrust. On that happy note, I conclude my remarks.
§ Mr. Mellor
I trust that the mood of euphoria that my hon. Friend the Member for Ipswich (Mr. Irvine) has so successfully created may be continued for the remaining minutes of the debate.
953 I begin by thanking my hon. Friend the Member for Harlow (Mr. Hayes) for the friendly comments that he incorporated in his speech. I entirely reciprocate them and for my part I am sorry if the badinage between us appeared a little more serious than it habitually is in the conversations that we have had together over the years.
The House should focus on a further example of increased provision within the Health Service when considering the background to the issue; one in which a considerable amount of progress has been made in treating fundamental and difficult eye disorders that arise within our society. Take, for instance, the distressing problem of cataracts. In 1976 there were 40,000 cataract operations. I am not making a party point. I am talking about the development of the service. By 1985 there were 59,000 cataract operations. Our target is to take that up to 70,000 by 1990 and I am confident that that will be achieved.
It is not just a question of ensuring that the treatment is available to deal with these difficult conditions. It is also important that we increase people's awareness of the significance of their eyes and the importance of not taking their eyes for granted, even when it appears that there is no reason to consider that they are in difficulties.
That is why, once again, the resources that the Government are making available, above and beyond what was made available by any of their predecessors, are aimed at trying to encourage eye awareness by proper promotional campaigns and to ensure that there is a proper supply of professional people at all levels of the service able and willing to deal with the rectification of these problems.
That is the way forward, the way in which we can ensure that the maximum number of avoidable eye conditions are detected early. That is the way we shall ensure that the community genuinely sees the necessity of having regular checks. Once again we are in exactly the same situation that we were in with dental charges. While a lot of people do go, even more do not, and it is overall eye awareness that needs to be raised.
Essentially, the argument comes down to this. The Government believe that against a background of over 20 million exemptions and the fact that most people will require an eye test only every two years—the recommended period—while many people leave it perfectly safely for three years, a £10 charge is not a burden in an increasingly prosperous society.
§ Mr. Gary Waller (Keighley)
My hon. and learned Friend referred to deterrence and the debate hangs to a considerable extent on whether people will be deterred from having eyesight tests. Will his Department have access to information about the number of eye tests being carried out, and, if it is discovered after a reasonable period that people are being deterred by any action taken by the House tonight, will the matter be looked at again?
§ Mr. Mellor
I appreciate that a number of people, like my hon. Friend, are worried about the matter. Yes, statistics will continue to be kept of NHS eye tests—those that continue for the exempt 20 million. We shall, by samples and other scientific ways, find out whether the number of eye tests in the rest of the community is growing on the same basis that it has been growing in recent years.
954 Of course, all this turns on the assessment that sensible people make of the evidence. Plainly, in such issues it is perfectly reasonable for one group of people to arrive at one conclusion and for others to arrive at another. I shall later say why I believe that what we have decided is based on a proper inference drawn from previous occasions when, for instance, we deregulated the optical industry.
Clearly, we shall want to monitor the consequences of the change. Of course we recognise the need to reconsider any aspects of these arrangements should the evidence require it. I hope that my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) and other right hon. and hon. Members who are concerned about this aspect will accept that that is said in good faith and that it will be carried through by the Government.
The opportunities offered to the profession will give opticians the prospect of building on the skill and experience of optometrists in offering the kind of service that the community needs, so encouraging people to make more use of their services. I quote from an article by Marvyn Slater, a Fellow of the British College of Optometrists, published in The Daily Telegraph on 18 October:With the prospect of a revitalised private service on the horizon optometrists can stop relying upon spectacle sales and offer their unique skills—the management of healthy eye disorders, visual ergonomics, visual and neurologically related educational disorders, industrial consultancy, low vision aids and assessment—to the 50 per cent. of the population who will be ineligible for NHS sight tests.I feel sure that he is pointing the way to an altogether more satisfactory future for optometrists than having them remain imprisoned within the framework that the present NHS imposes upon them. It will give them a chance to break out and to make their presence felt.
Why are the Government so confident that this measure can proceed, liberate resources to go elsewhere in the Health Service, and not cause difficulties in a prosperous society? It is because we have been here before. We have been through the battle in respect of the deregulation of opticians and the various dire predictions that were made then. I shall not quote them now, but suffice it to say that concern was expressed not only from the Opposition Benches but by my right hon. and hon. Friends as well.
My hon. Friend the Member for Edgbaston will recall the speeches that she made on the subject, when she expressed great fear about the consequences of that development. I say to my hon. Friend that I hope that she and others will take comfort from what has happened. It has shown that the predictions were not accurate and that the Government have been able to create an altogether better market and an altogether more satisfactory service than before. [HON. MEMBERS: "Oh!"] I detect a degree of scepticism among one or two of my hon. Friends and so I shall give them the facts upon which I rely for that observation.
First, although three quarters of the people who go for tests already wear spectacles and so know that they will have to pay, the number of tests is up by 1 million over that period. Secondly, sales of spectacles have increased by 10 per cent. which is a sign of the market's increased buoyancy. Thirdly, there have been considerable benefits from price reductions of a most marked kind, which have been in the consumer's interest, and wider choice.
The figures are very striking. The average cost of private spectacles in 1981 was £59.26. In 1986, five years on, it was £57.88. In other words, there was a reduction in 955 the average price of spectacles over those five years. Put another way, the average cost for NHS and private spectacles taken together fell from £44 in 1981 to £31 in 1985; a 28 per cent. drop in real terms. It is on that basis that we make the predictions we do about the consequences of this latest change.
Testing for glaucoma clearly concerns many people. My hon. Friend the Member for Edgbaston said that, whenever a person of the appropriate age was eye tested, a glaucoma test is also made. I do not want to take issue with that. I believe that there is concern about whether a test under the new system—a "deregulated" or "privatised" test—will include the test for glaucoma. We have powers under the Bill to make requirements about what the tests should comprise. I take very seriously the points made about glaucoma, and we shall want to discuss them with the professions and other interested parties to ensure the right result.
The debate is about how far in a mature and prosperous society people are prepared to pay modest charges for a service that most recognise will involve extra costs as soon as they embark on it. The difficulty in which my right hon. and learned Friend and his Ministers find themselves is that, even against a background of the most generous settlements that there have been for increased funding of the NHS, a range of competing priorities and demands must still be met: expensive high-technology medicine, the increasing requirements of an aging population and the need for enhanced psychogeriatric care.
I assure the House that, although my right hon. Friend the Chancellor has generously made the money available, it took a great deal of persuasion, as my right hon. and learned Friend said earlier. The case had to be made that the money would be properly targeted on improved patient services and not swallowed up in inefficiency and bureaucracy, or used for purposes that no longer required a heavy public subsidy. If we are unable to make these savings, surely some other choice will have to be made, and it is difficult to know how easy the decision will be. I ask my colleagues who oppose us at present to think very carefully about that aspect.
I also appreciate how difficult the issue is seen to be by many of my hon. Friends on the Back Benches. The appointment of my right hon. and learned Friend to the Department of Health was greeted very warmly by my colleagues. With his Ministers he has had the opportunity to look carefully at policy proposals for the future, and to consider what we shall have to pay to make the NHS work efficiently and to try to clear up the many problems such as excessively long waiting lists and inconsistencies in key performances between one district and another.
I hope very much that before casting their vote against my right hon. and learned Friend my hon. Friends will give thought to his categorical judgment that we can safely make the decision we are making, and that any alternative will cause grave difficulties to the NHS. As the second successive Secretary of State who has made this proposal, my right hon. and learned Friend should perhaps be entitled to the benefit of the doubt from the sceptics. I hope that in a spirit of common decency towards those who have been entrusted with such a difficult job they will think long and hard before making his job more difficult, and will allow his judgment to win the day.
956 On that basis, and in confidence that the evidence points in this direction, I ask the House to join us in rejecting the Lords decision and restoring the position that existed when the Bill left the Commons six months ago.
§ Question put, That this House doth disagree with the Lords in the said amendment:—
§ The House divided: Ayes 296, Noes 288.959
|Division No. 463]||[1.03 am|
|Adley, Robert||Dickens, Geoffrey|
|Alexander, Richard||Dicks, Terry|
|Alison, Rt Hon Michael||Dorrell, Stephen|
|Amery, Rt Hon Julian||Douglas-Hamilton, Lord James|
|Amess, David||Dunn, Bob|
|Amos, Alan||Durant, Tony|
|Arbuthnot, James||Dykes, Hugh|
|Arnold, Jacques (Gravesham)||Eggar, Tim|
|Arnold, Tom (Hazel Grove)||Emery, Sir Peter|
|Ashby, David||Evans, David (Welwyn Hatf'd)|
|Aspinwall, Jack||Fairbairn, Sir Nicholas|
|Atkins, Robert||Fallon, Michael|
|Baker, Rt Hon K. (Mole Valley)||Favell, Tony|
|Baker, Nicholas (Dorset N)||Fenner, Dame Peggy|
|Baldry, Tony||Field, Barry (Isle of Wight)|
|Banks, Robert (Harrogate)||Finsberg, Sir Geoffrey|
|Batiste, Spencer||Fishburn, John Dudley|
|Bellingham, Henry||Fookes, Miss Janet|
|Bendall, Vivian||Forman, Nigel|
|Bennett, Nicholas (Pembroke)||Forsyth, Michael (Stirling)|
|Benyon, W.||Forth, Eric|
|Biffen, Rt Hon John||Fowler, Rt Hon Norman|
|Blackburn, Dr John G.||Fox, Sir Marcus|
|Blaker, Rt Hon Sir Peter||Franks, Cecil|
|Body, Sir Richard||Freeman, Roger|
|Bonsor, Sir Nicholas||French, Douglas|
|Boscawen, Hon Robert||Gale, Roger|
|Boswell, Tim||Gardiner, George|
|Bottomley, Peter||Gill, Christopher|
|Bottomley, Mrs Virginia||Glyn, Dr Alan|
|Bowden, Gerald (Dulwich)||Goodlad, Alastair|
|Bowis, John||Goodson-Wickes, Dr Charles|
|Boyson, Rt Hon Dr Sir Rhodes||Gorman, Mrs Teresa|
|Brandon-Bravo, Martin||Gorst, John|
|Brazier, Julian||Gow, Ian|
|Bright, Graham||Grant, Sir Anthony (CambsSW)|
|Brittan, Rt Hon Leon||Greenway, John (Ryedale)|
|Brooke, Rt Hon Peter||Griffiths, Sir Eldon (Bury St E')|
|Brown, Michael (Brigg & Cl't's)||Griffiths, Peter (Portsmouth N)|
|Browne, John (Winchester)||Grist, Ian|
|Bruce, Ian (Dorset South)||Ground, Patrick|
|Budgen, Nicholas||Grylls, Michael|
|Burns, Simon||Gummer, Rt Hon John Selwyn|
|Burt, Alistair||Hamilton, Hon Archie (Epsom)|
|Butcher, John||Hamilton, Neil (Tatton)|
|Butler, Chris||Hanley, Jeremy|
|Butterfill, John||Hargreaves, A. (B'ham H'll Gr')|
|Carlisle, John, (Luton N)||Hargreaves, Ken (Hyndburn)|
|Carlisle, Kenneth (Lincoln)||Harris, David|
|Carrington, Matthew||Hayward, Robert|
|Cash, William||Heathcoat-Amory, David|
|Chalker, Rt Hon Mrs Lynda||Heddle, John|
|Channon, Rt Hon Paul||Hicks, Mrs Maureen (Wolv' NE)|
|Chope, Christopher||Hill, James|
|Clark, Hon Alan (Plym'th S'n)||Hind, Kenneth|
|Clark, Dr Michael (Rochford)||Hogg, Hon Douglas (Gr'th'm)|
|Clark, Sir W. (Croydon S)||Hordern, Sir Peter|
|Clarke, Rt Hon K. (Rushcliffe)||Howard, Michael|
|Conway, Derek||Howarth, Alan (Strat'd-on-A)|
|Coombs, Anthony (Wyre F'rest)||Howarth, G. (Cannock & B'wd)|
|Cope, Rt Hon John||Howe, Rt Hon Sir Geoffrey|
|Couchman, James||Howell, Ralph (North Norfolk)|
|Cran, James||Hughes, Robert G. (Harrow W)|
|Currie, Mrs Edwina||Hunt, David (Wirral W)|
|Curry, David||Hunter, Andrew|
|Davies, Q. (Stamf'd & Spald'g)||Hurd, Rt Hon Douglas|
|Davis, David (Boothferry)||Irvine, Michael|
|Devlin, Tim||Jack, Michael|
|Jackson, Robert||Rathbone, Tim|
|Janman, Tim||Redwood, John|
|Johnson Smith, Sir Geoffrey||Renton, Tim|
|Jones, Gwilym (Cardiff N)||Rhodes James, Robert|
|Jones, Robert B (Herts W)||Riddick, Graham|
|Kellett-Bowman, Dame Elaine||Ridley, Rt Hon Nicholas|
|Key, Robert||Ridsdale, Sir Julian|
|King, Roger (B'ham N'thfield)||Rifkind, Rt Hon Malcolm|
|King, Rt Hon Tom (Bridgwater)||Roberts, Wyn (Conwy)|
|Kirkhope, Timothy||Roe, Mrs Marion|
|Knapman, Roger||Rost, Peter|
|Knight, Greg (Derby North)||Rumbold, Mrs Angela|
|Knowles, Michael||Ryder, Richard|
|Lamont, Rt Hon Norman||Sackville, Hon Tom|
|Lang, Ian||Sainsbury, Hon Tim|
|Lawson, Rt Hon Nigel||Sayeed, Jonathan|
|Lee, John (Pendle)||Scott, Nicholas|
|Leigh, Edward (Gainsbor'gh)||Shaw, David (Dover)|
|Lennox-Boyd, Hon Mark||Shaw, Sir Giles (Pudsey)|
|Lightbown, David||Shaw, Sir Michael (Scarb')|
|Lilley, Peter||Shephard, Mrs G. (Norfolk SW)|
|Lloyd, Sir Ian (Havant)||Shepherd, Colin (Hereford)|
|Lloyd, Peter (Fareham)||Shepherd, Richard (Aldridge)|
|Lord, Michael||Shersby, Michael|
|Luce, Rt Hon Richard||Skeet, Sir Trevor|
|Lyell, Sir Nicholas||Smith, Sir Dudley (Warwick)|
|Macfarlane, Sir Neil||Smith, Tim (Beaconsfield)|
|MacGregor, Rt Hon John||Soames, Hon Nicholas|
|MacKay, Andrew (E Berkshire)||Speed, Keith|
|Maclean, David||Spicer, Sir Jim (Dorset W)|
|McLoughlin, Patrick||Spicer, Michael (S Worcs)|
|McNair-Wilson, Sir Michael||Squire, Robin|
|McNair-Wilson, P. (New Forest)||Stanbrook, Ivor|
|Major, Rt Hon John||Stanley, Rt Hon John|
|Malins, Humfrey||Steen, Anthony|
|Mans, Keith||Stern, Michael|
|Maples, John||Stevens, Lewis|
|Marland, Paul||Stewart, Allan (Eastwood)|
|Marlow, Tony||Stewart, Andy (Sherwood)|
|Marshall, John (Hendon S)||Stewart, Ian (Hertfordshire N)|
|Marshall, Michael (Arundel)||Stokes, Sir John|
|Martin, David (Portsmouth S)||Sumberg, David|
|Maude, Hon Francis||Summerson, Hugo|
|Mawhinney, Dr Brian||Tapsell, Sir Peter|
|Mayhew, Rt Hon Sir Patrick||Taylor, John M (Solihull)|
|Mellor, David||Taylor, Teddy (S'end E)|
|Miller, Sir Hal||Tebbit, Rt Hon Norman|
|Mills, Iain||Thatcher, Rt Hon Margaret|
|Miscampbell, Norman||Thompson, D. (Calder Valley)|
|Mitchell, Andrew (Gedling)||Thompson, Patrick (Norwich N)|
|Mitchell, David (Hants NW)||Thorne, Neil|
|Moate, Roger||Thurnham, Peter|
|Monro, Sir Hector||Townend, John (Bridlington)|
|Montgomery, Sir Fergus||Townsend, Cyril D. (B'heath)|
|Moore, Rt Hon John||Tracey, Richard|
|Morris, M (N'hampton S)||Tredinnick, David|
|Morrison, Rt Hon P (Chester)||Trippier, David|
|Moss, Malcolm||Trotter, Neville|
|Moynihan, Hon Colin||Twinn, Dr Ian|
|Neale, Gerrard||Viggers, Peter|
|Needham, Richard||Waddington, Rt Hon David|
|Nelson, Anthony||Wakeham, Rt Hon John|
|Newton, Rt Hon Tony||Waldegrave, Hon William|
|Nicholls, Patrick||Walden, George|
|Nicholson, Emma (Devon West)||Walker, Bill (T'side North)|
|Onslow, Rt Hon Cranley||Walker, Rt Hon P. (W'cester)|
|Oppenheim, Phillip||Waller, Gary|
|Page, Richard||Ward, John|
|Paice, James||Wardle, Charles (Bexhill)|
|Parkinson, Rt Hon Cecil||Watts, John|
|Patnick, Irvine||Wheeler, John|
|Patten, Chris (Bath)||Whitney, Ray|
|Patten, John (Oxford W)||Widdecombe, Ann|
|Pawsey, James||Wiggin, Jerry|
|Porter, Barry (Wirral S)||Wilkinson, John|
|Porter, David (Waveney)||Wilshire, David|
|Portillo, Michael||Wolfson, Mark|
|Price, Sir David||Wood, Timothy|
|Raison, Rt Hon Timothy||Yeo, Tim|
|Young, Sir George (Acton)||Tellers for the Ayes:|
|Younger, Rt Hon George||Mr. Tristan Garel-Jones and|
|Mr. Michael Neubert.|
|Abbott, Ms Diane||Eastham, Ken|
|Allen, Graham||Evans, John (St Helens N)|
|Alton, David||Evennett, David|
|Anderson, Donald||Ewing, Harry (Falkirk E)|
|Archer, Rt Hon Peter||Ewing, Mrs Margaret (Moray)|
|Armstrong, Hilary||Fatchett, Derek|
|Ashdown, Paddy||Faulds, Andrew|
|Ashley, Rt Hon Jack||Fearn, Ronald|
|Ashton, Joe||Field, Frank (Birkenhead)|
|Atkinson, David||Fields, Terry (L'pool B G'n)|
|Banks, Tony (Newham NW)||Fisher, Mark|
|Barnes, Harry (Derbyshire NE)||Flannery, Martin|
|Barnes, Mrs Rosie (Greenwich)||Flynn, Paul|
|Barron, Kevin||Foot, Rt Hon Michael|
|Battle, John||Forsythe, Clifford (Antrim S)|
|Beckett, Margaret||Foster, Derek|
|Beggs, Roy||Foulkes, George|
|Bell, Stuart||Fraser, John|
|Benn, Rt Hon Tony||Fry, Peter|
|Bennett, A. F. (D'nt'n & R'dish)||Fyfe, Maria|
|Bermingham, Gerald||Galbraith, Sam|
|Bevan, David Gilroy||Galloway, George|
|Bidwell, Sydney||Garrett, John (Norwich South)|
|Blair, Tony||Garrett, Ted (Wallsend)|
|Blunkett, David||George, Bruce|
|Boateng, Paul||Gilbert, Rt Hon Dr John|
|Boyes, Roland||Gilmour, Rt Hon Sir Ian|
|Bradley, Keith||Godman, Dr Norman A.|
|Bray, Dr Jeremy||Golding, Mrs Llin|
|Brown, Gordon (D'mline E)||Gordon, Mildred|
|Brown, Nicholas (Newcastle E)||Gould, Bryan|
|Brown, Ron (Edinburgh Leith)||Graham, Thomas|
|Bruce, Malcolm (Gordon)||Grant, Bernie (Tottenham)|
|Buchan, Norman||Gregory, Conal|
|Buckley, George J.||Griffiths, Nigel (Edinburgh S)|
|Caborn, Richard||Griffiths, Win (Bridgend)|
|Callaghan, Jim||Grocott, Bruce|
|Campbell, Menzies (Fife NE)||Hampson, Dr Keith|
|Campbell, Ron (Blyth Valley)||Hannam, John|
|Campbell-Savours, D. N.||Hardy, Peter|
|Canavan, Dennis||Harman, Ms Harriet|
|Carlile, Alex (Mont'g)||Haselhurst, Alan|
|Carttiss, Michael||Hattersley, Rt Hon Roy|
|Cartwright, John||Hawkins, Christopher|
|Chapman, Sydney||Hayes, Jerry|
|Churchill, Mr||Hayhoe, Rt Hon Sir Barney|
|Clark, Dr David (S Shields)||Haynes, Frank|
|Clarke, Tom (Monklands W)||Healey, Rt Hon Denis|
|Clay, Bob||Heffer, Eric S.|
|Clelland, David||Henderson, Doug|
|Clwyd, Mrs Ann||Heseltine, Rt Hon Michael|
|Cohen, Harry||Hicks, Robert (Cornwall SE)|
|Colvin, Michael||Hinchliffe, David|
|Cook, Robin (Livingston)||Hogg, N. (C'nauld & Kilsyth)|
|Coombs, Simon (Swindon)||Holland, Stuart|
|Corbett, Robin||Holt, Richard|
|Cousins, Jim||Home Robertson, John|
|Crowther, Stan||Hood, Jimmy|
|Cryer, Bob||Howarth, George (Knowsley N)|
|Cummings, John||Howell, Rt Hon D. (S'heath)|
|Cunliffe, Lawrence||Howells, Geraint|
|Cunningham, Dr John||Hoyle, Doug|
|Darling, Alistair||Hughes, John (Coventry NE)|
|Davies, Rt Hon Denzil (Llanelli)||Hughes, Robert (Aberdeen N)|
|Davies, Ron (Caerphilly)||Hughes, Roy (Newport E)|
|Davis, Terry (B'ham Hodge H'l)||Hughes, Sean (Knowsley S)|
|Day, Stephen||Hume, John|
|Dewar, Donald||Illsley, Eric|
|Dixon, Don||Ingram, Adam|
|Dobson, Frank||Janner, Greville|
|Doran, Frank||Jessel, Toby|
|Douglas, Dick||John, Brynmor|
|Dover, Den||Johnston, Sir Russell|
|Duffy, A. E. P.||Jones, Barry (Alyn & Deeside)|
|Dunnachie, Jimmy||Jones, Ieuan (Ynys Mön)|
|Jones, Martyn (Clwyd S W)||Owen, Rt Hon Dr David|
|Kaufman, Rt Hon Gerald||Parry, Robert|
|Kennedy, Charles||Patchett, Terry|
|Kilfedder, James||Pattie, Rt Hon Sir Geoffrey|
|Kinnock, Rt Hon Neil||Peacock, Mrs Elizabeth|
|Kirkwood, Archy||Pendry, Tom|
|Knight, Dame Jill (Edgbaston)||Pike, Peter L.|
|Knox, David||Powell, Ray (Ogmore)|
|Lambie, David||Prescott, John|
|Latham, Michael||Primarolo, Dawn|
|Leadbitter, Ted||Quin, Ms Joyce|
|Leighton, Ron||Radice, Giles|
|Lestor, Joan (Eccles)||Randall, Stuart|
|Lewis, Terry||Redmond, Martin|
|Litherland, Robert||Reid, Dr John|
|Livingstone, Ken||Richardson, Jo|
|Livsey, Richard||Roberts, Allan (Bootle)|
|Lloyd, Tony (Stretford)||Robertson, George|
|Lofthouse, Geoffrey||Robinson, Geoffrey|
|Loyden, Eddie||Robinson, Peter (Belfast E)|
|McAllion, John||Rogers, Allan|
|McAvoy, Thomas||Rooker, Jeff|
|McCartney, Ian||Ross, Ernie (Dundee W)|
|McCrea, Rev William||Ross, William (Londonderry E)|
|McCrindle, Robert||Ruddock, Joan|
|Macdonald, Calum A.||Salmond, Alex|
|McFall, John||Sedgemore, Brian|
|McGrady, Eddie||Sheerman, Barry|
|McKay, Allen (Barnsley West)||Sheldon, Rt Hon Robert|
|McKelvey, William||Short, Clare|
|McLeish, Henry||Skinner, Dennis|
|Maclennan, Robert||Smith, Andrew (Oxford E)|
|McNamara, Kevin||Smith, C. (Isl'ton & F'bury)|
|McTaggart, Bob||Smyth, Rev Martin (Belfast S)|
|McWilliam, John||Snape, Peter|
|Madden, Max||Soley, Clive|
|Madel, David||Spearing, Nigel|
|Maginnis, Ken||Steel, Rt Hon David|
|Mahon, Mrs Alice||Steinberg, Gerry|
|Mallon, Seamus||Stott, Roger|
|Marek, Dr John||Strang, Gavin|
|Marshall, David (Shettleston)||Straw, Jack|
|Marshall, Jim (Leicester S)||Taylor, Mrs Ann (Dewsbury)|
|Martin, Michael J. (Springburn)||Taylor, Matthew (Truro)|
|Martlew, Eric||Thomas, Dr Dafydd Elis|
|Mates, Michael||Thompson, Jack (Wansbeck)|
|Maxton, John||Turner, Dennis|
|Maxwell-Hyslop, Robin||Vaughan, Sir Gerard|
|Meacher, Michael||Vaz, Keith|
|Meale, Alan||Walker, A. Cecil (Belfast N)|
|Meyer, Sir Anthony||Wall, Pat|
|Michael, Alun||Wallace, James|
|Michie, Bill (Sheffield Heeley)||Walley, Joan|
|Michie, Mrs Ray (Arg'l & Bute)||Wardell, Gareth (Gower)|
|Mitchell, Austin (G't Grimsby)||Wareing, Robert N.|
|Molyneaux, Rt Hon James||Welsh, Andrew (Angus E)|
|Moonie, Dr Lewis||Wigley, Dafydd|
|Morgan, Rhodri||Williams, Rt Hon Alan|
|Morley, Elliott||Williams, Alan W. (Carm'then)|
|Morris, Rt Hon A. (W'shawe)||Wilson, Brian|
|Morris, Rt Hon J. (Aberavon)||Winnick, David|
|Morrison, Sir Charles||Winterton, Mrs Ann|
|Mowlam, Marjorie||Winterton, Nicholas|
|Mullin, Chris||Wise, Mrs Audrey|
|Murphy, Paul||Worthington, Tony|
|Nellist, Dave||Wray, Jimmy|
|Nicholson, David (Taunton)||Young, David (Bolton SE)|
|Oakes, Rt Hon Gordon|
|O'Brien, William||Tellers for the Noes:|
|O'Neill, Martin||Mr. Frank Cook and|
|Orme, Rt Hon Stanley||Mr. Allen Adams.|
§ Question accordingly agreed to.
§ Amendments (b) to (d) to the words so restored to the Bill agreed to.
§ Consequential amendments (e) and (f) agreed to.
§ Lords amendment No. 23 disagreed to.
§ Amendment (b) to the words so restored to the Bill agreed to.960
§ Lords amendment Nos. 24 and 25 agreed to. [Special Entry].
§ Lords amendment No. 26 disagreed to.
§ Amendments (b) to (d) to the words so restored to the Bill agreed to.
§ Consequential amendments (e) and (f) agreed to.
§ Lords amendments Nos. 22 and 28 agreed to. [Special Entry].