§ Mr. Robin Cook (Livingston)
I beg to move,That an humble Address be presented to Her Majesty, praying that the National Health Service (Optical Charges and Payments) Regulations 1989 (S.I., 1989, No. 396), dated 8th March 1989, a copy of which was laid before this House on 10th March, be annulled
§ Mr. Speaker
With this it will be convenient also to discuss the 11 other National Health Service prayers:That an humble Address be presented to Her Majesty, praying that the National Health Service (Optical Charges and Payments) (Scotland) Regulations 1989 (S.I., 1989, No. 392), dated 9th March 1989, a copy of which was laid before this House on 10th March, be annulledThat an humble Address he presented to Her Majesty, praying that the National Health Service (Dental Charges) Regulations 1989 (S.I., 1989, No. 394), dated 8th March 1989, a copy of which was laid before this House on 10th March, be annulledThat an humble Address be presented to Her Majesty, praying that the National Health Service (Dental Charges) (Scotland) Regulations 1989(S.I., 1989, No. 363), dated 7th March 1989, a copy of which was laid before this House on 10th March, be annulledThat an humble Address be presented to Her Majesty, praying that the National Health Service (Charges for Drugs and Appliances) Regulations 1989 (S.I., 1989, No. 419), dated 9th March 1989, a copy of which was laid before this House on 10th March, be annulledThat an humble Address be presented to Her Majesty, praying that the National Health Service (Charges for Drugs and Appliances) (Scotland) Regulations 1989 (S.I., 1989, No. 326), dated 3rd March 1989, a copy of which was laid before this House on 10th March, be annulledThat an humble Address be presented to Her Majesty, praying that the National Health Service (General Ophthalmic Services) Amendment Regulations 1989 (S.I1989, No. 395), dated 8th March 1989, a copy of which was laid before this House on 10th March, be annulledThat an humble Address be presented to Her Majesty, praying that the National Health Service (General Ophthalmic Service) (Scotland) Amendment Regulations 1989 (S.I., 1989, No. 387), dated 8th March 1989, a copy of which was laid before this House on 10th March, be annulledThat an humble Address be presented to Her Majesty, praying that the National Health Service (Travelling Expenses and Remission of Charges) Amendment Regulations 1989 (S.I., 1989, No. 517) dated 20th March 1989, a copy of which was laid before this House on 20th March, be annulledThat an humble Address be presented to Her Majesty., praying that the National Health Service (Travelling, Expenses and Remission of Charges) (Scotland) Amendment. Regulations 1989 (S.I., 1989, No. 393), dated 9th March 1989, a copy of which was laid before this House on 10th March, be annulledThat an humble Address be presented to Her Majesty, praying that the National Health Service (Travelling Expenses and Remission of Charges) Amendment (No. 2) Regulations 1989 (S.I., 1989, No. 614), dated 6th April 1989, a copy of which was laid before this House on 7th April, be annulledThat an humble Address be presented to Her Majesty, praying that the National Health Service (Travelling Expenses and Remission of Charges) (Scotland) Amendment (No. 2) Regulations 1989 (S.I., 1989, No. 616), dated 6th April 1989, a copy of which was laid before this House on 7th April, be annulled
§ Mr. Cook
Twelve prayers relating to the Health Service are before the House tonight and all relate to charges for drugs and appliances. I trust that the House will forgive me if I do not divide my time equally between the 12 prayers. Several matters of substance are raised in the regulations, but I must confess that Opposition Members do not hold strong views about the price of wigs prescribed on the National Health Service. Although I know that the price of wigs is on the way up, I am greatly relieved to note—
§ Mr. Frank Dobson (Holborn and St. Pancras)
Is there a special concession for wigs for members of the legal profession?
§ Mr. Cook
I think that on this occasion I can give my hon. Friend an assurance on behalf of the Government that wigs for the legal profession are not under discussion.
I am relieved to note that, whatever the rate of inflation for human hair wigs, it is at least not as high as the rate of inflation which appears to be affecting the budget for advertising—
§ Mr. Cook
The hon. Gentleman raises an interesting point which, of course, has been a matter of discussion between the Front Benches. I must advise the hon. Gentleman that our difficulty is that prayers, unfortunately, do not get the same protection in terms of time before the House that orders get. If the hon. Gentleman would like to join us in pressing for the same amount of time for debate on prayers as the House provides for debate on orders, I should be happy to ensure that there were separate rounds of debate. I am sure that the hon. Gentleman will have adequate time to deploy his point and if he chooses to seek to divide the House on the basis that the charge for wigs is an unreasonable imposition, I shall give favourable consideration to advising my colleagues to join him in the Division Lobby.
I am relieved that the rate of inflation in the charges in the regulations on wigs, other appliances and drugs is at least not as high as the rate of inflation that the Department of Health has just applied to its own advertising budget, because it has been discovered that the rate of inflation for that for the current year is no less than 87 per cent. Opposition Members urge the Department of Health to apply that uprating to its expenditure on patient care rather than on its expenditure on advertising it.
I do not propose to delay the House further on such matters because the matter of substance to which I wish to draw the attention of the House and to which I shall be directing the remainder of my remarks is the instrument providing for the exemption from the charges for eye tests. That is something of real substance which touches on a matter of great public policy. It has been an issue of considerable controversy in the House, both between the different parties in the House and among Conservative Members.
The particular issue for debate tonight is why the regulations providing for exemption from charges do not provide for exemption from the charges for pensioners. 1004 After all, pensioners make up the majority of those coming forward for eye tests. Indeed, pensioners represent 60 per cent. of the people who go to opticians for eye tests. Pensioners are not automatically exempt under the provisions. Tonight I wish to challenge whether, in the light of the evidence that is now available to us about the charges for eye tests, it is right to continue to exclude pensioners from exemption from the charges.
I recall that we last debated this matter on 1 November, when the Secretary of State for Health, whom I am delighted to see has been able to free himself from other engagements to join us on this occasion, made the central point that the charges for eye tests would be so low that it was not necessary to worry about those groups that were not exempt. If I may say so, he was characteristically robust in stating his view. In the course of the debate he asserted that it was his strong opinion that competition would drive down charges for the eye test.
I shall share with the House a couple of quotations from the Secretary of State's speech. He said:I do not believe that all opticians will maintain a charge for a sight test which is equivalent to the present NHS fee".Later he said: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."— [Official Report, 1 November 1988; Vol. 139, cc. 928, 930]That was a clear statement of faith that a number of opticians would charge less than the NHS fee, including, for a curious reason not immediately clear to me, particularly opticians in Leeds and Hull. The NHS fee was then £9.75.
The right hon. and learned Gentleman's second statement of faith was that not only would some opticians charge less than the NHS fee, but a number— at times in this passage of his speech he appeared to think that it would be the norm— would make no charge at all. It was on that basis that he invited the House to approve the charge for eye tests. On that basis the House approved the charge, without agreeing to an exemption for pensioners and in the full knowledge that the regulations before us now would be laid without providing such an exemption.
Last week, my office carried out a survey of opticians in a couple of dozen towns throughout Britain, from Aberdeen to Falmouth, covering twice as many opticians. Nowhere among the 50 opticians whom we sampled did we find a single optometrist offering an eye test free. Nowhere among the ones that we sampled did we find anyone offering a test for less than £.10.40. Boots, which caters for 26 per cent. of the market, is charging an eye test fee of £10.50. Dollond and Aitchison, the next market leader, charges £10.40. Between them, those two firms have 40 per cent. of the market, so those are not untypical figures which we specially searched out. They represent the market leaders.
Among the independents, we identified opticians who were charging between £10.50 and £12.50 as a norm. Quite a number of the optometrists that we sampled were charging £15. We even found one optometrist who was charging £17.50. Ironically, I am bound to say that was the optometrist nearest the Department of Health, from whom the Department could most readily have sought advice.
1005 We included Leeds and Hull in our sample. There we found that the eye test was not free, nor indeed was the charge £9.75 or less. The optometrists that we sampled at random in Leeds and Hull were charging between £10.40 and £12.50.
As the Secretary of State knows, I wrote to him giving the results of the survey. [Interruption.] If the Secretary of State wishes to intervene, I shall give way. I am unable to follow his sedentary interruption. The Secretary of State replied to me on 10 April. I was rather distressed that his letter commenced, "Dear Mr. Cook". That is a sad comedown from the days of the former Parliamentary Under-Secretary of State, the hon. Member for Derbyshire, South (Mrs. Currie), who always started her letters to me, "My Dear Robin".
In his letter, the Secretary of State admitted that he would not disagree that some opticians had set their charges at £10 and £12. It would have been very difficult for him to disagree. I am sure he will agree that I am a fair-minded man who would not seek to deny him credit where it is due. I will give him the credit that he managed to find one optician, whom he named, who is providing a free sight test—a Mr. N. J. Bailey, an optician in Dover. In the length and breadth of Britain, we have one optician in Dover providing free sight tests. I regret to say that I have not been able to discover the cost of a second-class return rail fare from London to Dover, but I doubt whether the competition of one optician in Dover providing free sight tests will significantly depress the market in central London.
Of course, before my survey we knew that the Secretary of State was well aware of what was happening in the market. We knew, too, that he was aware of the fact that optometrists, contrary to his assurances to the House, were not only charging the equivalent of the full NHS fee, but were actually charging more. We knew that because, on 13 March, the right hon. and learned Gentleman issued a consultative document to the optometrists' profession proposing a cheapie—a quick eye test that would simply test whether the person coming into the optometrist's premises could read without glasses.
My hon. Friend the Member for Strathkelvin and Bearsden (Mr. Galbraith) will be developing the medical points at issue in the proposed two-tier eye test. All I wish to do at this stage is to draw the House's attention to the fact that this circular document, and the proposal contained within it, is in flat contradiction to the assurance that the right hon. and learned Gentleman gave the House when we debated this matter on 1 November. I am sorry to see that the right hon. and learned Gentleman is shaking his head, because I shall read his own words as they are recorded. He said:I believe that the bulk of responsible optometrists and opticians give a full sight test …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 necessary if we find that people are given quick sight tests and not screening for glaucoma… What I said is important and is relevant to the detection and treatment of glaucoma."— [Official Report, 1 November 1988; Vol. 139, c. 932.]Far from using the powers to which he referred in that exchange, the Secretary of State has circulated the profession before coming to Parliament and asking for powers to make it legal not to screen for glaucoma and to introduce a cheap formal eye test that will meet the form of an eye test without meeting any of the substance of the examination of the eye. I serve notice on the Government 1006 that, when that order is brought before the House—if they are so ill advised as to persist against the unanimous advice of the profession not to do so— it will be our intention to divide the House and to invite Government Back Benchers, who were taken in by the Secretary of State's assurance on 1 November, to join us in voting it down.
In the meantime, we are left with tonight's regulations, on which I would wish to make three observations arising from the evidence that I have paraded in the course of my speech. My first observation is that it is now clear—certainly allowing for the fact that Boots and Dollond and Aitchison corner 40 per cent. of the market—that the great majority of optometrists' clients are being charged a fee for the eye test that is not only equivalent to the previous NHS fee, but in many cases represents a generous mark-up on that fee.
The conclusion must be that competition within the Health Service, far from forcing prices down— as the right hon. Gentleman promised us only six months ago—has the effect of driving prices up. That is not especially surprising, because what has happened with the passage of the Health and Medicines Act 1988 is that the NHS has given up its advantageous position as the monopoly purchaser of eye tests. Having given up that role, it need not surprise right hon. and hon. Members, with their understanding of market mechanisms, to discover that the effect of the NHS withdrawing as monopoly purchaser has been to allow the market to drive up prices rather than to lower them.
Secondly, we must form some conclusions from the events of the past six months and the assurances given to the House on 1 November about the conduct of the Secretary of State for Health. The Secretary of State has plainly been proved wrong in his promises about what would happen to the charges for eye tests. He has not been merely proved wrong; he has been proved wrong in glorious technicolor panorama. In itself, that is not unique in politics. What is interesting about the Secretary of State's predicament and mistake is that he got it wrong precisely because he refused to listen to the profession that advised him not to persist with abolishing the free eye test. The profession warned him that the charge for eye tests would be between £10 and £15. I remember seeing that advice when we debated this matter last autumn. In his speech on 1 November, the Secretary of State said that he did not believe the optometrists who were offering that advice.
There is a clear parallel between the Secretary of State's refusal to listen to the advice of the informed profession in that case and his current conduct in relation to the White Paper on National Health Service reforms. In the consultative period— there is always a consultative period — on the White Paper, the Secretary of State has again been fond of asserting his strong opinions. He has refused to listen to the detailed, cogent criticisms of the profession which understands better and knows at first hand the needs of the Health Service; therefore, he has every prospect of being equally wrong in the conclusions that he draws from the White Paper debate.
The second and rather more worrying conclusion from the events of the last six months, in particular the production of the consultative document of 30 March, is that the Secretary of State does not keep his word. In November, he assured the House that he would not stand for a reduced-price, quick eye test. In March he proposed to make such a test legal. That is no comfort to those in the 1007 Health Service and to those who depend on it who are being invited to trust his assurances on the White Paper. To get it wrong was forgiveable but to break a pledge to Parliament is not.
I now come to my last observation on recent evidence. It relates to pensioners who are not exempted by the regulations. In the original debate the House voted by a narrow margin to approve the charges for eye tests. It did than on the assurance that the charges were likely to be less than £9.75 and might well turn out to be free. They have turned out to be anything but free. The charges range from £10.40 to £17.50. I need hardly explain that pensioners cannot readily afford such charges.
Many pensioners will now fail to turn up for regular eye checks. Some of those who fail to do so will put their sight at risk. I regret to tell the House that we cannot amend the regulations. We can only reject or pass them. I cannot advise the House to reject them because they provide for limited exemptions. Regrettably the exemptions do not apply to all pensioners. I invite the Under-Secretary of State to reflect on the evidence that is now available to the House and which was not available in November about the reality of eye test charges. In view of that serious evidence and the assurances of the Secretary of State, I invite the Under-Secretary to come back with further regulations to provide the same exemption to all pensioners. If he does that, he will not only safeguard pensioners but rescue the reputation of the Secretary of State
§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)
The hon. Member for Livingston (Mr. Cook), in opening the debate covering all 12 instruments, dealt selectively with one of them, that concerning the exemptions for sight tests, and I note that he does not intend to advise his hon. Friends to divide the House, presumably on all 12. He made three points, and I shall deal with those before dealing with each of the 12 instruments.
His first point concerned pensioners and the eye test. I remind the House that about 2 million pensioners who are in receipt of income support will have full access to free National Health Service sight tests. Further, as anyone who has taken the trouble to study the measures will see, those with an income of just above the levels of income support will also qualify for assistance for the eye test on a scale which declines according to the income of the individual and the family. So a substantial number of pensioners will qualify for the free eye test.
We believe that a charge of £10 every, say, three years is a reasonable and fair cost for a pensioner to bear, bearing in mind that the income of pensioners as a whole has risen substantially in the last decade and that pensioners, like other members of society, with increased income and increased disposable resources, will be able to make sensible decisions about what to do about taking care of their health.
Next, the hon. Member for Livingston talked about the levels at which private sight test fees were settling. His quotations from the letter from the Secretary of State for 1008 Health were selective. He glossed over the fact that it is clearly far too early, as my right hon. and learned Friend pointed out in his reply, to draw any conclusions.
The hon. Member for Livingston and anyone with experience of the interplay of market forces in this, as in any other sphere, knows that it takes time for the participants in that market to make sensible decisions about where to pitch their fees. It is too early to make a judgment, and for the hon. Gentleman to quote the range of from £10 to £17 is not a fair representation of the present position.
Of the largest suppliers, Boots is charging £10.50 and Dollond and Aitchison £10.40. The hon. Gentleman knows that the reimbursement figure for the NHS sight test is £10.40. It is far too early to make a judgment about where other competitors in the market will pitch their fees. They will wish to see what degree of business Boots and Dollonds attract at that level
§ Mr. Nicholas Winterton (Macclesfield)
My hon. Friend said in answer to the hon. Member for Livingston (Mr. Cook) that he believes that a pensioner will need to have his or her eyes tested once every three years. Why did he select that time scale? I thought that elderly people might need an eye test at least once a year. On that basis, £10 every year for a pensioner is a heavy financial burden
§ Mr. Freeman
I would not wish to prescribe what is the correct frequency, and I am sure that my hon. Friend would not do so either. I was suggesting the sort of frequency for those who do not have disease. Under the regulations, those with diabetes and glaucoma, and those related in families to people who are so suffering, will continue to have free tests.
While I was not suggesting the frequency of testing, on average— and we know that there is no such thing as an average pensioner— the Government believe that going for a test, assuming that one is free of disease and free of a history of disease, every three years and paying about £10 is a reasonable expense set in the context of growing disposable income on the part of the retired.
The hon. Member for Livingston then referred to private sight tests and the consultation document which has been circulated by the Department of Health. It is a consultative document and we are still consulting on the possibility of regulating those who choose to have a private sight test and who might not choose to have an examination as part of that test, doing so perfectly understanding that they are not having a full examination of the eye.
These regulations are about increasing the resources for the National Health Service through reasonable charges and sensible policies about the provision of optical services whilst ensuring that people who cannot afford to pay for various NHS services are protected.
It might be for the convenience of the House if I consider the regulations in the order in which they appear on today's Order Paper. There are 12 instruments in all, six for England and six parallel instruments for Scotland. I will begin with the National Health Service (Optical Charges and Payments) Regulations 1989 and their Scottish equivalents.
These regulations provide a new scheme for vouchers to be issued in appropriate cases for help with the cost of a private sight test, increase the value by 5 per cent. overall of existing vouchers for glasses and extend on a statutory 1009 basis the voucher scheme for the repair and replacement of spectacles under certain circumstances. In particular, I would like to draw the attention of the House to the provisions which allow help for those on low income towards the cost of a private sight test. That meets a commitment we agreed during the debate on the Health and Medicines Bill.
Briefly, the regulations will ensure that those who are assessed as being able to contribute from their income an amount less than the current NHS sight test fee of £10.40 will he eligible for a voucher towards the cost of their private test. The actual value of the voucher will vary in each case according to the private sight test fee and the amount of the individual's assessed contribution.
The regulations also introduce arrangements which will allow help under the voucher scheme to extend to the repair and replacement of spectacles in certain circumstances. Children will continue to receive help no matter what the circumstances of the damage or loss to their spectacles. Under these regulations, however, for the first time adults will receive help where the loss or damage has occurred as a direct result of illness. We have deliberately taken a wide definition of illness so that family practitioner committees will have discretion to decide whether or not to allow the claim, after making such inquiries as they think fit. I am sure these arrangements will be welcomed by both sides of the House.
We are, therefore, through this set of regulations giving help with the cost of the private sight test, increasing voucher values and introducing a new repair and replacement scheme for spectacles for those adults suffering from illness who get help under the voucher scheme.
The National Health Service (Dental Charges) Regulations 1989 and their Scottish equivalents fulfil the commitment we made during the passage of the Health and Medicines Bill to extend the system of fully proportional charges for dental treatment to include dentures and bridges, which were previously on a fixed scale of charges. This means that all charges for dental treatment in the general dental services, and the charges for dentures and bridges in the hospital service— the only charges levied in the hospital dental service— are now on a uniform charging basis as a fixed proportion of cost. That proportion remains at the level fixed last April for dental treatment, namely 75 per cent. There is no change in the maximum charge for a course of treatment, which remains at £150.
There is no increase in charges for routine dental treatment as a result of these regulations. They remain at 75 per cent. of the fees payable to dentists, and will therefore increase only when those fees are increased and in the same measure. As a result of bringing dentures and bridges within the same proportional system as other treatment, there is an increase in denture charges of an average of about 10 per cent. to bring them up to 75 per cent. of costs. They were previously charged at a flat rate which was fixed originally at 75 per cent. of the fees. However, they did not go up when fees were reviewed last October, and they are now being brought back into line with other treatment. Charges for most bridges are not being increased because there was very little change in their costs when fees were reviewed last October.
The dental profession has long advocated proportional charging and warmly welcomed our decision to introduce it for routine treatment last year. It also welcomes these 1010 regulations inasmuch as they complete the simplification process by bringing dentures and bridges within the proportional system. Consumer interests have also welcomed these measures as fairer and simpler all round.
I should add in all fairness that the profession and other groups have argued that the 75 per cent. rate is too high. That is not an argument that the Government would accept. It is much less than the 100 per cent. that applied to millions of small courses of treatment before April 1988. An estimated 6 million courses of treatment were cheaper in cash terms in 1988–89 than the year before. There is certainly no evidence that the current level of charges is proving a deterrent. The number of courses of treatment in 1988–89, the first full year of proportional charging for most treatment, up to February, which is the latest month for which we have figures, is up by no less than 5.6 per cent. on the corresponding period in 1987–88. We are heading for the largest year on year increase since 1973. That continues an upward trend which has seen the number of courses of dental treatment rise by 19 per cent. in England and Wales since 1979, from 28.5 million in 1979 to nearly 33.8 million in 1987–88.
The cost for a dental examination is £3.15 and that charge should bring in about £50 million in 1989–90 for the benefit of the NHS as a whole. The 75 per cent. rate, with the exemptions which apply to about 40 per cent. of the population, means that the taxpayer is paying about two thirds of the cost of all general dental treatment. The patient pays in aggregate about one third
§ Mr. John Greenway (Ryedale)
There has not yet been any consumer resistance to the charges, but is my hon. Friend aware that many patients are expressing to their dentists considerable surprise that the examination fee is as little as £3.15?.
§ Mr. Freeman
I am grateful to my hon. Friend for reminding the House that the charge for a dental examination will be £3.15.
The National Health Service (Charges for Drugs and Appliances) Regulations 1989 and their Scottish equivalent introduce a modest increase in prescription charges. They also consolidate the existing regulations with some minor amendments. The prescription charge rose by 20p on 1 April from £2.60 to £2.80—an increase of 7.7 per cent. which will represent about 43 per cent. of the average prescription cost. We believe that it is right for those people who can afford to do so to make a contribution towards the cost of their medication by paying a charge. Equally, we think it is right and proper to increase that charge in line with the increasing costs of the NHS. The increase will provide an extra £10 million in income during this year. Therefore, the extra money raised by the charges represents a real and valuable addition to the total resources available to the NHS.
More than three quarters of prescriptions are dispensed free of charge because of the wide-ranging exemption arrangements. In addition to those on a low income, no prescription charges are paid by pensioners, children under 16, students under 19, expectant and nursing mothers and people who suffer from a number of specified medical conditions. Only people who can afford to pay the charges have to do so. What is more, there are arrangements to protect those even in that group who need a large amount of medication.
1011 There are available pre-payment certificates, or "season tickets", which, in effect, set a maximum to the amount that any individual has to pay. Nearly 5 per cent. of prescriptions now go to holders of season tickets. The regulations also increase the charges, roughly proportionately, for the annual and four-monthly season tickets. Season tickets continue to represent excellent value. They will save money for anyone who needs more than 14 items in a year or more than five prescriptions during a four-month period.
There is no evidence that increases in charges deter people from getting the medicines they need. Last April we put the prescription charge up by 20p, just as we are doing this year. Last year 3461 million items were dispensed in England— an increase of 11 million over the 1987 figure which was nearly 13 million over the 1986 figure. Indeed, apart from the year when we introduced the elected list, the number of prescriptions dispensed has risen regularly since 1981.
The National Health Service (General Ophthalmic Services) Amendment Regulations 1989 and their Scottish equivalent restrict National Health Service free sight tests to certain restricted categories, comprising about 40 per cent. of the population. We concluded last year that it was right that those who could afford to should pay for the cost of a private sight test. The moneys saved, an estimated £85 million a year in Great Britain, are to be used in various initiatives— primary care services such as facilities in general practice, health education and improving the availability and quality of general dental services. Hon. Members will recall that we promised during the passage of the Health and Medicines Act 1988, under which these regulations are made, that those who could not reasonably be expected to pay for a private sight test and those who for medical reasons needed to have sight tests more frequently would continue to benefit from free National Health Service tests. For this reason, the regulations provide that the following groups remain under the umbrella of the National Health Service: children under 16, full-time students under 19, people and their partners receiving income support or family credit, those on a low income who have been assessed as being entitled to full help with National Health Service costs, the registered blind and partially sighted, people needing certain complex lenses, diagnosed diabetics and glaucoma patients and close relatives of glaucoma patients aged 40 and over.
Additionally, people who are required as part of their treatment under the hospital eye service to have regular sight tests, for example, those awaiting an operation for a cataract, will continue to be eligible for free National Health Service sight tests when these are undertaken by a high street optician. These arrangements will, I estimate, cover about 40 per cent. of all sight tests. I have already mentioned that other people whose income is just above the level at which they would qualify for full help with National Health Service costs will be able to get a voucher towards the cost of their private test.
I would now like to touch on the effects of our proposals on those who will have private sight tests. As I said, it is too early to draw conclusions from the fees that opticians are talking about at the moment. But already we can see variety coming into the market, and it will clearly 1012 pay the customer to shop around. As I said earlier, the big multiple chains seem to have settled for the moment on a fee of around £10, in line with the National Health Service fee of £10.40 reimbursed to the optician for those who qualify for a free test. But I have to say that, even at a fee of £10, it seems to me unreasonable to argue that a customer is likely to be deterred from having a test about once every three years.
We stand by these regulations. We believe that they are right and that they will ensure that help is given where it is needed most
§ Mr. Robin Cook
The Minister has now twice relied on saying that the charge made by Dollond and Aitchison is equivalent to the new NHS fee, which came into effect on the same date as charges were abolished, and which is now £10.40. I remind him that the Secretary of State said on 1 November:I do not believe that all opticians will maintain a charge for a sight test which is equivalent to the present NHS fee". —[Official Report, 1 November 1988; Vol. 139, c. 928.]If the Department's view is now that it is acceptable that opticians charge a fee for sight tests which is equivalent to the NHS fee, will the hon. Gentleman at least admit that the Secretary of State's advice was wrong, and that the House was invited to approve the charges for the eye test on the basis of mistaken assurances from the Secretary of State?
§ Mr. Freeman
I entirely reject that charge. The hon. Gentleman knows full well that the free market takes time to have an effect. He cannot expect market forces in the first week of a new regime to alter charges out of all proportion to those being charged by two of the major suppliers.
The hon. Gentleman quoted selectively from my right hon. and learned Friend's reply. He gave the example of a company— Specialeyes—which has 59 outlets throughout the country and which will charge most people £9.25, while offering pensioners sight tests for £2.50. The hon. Gentleman deliberately ignored that large chain in his selective quotation. Replying to the hon. Gentleman, my right hon. and learned Friend concluded:I have no doubt that as time goes on we shall see prices reduced to levels lower than the National Heath Service sight test fee.With patience, and with the full effect of a new and competitive market, we shall see the benefits of competition being reflected in lower prices, to the benefit of all who choose sight tests.
I commend the regulations to the House and invite my hon. Friends to reject the prayers.
§ Mr. Ronnie Fearn (Southport)
I am extremely pleased that the House has been given another opportunity to debate this tiresome subject— the controversial issue of charges for dental and eye examinations— and to discuss the recent increase in prescription charges. In such circumstances it is difficult not to repeat what I, along with many other hon. Members, have said on numerous occasions here and elsewhere, but as the Government have a tendency to bury their head in the sand it is often necessary to keep digging until the argument hits home.
Charges for eye tests and dental checks contradict an important factor in health care— prevention. The health of the nation will be the poorer for such a move; more 1013 disgracefully, the nation's poor will suffer most. Charges deter people from seeking help and treatment, despite what the Minister has said. I find it remarkable that the Government can brush off the introduction of such charges with comments implying that, because the charge will be only £3.15 every six months or so, it will not act as a deterrent. Even if we ignore the fact that many people detest going to the dentist in any case and that any excuse not to do so will be jumped on, such comments highlight the extent to which the Government are out of touch with what is happening in a large part of our society
§ Mr. John Greenway
The Gentleman cannot have been listening to what my hon. Friend the Minister said in his speech, that in 1988–89 the number of courses of dental treatment rose by 5.6 per cent. How does he square that statistic with what he has just said about dental attendance?
§ Mr. Fearn
Certainly the information given in publicity has induced people to go for tests in the last year, but now that the charges are coming in I am sure that those figures will drop.
When a family's income in take-home pay can be as little as £70 a week, £3.15 is a lot of money— particularly when we add the prescription charge of £2.80 per item and the £10 to £18 which may be charged for an eye test. I know that some categories are exempt from charges, including those in receipt of family credit or income support; but I also know that the take-up rate for those benefits is very poor, despite the recent adaptation of the statistics by the Department of Social Security. A number of factors could account for that. Some people are too proud or too independent; others cannot cope with the interminable form-filling and questions, the long wait— the whole degrading exercise. Yet others have not the wherewithal to make it through the bureaucratic jungle. There is no doubt that they will suffer as a result of the charges.
Then there are the low-income groups who are not entitled to support, but who nevertheless struggle every week to make ends meet. Children, because they are exempt, may not be harmed by the regulations, but parents may well put off visits to the optician, dentist and doctor because their children need a pair of shoes or other article of clothing. Our senior citizens, who have contributed to the health and welfare of the country all their lives, should be entitled to seek the health care that they need regardless of their ability to pay, to ensure a decent quality of life without the hindrance and encumbrance of state administration.
Even those who are allowed to claim may find that they cannot obtain vouchers because— as we have been reading lately— backlogs cause them to be "out of time". Regulations should allow discretion for late claims. The elderly may suffer the most, although they are the people who should be using the services the most. Regular inspection by a dentist can identify pathological changes in tissue and bone structure, and an eye examination can pick up many diseases. Regulation 13B in statutory instrument 1989 No. 395 and regulation 14B in No. 387 (S.41), although welcome in the circumstances, rather miss the point. Many people will be deterred from visiting an optician for an eye test and therefore the diseases which would place them in the exempt category will not be detected.
1014 I mentioned earlier that the Government justified the introduction of dental charges by claiming that the charge was small at £3.15. I recall others claiming that market forces would reduce or even eliminate charges for eye tests. The recent survey, reported in most newspapers, certainly has shown how wrong the Government are to rely on market forces. The letter which the Minister issued as a press release dated 10 April, obviously because he was proud of its contents, shows how unfair, unpredictable and unreliable the market is and that it certainly should not be one of the determinants as to the availability of health care for any particular individual. Not everyone can shop around. The elderly, the disabled, young parents, those who cannot afford fares or those who do not have adequate public transport facilities cannot always do so. Others in rural areas do not have the outlets from which to choose. Unfortunately, not everyone lives in Dover or Witney in Oxon where we are told that charges are below £10. It is quite inappropriate that a crucial factor in the good health of individuals should be left to the whims of the market and could mean that one pensioner pays £2.50 while another pensioner in a neighbouring area may pay as much as £17.50 for an eye test. Does the Minister really believe that the latter will not be deterred from seeking help?
It is never very clear exactly what we are talking about in terms of charges for eye tests. Are we talking about a full eye examination or an eyesight test only? Will consumers be aware of exactly what they are paying for? As I understand it, and I hope that the Minister will correct me if I am wrong, patients who are exempt from charges can be sure of getting a full eye examination while those who have to pay do not have such a guarantee. What type of test will a pensioner who has to pay only £2.50, as per the Minister's press release, receive? Of course the full eye examination is most beneficial as diseases and other problems can be detected during that exercise.
Another group of people who will be adversely affected and do not appear to be exempt are those who receive a disability allowance but are not on income support. Perhaps the Minister will clarify the position of such people. By definition it is more difficult and often more expensive for them to go about their daily business. They are often pushed to make ends meet, but because their allowance is 20p or 40p more than social security regulations state, they are not entitled to income support or other benefit. When they need to have their eyes tested or their teeth checked, will they have to undergo the bureaucratic nightmare of a means test to find out whether they are entitled to full payment, part payment, third payment, quarter payment or any of the other possible combinations?
Statutory instruments Nos. 517, 393, 614 and 616 seek to increase the amount of deductions to be calculated before entitlement, in line with social security upratings. That is yet another example of the Government not living in the real world. They automatically assume that life is hunky-dory, full of happy families who are all aware of and are fulfilling their responsibilities to each other. But life is not like that. Many families have non-dependent relatives living with them who cannot or will not contribute £12.50. In the case of young dependants or others in low-paid work, they often cannot afford to contribute. The parents are keeping their children's heads 1015 above water. In other cases family and communications break-downs may have been brought about by poor living conditions and lack of finances.
Why is it that whenever the Government introduce legislation or make regulations, whether to introduce charges or give taxes away, it is always those who are already struggling who are hit the hardest? I believe that it was Sir Keith Joseph who first referred to the "cycle of deprivation" and said that it must be broken. Every move that the Government make adds to that cycle and it becomes a vicious circle.
The good health of individuals is paramount to the wellbeing of the nation. Ill health is a serious restriction on the freedom of any individual. The promotion of good health through prevention, diagnosis and treatment can benefit all collectively and individually. Charges deter people from using the Health Service and contribute to a system in which there is provision for the rich and provision for the poor.
We are told that the total charge for NHS services amounts to £640 million. We know that the present charges are designed to save between £50 million and £70 million. Those are large amounts but represent only 3 per cent. or 4 per cent. of the total cost of the Health Service. I am certain that if the Government so desired they could easily transfer such charges to levies on some industries such as, for example, tobacco, alcohol and many others which could have the added benefit of contributing to good health promotion.
Elimination of the present charges would reduce the administrative burden and make life a great deal easier and healthier for us all.
§ 11.6 pm
§ Mr. John Prescott (Kingston upon Hull, East)
On a point of order, Mr. Deputy Speaker. You will recall that we have just completed a long and involved debate on the King's Cross fire and the Fennell report. The Secretary of State for Transport told us that the delay in holding the debate was because he wanted to give the House the fullest amount of information concerning that terrible tragedy.
During the debate the Secretary of State was pressed by my hon. Friend the Member for Lewisham, Deptford (Ms. Ruddock) on the relationship between the Home Office and the Department of Transport and on matters concerning the emergency and fire services.
During the debate a story appeared on the tapes saying that the Department of Transport has now ordered an investigation into some allegations made in a letter in The Times this morning. I read that letter, which was from Sir Keith Bright who was in charge of the services. I considered it to be partly due to sour grapes.
To find out from the tapes tonight that the Department has ordered an investigation is a matter of subtance and concern. If it is true and the Secretary of State withheld the information from the House during the debate, it would amount almost to contempt of the House. I ask you, Mr. Deputy Speaker, through the offices of the House, if you will ask the Secretary of State to make a statement and, if it is not possible tonight, he should make a statement tomorrow because he has a sad history of withholding informaton from the House
§ Mr. Deputy Speaker (Mr. Harold Walker)
I am not sure to what extent that is a matter for the Chair. Doubtless what has been said will have been heard on the Treasury Bench and conveyed to the Secretary of State. In any case, I shall ensure that Mr. Speaker is aware of what has been said.
§ 11.8 pm
§ Mr. Michael Carttiss (Great Yarmouth)
My contribution to the debate can, I am happy to say, be brief. However, unhappily, I have to repeat that I have not changed the view that I held and expressed in the House last April and when we debated the Health and Medicines Bill. I listened to my hon. Friend the Under-Secretary with great care, but I am still unable to acknowledge that there is not a fundamental principle at stake. I do not intend to enter into arguments about deterrence, what people can afford or what market forces will produce in terms of the eventual level of charges. My argument has always been and is confined to the fact that I was proud that in our National Health Service we had the fundamental right to free inspections of teeth and eyes. I have not opposed, and do not oppose tonight, the increases in prescription charges. I acknowledge that within these regulations there are wide exemptions and that many people will not find themselves in great difficulties. But the issue of people being entitled to have their teeth inspected without a charge is fundamental to the concept of preventive medicine.
The hon. Member for Southport (Mr. Fearn) was interrupted by my hon. Friend the Member for Ryedale (Mr. Greenway), who made the point that some people are surprised that they are being charged only £3. I am not surprised that some people are surprised. But for many people in my constituency, where we still have an unemployment rate of 10 per cent.—well above the national average and dramatically above the East Anglian regional average, which is much lower than the national average— £3 for teeth inspections and £10 for eye tests has an effect. The fact that innumerable of my hon. Friends who represent wealthy areas in south-east England find that their constituents are surprised that the charge is a mere £3 does not have much impact on the elderly folk who come to retire in Norfolk, as well as those who were born and bred there and who live in an area of low average incomes, apart from the high unemployment which I have already mentioned.
The Government have had a most successful economic policy and are talking about repaying billions of pounds of the national debt— for very good reasons. They are now talking about £50 million or so to do away with what has been a fundamental right within the National Health Service. Notwithstanding all the logical arguments advanced by my hon. Friend the Minister tonight and by my right hon. and learned Friend the Secretary of State and my hon. and learned Friend the Minister of State in previous debates, it is still what I called last year a piddling measure. I repeat that tonight and I go further. It is an idiotic measure. I am not surprised that few people in the constituency of my hon. Friend the Member for Ryedale are worried about £3. They are probably so overwhelmed by the general unpopularity of what the Government are doing generally to reform the Health Service that they view the imposition of a fee for teeth and eye inspections as a minor feature of a rather bad story all round.
Before some of my hon. Friends think that I am opposed to the Health Service reforms, I must say that I believe that there is an enormous amount of good in the White Paper. However, the regulations require us as Conservative Members to vote for measures that are 1018 unnecessary, ineffective, and merely upset people so that they will not then see the value of the enormous and successful work that the Government are doing.
I must record that I cannot support the charges. If an opportunity were to arise in the ballot for private Members' Bills, the issue that I would want to put at the top of my list of priorities would be to restore the free tests. I hope that even at this late hour my Front Bench colleagues will take back the regulations. It does them no credit to be here at this time of night asking us to support them again.
§ Mrs. Audrey Wise (Preston)
The press statement issued by the Department said that the regulations were not imposing a charge, but removing a subsidy. That curious use of words typifies the attitude of dissimulation and deceit which surrounds this affair. The Minister has said that it is too early to make judgments about the prices being charged for eye examinations by opticians, but his right hon. and learned Friend the Secretary of State was willing to make forecasts and judgments about that even before the Health and Medicines Bill became an Act.
We were told that market forces take time to operate. But we were not told why on earth market forces should lead people to work for nothing. That does not happen in any other field, so why should it happen in this one?
Why should eye examinations, which may or may not lead to the prescription of spectacles, and which involve a most highly skilled person who has had long and most exacting training, be free? I can conclude only that it exposes ministerial ignorance of anything to do with eyes, eye examinations or optical practice. There is no way that opticians can recoup the cost of eye examinations if they offer them as freebies. If that cost is thrown in with the rest of the transaction, opticians will come a cropper, because there may be no "rest" of the transaction. Between one fifth and one quarter of eye examinations do not result in a prescription for glasses. Therefore, an optician cannot even add the cost to that of the spectacles, yet I have no doubt that that is the basis on which the ministerial forecasts were made. It is impossible for people to offer services or goods for nothing, whether we have a market economy or whatever. It will not happen with optics.
The Minister's statement about three-year frequency was rightly challenged by the hon. Member for Macclesfield (Mr. Winterton). He went on to repeat the claim that every three years is the appropriate frequency. How then can people have the National Health Service eye examination to which they are entitled without question once a year? Why is the normal advice to people without problems that it is a good idea to have an eye examination every two years? The three-year period is simply a device to try to minimise the effect of what the Government are doing.
My hon. Friend the Member for Livingston (Mr. Cook) said that he will not advise Opposition Members to oppose the measure in the Lobby tonight, and he gave one or two reasons for that. However, the overwhelming reason is that it is actually now in operation. It is a peculiar Parliament which discusses the propriety and appropriateness of regulations 12 days after they were put into operation. We should protest about that.
I have one or two more things to say about the date of operation. I do not know whether the Ministers realise it.
1019 but family practitioner committees throughout the country were unable to give authoritative advice to opticians about the date of operation of the change within two weeks of it being due to come into effect. Family practitioner committees were telephoned by opticians within a fortnight of 1 April, asking, "Is it 1 April? When is it? We do not know. We have had no information." The committees had to say, "We do not know. We have had no information either." That is an extraordinary way to proceed.
I have sat through proceedings in which the phrase "removing burdens from business" has been repeated ad nauseam. I am amazed to find that people who use that argument as a justification for removing rights from working people should be so insensitive to the needs of business as to carry out this change in such a way. I will tell the House exactly what has happened. The Minister has not bothered to do so. The date of operation was a dark secret even from family practitioner committees, on whom opticians rely for their authoritative information. Family practitioner committees received the appropriate forms only within a few days of the magic date of 1 April, so in many areas the forms had to be delivered by hand to opticians in order that they might have them when they would have to be used.
When the opticians got the forms they looked at them. What did they find? I do not know how much the Minister knows about this matter. In fact, I am working on the basis that Ministers know nothing, but I thought that someone in the Department would know one or two things. I thought that after more than 40 years of printing forms for eye examinations the Department would know that opticians, and everybody else who has anything to do with eye examinations or with the prescription or provision of glasses— indeed, anything at all to do with eyes— works on the basis of "Right first, left second." Everything is written in that way. This Government, who boast of removing the burdens from business, managed to produce an assortment of forms, all of which were printed on the basis of "Left eye first, right eye second." So the opticians, whom the Minister expects to give their services free, are having to cross out the wrong words and write in the correct words. That is having to be done for every patient in every optical practice— and, having seen the forms, I can tell the Minister that there is not much space.
This is the absolute botch-up, the howler of a procedure that the Government have presided over. Yet they are the Government who propose, within the next two years, to change the whole operation of every hospital in the country and GPs' practices— to do things for which no factual basis has been laid, things which, apart from the fact that they are wrong anyway, cannot be carried out in an efficient way.
This one limited area, involving such simple things as which eye is described first, could be taken as a tiny case study of what is likely to happen. I dare say that surgeons sometimes have to fill in forms and that they have procedures. I should not like them to mix up right legs and left legs, as opticians may be at risk of mixing up right eyes and left eyes.
But that is not the only error. It is not even possible to use carbon paper, so names and addresses have to be written in twice because the form is designed in such a way 1020 as to make it impossible to fill it in rationally. That is what the party of business— the party concerned to remove burdens from business— has managed to do to optical practices throughout the country.
But there is worse to come. Having failed to persuade opticians to give "freebies", the Government have introduced the idea of "cheapies". I shall not go on at length about this, though it is certainly relevant to the regulations that we are discussing. For example, if a person does not realise at the time of the test that he is entitled to a free National Health Service eye examination but realises later that he was so entitled, then he will be entitled to a refund of the cost of the test. I do not know what is in Ministers' minds, but if such a person were to opt for a "cheapie" test, if it ever became possible, what refund would he get? Having been entitled to a full eye examination, he would not have received one. So what would happen? The Government are getting into really deep water.
But, on the principle, they are getting into even deeper water. If optometrists or ophthalmic medical practitioners could invite patients to sign pieces of paper to the effect that it is all right if they are not given a full examination, that is tantamount to saying, "Sign to say that it is OK if I am negligent." The idea that that is in any way proper or desirable, or likely to lead to the protection of the nation's eye health, is just ludicrous. That, however, is what is proposed. At least that is the proposal which is the subject of consultation. I was surprised when the Minister told us that consultation is still taking place, but that gave me some hope, as the original time limit has expired. I hope that that example of unusual delicacy means that the Government are having second thoughts. I can tell the Minister that if there are not second thoughts, there will be severe trouble. Surely the Government are not prepared to say to professional people, "Ignore your common law duty of care to your patients; get them to sign to say that it is all right if you do not do it properly." Surely the Government cannot expect that approach to be accepted. As I wish trouble to be saved all round, I hope that the Government will proceed no further with that ludicrous suggestion.
If the Government take the matter further, it will be because they have been caught out after having promised that the cost of an eye examination would vanish into thin air, or that it would be provided as a mere bagatelle, for nothing or next to nothing. They will have been caught out in misleading the public and they will be looking for an alternative. The alternative will damage those who, because of lack of knowledge, or through poverty, succumb to the Government's blandishments. In effect, the Government will say, "It is all right. Assume that you do not really need a proper eye examination. Trust to luck and pay £5 instead of £10." Conservative care of eyes brings us to that.
§ Mr. Tony Baldry (Banbury)
My hon. Friend the Under-Secretary dealt in detail with the practicalities of the regulations. My hon. Friend the Member for Great Yarmouth (Mr. Carttiss) and the hon. Member for Preston (Mrs. Wise) spoke about the principle that lies behind the regulations and behind charging, and it is on the principle that I wish shortly to detain the House.
1021 Although the National Health Service costs the average family about £35 a week— about £1,820 a year—the service that it provides is all too often seen as costless by both those who use it and those who work in the Health Service. Payment for service is never mentioned. It is not discussed or itemised, and there are many who are unaware of or unconcerned about what the NHS costs. That has important implications for the use of the services that are provided.
It is right that the NHS should be free to those who need its services at the time that they need them, and be paid for mainly out of taxation. That has been the principle of the NHS ever since it came into being in 1948. From almost the first day of the service, however, it became clear that there would be concern about costs. Whenever NHS charges are introduced or debated in the House, or in the country, there is a tendency for the Opposition, and some of my hon. Friends, to treat them as the first charges to be introduced. Charges were first introduced by the Labour Government who introduced the NHS in 1948. By 1949, they had had to introduce charges. They recognised that it was impossible to sustain the costs of the NHS without charges.
One of the criticisms made about the measures that the Government intend to introduce is that they may reduce spending on the NHS. That was one of Beveridge's intentions. He and those who introduced the NHS thought that by having a National Health Service that would improve patient care the amount of money spent on the Health Service would be reduced. The NHS was introduced in 1948 on that basis.
The Labour Government soon found that if there was infinite demand, there was an infinite cost. Therefore, by 1949— only a year later— Cripps, as Chancellor of the Exchequer, was obliged to bring in legislation to introduce prescription charges. They did not become effective until 1951 when Gaitskell was Chancellor of the Exchequer. In the Budget of that year, on what did that same Labour Government introduce charges? I will tell my hon. Friend the Member for Great Yarmouth: they introduced charges on teeth and spectacles. So there is nothing new about charges for some items. They have been in force almost as long as the National Health Service itself.
The charges that were introduced in 1951 did not apply to needy categories of patients who were exempt. I strongly suspect that if we were to check what categories were exempt in 1951, we would find that they do not differ substantially from the categories which will be exempt now.
There is nothing new in the concept of charges for certain items under the National Health Service. That concept was introduced as far back as 1949 by the Labour Government, the very same Government that only a year before had introduced the National Health Service. They brought in the charges because they recognised that there were certain items for which there was a need to raise money; they also recognised that there was a need to ensure that people had some appreciation that those services were not totally without cost.
When we are debating the National Health Service in future I hope that there can be at least a little intellectual honesty about the history of the introduction of the service. Hon. Members should realise that while we are giving a first-class service through the NHS it is on occasions necessary to make modest charges for certain items.
§ Mr. Terry Davis (Birmingham, Hodge Hill)
Understandably my hon. Friend the Member for Livingston (Mr. Cook) concentrated on the new arrangements for eye examinations and the charges being introduced by the Government. I agree entirely with his comments and with the comments by my hon. Friend the Member for Preston (Mrs. Wise).
I want to deal with a different aspect of the regulations. The Parliamentary Under-Secretary of State emphasised that we are debating 12 separate statutory instruments. I listened carefully to what he said. He stopped, as I thought, in mid flight and unfortunately made no reference to the last four statutory instruments on the Order Paper. I refer specifically to the National Health Service (Travelling Expenses and Remission of Charges) Amendment Regulations 1989. There are four sets of regulations on that matter, Nos. 517, 393, 614 and 616.
The first two of those statutory instruments— Nos. 517 and 393— affect the amount of contribution assessed for a non-dependant living in the home of someone who is applying for a voucher for glasses. The second pair of regulations amend the first two, because the Government got it wrong when they published the original regulations in March.
The hon. Member for Southport (Mr. Fearn) referred to these regulations, but even he underestimated the effect of the increases in the contributions that are assessed for non-dependants living in the homes of people who are applying for assistance for the cost of glasses. He rightly pointed out that there is a deduction for housing costs for the assessed contributions which will affect the amount given to assist someone who has a voucher. The real effect is not just £12.50 at the top of the scale. It could be as much as three times that amount.
If the hon. Member for Southport works through the calculations, he will find that the excess of income over resources for any applicant for assistance is multiplied by a factor of three. It follows that, if income equals requirements—according to the income support regulations and calculations— that applicant will find that he or she is contributing three times the amount of the deduction from housing costs. It can be three times £12.50 in a family where one non-dependant has an income of more than £52.10 per week. A penal contribution can be expected from someone who has a voucher.
The Under-Secretary of State told the House that the value of vouchers has been increased by 5 per cent. and that in his opinion the charges were reasonable. As I have already mentioned, he did not touch on those four statutory instruments and, therefore, he did not give himself the opportunity to point out the amount of the increase in those assessed contributions towards housing costs for non-dependants living in the homes of applicants for help. If he had touched on that, he would have had to tell the House that the Government have introduced a contribution for a non-dependant who is under 25 years old and receiving income support. That new contribution is introduced by these regulations at the rate of £3. That contribution of £3 can be multiplied by a factor of three, so that the parent— who may be a man or woman pensioner— can be asked to contribute as much as £9 towards the cost of glasses as a result of that under 25-year-old person on income support living at home. That, of course, is a new introduction and the increase is 1023 infinite. However, the increase is more than double for someone in the middle of the scale, because the contribution is being increased from £3.45 to £7.20 for a non-dependant whose income is less than £49.20. At the so-called top end of the scale, for someone whose income exceeds £52.10 a week the contribution is being increased from £8.20 to £12.50, which is an increase of more than 50 per cent. Those are massive increases by any stretch of the imagination or calculation. They are increases that, by definition, are being applied to families who are living in poverty. It is, in effect, increasing a tax that is paid by poor families. It is paid often by pensioners, who are applying for assistance with the cost of necessary glasses, and who happen to have a non-dependant— often a grown-up son or daughter— in their homes.
The Minister did not give himself the chance to tell us how many people are affected by those increases. I hope that, when his hon. Friend the Under-Secretary of State for Scotland replies to the debate, he will tell us how many people will be adversely affected by the increases in the contributions of non-dependants covered by the four statutory instruments.
I want to mention another aspect of the regulations because the House should be concerned not only with what is happening under these regulations, but with what has happened as a result of the regulations that the statutory instruments amend. In other words, the House should be concerned about what has happened during the past 12 months.
My interest in this detailed but important aspect of the regulations arose as a result of a constituent's inquiry. I engaged in correspondence with the Department of Health about my constituent's case. My constituent is a pensioner and his wife is also receiving a retirement pension. Their combined pensions mean that they have an income slightly in excess of the level for income support. Therefore, a voucher is needed for glasses for the husband. Their grown-up son lives in their home and that son did not want to tell his parents—and did not see why he should tell the Government— the amount of his wages every week. Under the old regulations, before the changes that were made about a year ago, he did not have to reveal his wages because the contribution towards housing costs was a standard amount and there was no inquiry into income or means or into the financial affairs of a non-dependent grown-up son or daughter living with retired people. The Government have now introduced a means test for such non-dependants and that son now has to tell the Government and his parents, because he has to put his income on the form, the amount of his weekly income. He refused to do that because he said he did not see why he should have to provide that information.
I wrote to the Minister and asked the reason for the information about income. I received a courteous reply, but the letter did not tell me what I most wanted to know, which was what would happen if my constituent's son still refused to give the information. I received another reply from the Minister who told me that the non-dependant's contribution would be assessed at the maximum rate. The Minister's letter contained detailed figures. When I checked those figures with the assistance of the Library 1024 staff, I found that they bore no relation to the figures that had been approved by the House a year ago in statutory instruments. They were on a different scale.
Within 24 hours I contacted the Minister's office and 10 weeks later I received a letter from the Under-Secretary of State for Social Security telling me that the instructions issued to the agency benefit unit were incorrect. That was in the middle of January. For months the agency benefit unit had been assessing non-dependant's contributions on incorrect instructions. In every case, the non-dependant's contribution was assessed at £3 more than it should have been under the regulations approved by the House.
I have already explained how the amount to be paid by a person with a voucher is calculated. The penalty, the excess which someone— often a pensioner— has to contribute, can be as much as £9, three times the £3 mistake. In his letter the Minister was kind enough to tell me that fresh instructions would be issued to the agency benefit unit. The House will be pleased to learn that after 10 weeks the Government took the action that was necessary to correct their inaccurate instructions. Can the Minister say how many people were adversely affected by the mistake? How many paid £3 or £9 or an amount in between which they should not have paid for glasses? What have the Government done to refund the money that those people have paid? I await answers to those questions with great interest.
§ Mr. John Greenway (Ryedale)
I shall be brief. I should like to make a comment and a plea to my hon. Friends on the Front Bench. My comment is that, in this debate and in the other debates that we had on these charges in November and seven or eight months earlier, it has been said that the amount raised by these charges is insignificant. My hon. Friend the Member for Great Yarmouth (Mr. Carttiss) spoke about a "piddling measure". There is some uncertainty about whether the amount raised by the dental and optical charges will be £140 million or £150 million. That amount is by no means insignificant.
I am sorry that the hon. Member for Livingston (Mr. Cook) has just left the Chamber, because I wanted to remind him and the House of what he said in the Budget debate. He spoke about the likely cost of the tax relief of £40 million a year for private medical insurance for old age pensioners. He said:£40 million is sufficient to pay the annual salaries of 3,000 nurses or 1,000 consultants. It is enough to purchase 20,000 ventilators or 1,300 ambulances. It is enough to meet the operating costs of 35,000 cataract removals or of 17,000 hip replacements."— [Official Report, 16 March 1989; Vol. 149, c. 569.]That is what can be done with £40 million. These measures raise about three and a half times that figure, so we are not talking about an insignificant amount.
The Minister pointed out that the take-up is increasing. It happens when charges are changed— this has occurred for the last 30 or 40 years— that for a month or two there is a small reduction in demand. Over a period— say, when we review the position in a year or two— we will find that there has not been a significant change.
In the three speeches that I have made in the House on this issue I have appealed to the Government to introduce a new contract for general dental practitioners. Members of the dental profession are disappointed that negotiations 1025 on a new contract have not yet commenced. There is fear that perhaps the profession has missed the boat and that the new contract will not appear.
It is appreciated that, with the general practitioner contract being in the forefront of the Government's mind, the dental profession may have to be patient. I hope that the Minister will repeat the assurance that was given as long ago as last June— that the Government are determined to negotiate and introduce a new contract for general dental practitioners.
The present arrangements for remunerating dentists are 40 years old and out of date. We must have a new arrangement which reflects modern trends in dentistry— the reduction in dental decay— and which will be more beneficial to patients and the profession.
When we discussed these issues on 1 November last, I said that the introduction of charges of this type was often an unpopular step. But I urge hon. Members to reflect that an unpopular measure does not always mean that what is proposed is unreasonable. What the Government propose is right and is in the interest of the NHS, and I hope the House will not divide on it tonight.
§ Mr. Nicholas Winterton (Macclesfield)
At this hour I will be brief and simply put a few questions to the members of the Treasury Bench, and particularly to the Under-Secretary of State for Scotland, who will reply to the debate. My hon. Friends will be aware that I was one of those on the Government Benches who strongly opposed the introduction of charges for dental inspections and eye examinations.
Does not the introduction of charges in these spheres fly in the face of the philosophy of preventive medicine, which I thought was a No. 1 priority with the Government? Preventive medicine can save money. After all, if relatively cheap treatments are carried out early enough, the heavy cost of certain eye and dental treatments can be avoided. In other words, the small sums of money to which we are referring in these charges could be dissipated in other ways.
Is the Minister aware of the co-operation which to date has often existed between opticians and optometrists and eye hospitals in centres of excellence, where competent and able professional optometrists have assisted eye hospitals and taken the pressure off those hospitals, to the advantage of the NHS as a whole? I understand from the profession of optometrists and opticians that, because of the implementation of charges, that relationship is likely to be destroyed or, at best, undermined.
My colleagues on the Conservative Benches often talk about the great benefits of the untrammelled free market. We have seen the problems that can occur with the untrammelled free market in the City and the disasters that resulted from that. It would be constructive, rational and sensible to discuss these proposals with the professions that will be involved, as they are intimately well informed about these matters. The professions should be consulted before the Government introduce measures—and in this case charges— which will affect two very important sectors of the National Health Service.
I believe that the professional services do not always need to be open to the free market to provide the best possible service to the people of this country. As I have said, in certain areas we can see that the Government are 1026 forcing the free market upon the professions. The morality, discipline and self-discipline of those professions are disappearing and the public are suffering dramatically as a result. Costs are also rising.
My hon. Friend the Minister said that people will be able to shop around. Should people who require professional skilled help have to shop around? Do they not go to a professionally qualified person and expect to receive good and reliable treatment? If they have to pay for that treatment, do they not expect it to be provided at an acceptable and reasonable price?
I do not believe that costs are involved in the issues that we are considering today. Many people who require help are least able to shop around and take advantage of what my hon. Friend the Minister described as the free market. I speak with some knowledge about these matters as I have served on the Select Committee on Social Services for many years and I have met many people concerned with the professions who have expressed dissatisfaction and unhappiness that the Government are following this road. They do not believe— and I do not believe— that the public and those who require treatment and assistance will benefit.
It is extraordinary that the House should debate a matter at this time of night which involves a maximum, as I understand it, of £60 million, when these measures will result in substantial additional costs on the Health Service in future.
I hope that my right hon. and hon. Friends on the Treasury Bench realise that opposition to the charges does not rest exclusively with the Opposition parties. It is felt very deeply on the Conservative Benches as well— and not because we are dogmatic or trying to appeal to groups outside the House whose votes we may need at the next election. Those of us who voted against the charges during debates on the Health and Medicines Bill did so because we were convinced that the Government had not presented a good case and because going against the philosophy of preventive medicine would not benefit the people of this country.
§ Mr. Sam Galbraith (Strathkelvin and Bearsden)
I want first to thank the hon. Member for Macclesfield (Mr. Winterton). He dealt with the broad general principles involved with the charges for eye tests and the question of preventive medicine. We have debated those issues before and, as the hon. Member for Macclesfield spoke about them so eloquently, he has removed from me the obligation to deal with them tonight. I am grateful to him for his contribution about the general principles.
As the Minister said, there are 12 sets of regulations before us, half referring to England and Wales and the other half to Scotland. There are no significant differences between those two groups so I shall not confine my remarks to one or the other.
Like my hon. Friend the Member for Livingston (Mr. Cook), I want to concentrate on the regulations which deal with charges for general ophthalmic services and those dealing with exemptions. Having heard the hon. Members for Banbury (Mr. Baldry) and for Ryedale (Mr. Greenway), I take more than a passing interest in the. regulations dealing with charges and, in particular, wig charges in the NHS. That is not because of my particular problem in that regard. I take a passing interest having 1027 been responsible for great charges for wigs in a former life because of the nature of my work. It was part of my work dealing with patients who had what is known as traumatic alopecia, which involves having one's head shaved prior to a particular procedure. That was expensive, but I was not aware of the charges at that stage.
The hon. Member for Ryedale pointed out that it was important to know of the charges because that reflected a discipline within those who work in and use the services. I changed my practice so that that expense did not fall on the NHS. I did so with no knowledge of the charges, simply because I thought that it was necessary. My point is that it is not necessary to know of the charges in order to change practice. I also did so without a budget of my own and without my hospital opting out. I think that saved the NHS a considerable amount. That is one reason for my interest in that.
I was interested to hear the hon. Members for Banbury and for Great Yarmouth (Mr. Carttiss) talking about the introduction of charges. When the Health and Medicines Bill was debated in Committee I made a deal with the right hon. Member for Braintree (Mr. Newton) that as long as I accepted that the Labour party was the first to introduce charges, he would never mention the matter again.
However, the important point about charges, which was touched on by the hon. Member for Macclesfield, is that the charges that we are debating are different in concept. Previous charges have been made for the provision of treatment. These charges are for screening processes. If someone has a problem and needs treatment for which there is a charge, there is a deterrent effect, but the treatment is likely to be taken up. However, if someone is told there is probably nothing wrong with him but it would be useful to be screened for which there would be a charge, that does have a deterrent effect. There is an important quantitative difference in charges for screening processes.
The Minister said that he thought that it would be— to use his word— unlikely that charges would have a deterrent effect. When we debated the Health and Medicines Bill in Committee, my hon. Friend the Member for Livingston read out various statements that were made, such as that it was unlikely that the charge would stay the same, that the charge would go down or that it was likely to go down. That has not been borne out by fact.
I have no confidence that, as the Minister suggested, the market will regulate costs and the price will go down. As the hon. Member for Macclesfield said, the market is not quite the same in health care as elsewhere. A colleague of mine in private practice wished to reduce his work load. He thought that the way to do that was to put his prices up. Much to his amazement, rather than reduce it, it significantly increased the number of people who came to him. It is an American philosophy, apparently, of which I was not aware, that the way to attract patients is to put the price up because they think that they are getting a better service. I am not confident that prices will fall. The market does not operate in health care. All our experience of health care systems that operate a pricing mechanism is that prices inevitably rise.
The Minister said that prices will not prove a deterrent. He said that 2 million pensioners will be exempt. He did not mention that that means that 7.7 million will not be.
1028 He said that even those who are not exempt will be eligible for subsidy if their income is just above income support level. I hope the Minister realises that, to get the subsidy, people have to fill out a lengthy form. It will surprise such people to be asked on the formAre you going to visit someone in prison?Pensioners and others who want to claim for an eyesight test will wonder what on earth that has to do with their vision.
This complex application form includes many questions:Do you and your partner have a home improvement loan or loan for repairs? …We will get in touch with you about this …Do you or your partner get housing benefit? Tell us the full amount for rent and rates and the amount for rent after housing benefit is taken away. This will be the actual amount of rent you pay …If you or your partner are a council tenant, or if you agree that the council will pay housing benefit straight to your landlord or landlady …and so on. I hope that the Minister gets the point. These complicated methods of claiming help for those just above income support are a disincentive to claiming.
The regulations on general ophthalmic services list those who will gain exemption. The Minister also read out the list of those who will be exempt; I ask him for an assurance that it will be kept under review. One or two necessary exemptions may not have been included. These exemptions were wrung out of the Government in Committee and on Report. One of the concessions that we obtained was that for people aged 40 or over who are the parents, brothers, sisters or children of people diagnosed as suffering from glaucoma. Grandparents are missing from the list. Will the Minister include them? There are not many of them, and I see no valid reason for their exclusion.
Will the Minister consider exempting patients with cataracts? By that, I do not mean those whose condition has been dealt with— they will be eligible because of their complex optical appliances— but those who have been diagnosed and are having regular examinations.
On Report, the Minister of State gave an undertaking that the uptake of tests and waiting lists in hospitals would be closely monitored. What systems are in place to enable that monitoring to be done? If there is evidence of lower take-up, will the Government reconsider this matter?
The Minister asked for our comments on a matter that is not in the regulations; I am only too pleased to give him mine. I was surprised that the two-tier sight tests were proposed at all. On Report, the right hon. Member for Braintree introduced what is now section 14 of the Act. He told us then that new clause 15 wasessentially a consumer protection provisionHe said that it differed from the original clause, and had therefore been tabled rather than a mere amendment, in thatwe have decided that it is right to take the power, which curiously does not exist at present, to specify clearly in regulations what duties a practitioner must perform as part of a sight testAs the House is aware, the sight test is generally understood and expected to include a test to establish whether spectacles are required, and an eye examination in which signs of injury …may be detected …It is our intention that, under whatever arrangements people receive a sight test, there should be certainty about what they are getting and that it should include a proper eye examination."—[Official Report, 13 April 1988; Vol. 131, c. 226.]The right hon. Gentleman did not say that it might. He did not say that there would be a differential in sight tests. That is what we were led to believe, and that was our understanding. Imagine our surprise when we found that 1029 the proposal was not for a proper eye test, but for a two-tier test. One tier will be for refraction of vision; the other will be the full eye test.
I ask the Minister to consider that proposal very carefully. He said that he might be swayed by argument, and I trust that I will be able to persuade him not to introduce the two-tier test. For ophthalmic medical practitioners it will pose considerable ethical problems, based on what is expected under the General Medical Council's "fitness to practise" rules and regulations, under which it is incumbent on them to do whatever they think necessary.
I understand that under the proposals the ophthalmic medical practitioner or optician will have to state clearly that two sight tests are available, and that one will not include the full examination. What will be the position should a patient present to an ophthalmic medical practitioner or optician and agree to the simple sight test but not to the full examination? In the course of that test, either from the history or from the initial sight test, what will happen if the practitioner feels, on the basis of either the patient's history or the initial test, that a further examination is necessary? Will the patient be entitled to that further examination free, or will he have to pay for it? Can he opt out of having the test at all? That will, as I have said, present an ethical problem; more important, it will present a considerable health problem for the patient.
Throughout the Committee and Report stages of the Bill much emphasis was put on the need for a full eye examination, rather than an examination limited to a test of vision. I hope that the Minister will consider carefully before proposing regulations for a two-tier examination. I assure him that Opposition Members will vote against any such regulations.
§ 12.7 am
§ The Parliamentary Under-Secretary of State for Scotland (Mr. Michael Forsyth)
I am happy to give the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) the assurance that he sought that the exemptions will be kept under review. I am sure that he will recognise that as we are currently considering the results of consultation on the question of a two-tier test— as he describes it— his comments will have been heard by my hon. Friend the Parliamentary Under-Secretary for Health and will be taken into account.
The concept of asking patients to make a contribution towards the cost of their treatment is not new, and certainly not original to the present Government, as the hon. Gentleman himself acknowledged and as was emphasised by my hon. Friend the Member for Banbury (Mr. Baldry). It is therefore difficult to understand the protests being made about the rational development of that principle. What is even stranger is the challenge to measures concerned with providing relief from charges for those on low incomes.
The hon. Member for Strathkelvin and Bearsden asked me whether there would be proper systems to review the take-up of sight tests, both private and NHS. We will certainly undertake a survey of private tests through NOP in the autumn. He also asked about cataract sufferers, who will be able to obtain free NHS sight tests if they are referred by their hospital consultants.
The hon. Member for Southport (Mr. Fearn) and the hon. Member for Strathkelvin and Bearsden complained 1030 about the problems of form filling, particularly for the elderly. I have a certain amount of sympathy with the hon. Member for Southport's complaints about form AG1, which is a daunting prospect for some people, although research has shown consistently that the key element as to how well claimants deal with forms is the clarity of individual pages and not the overall length of the form. However, I dare say that the hon. Gentleman's experience. like mine, is probably not entirely in line with those findings. He will be delighted to know that we are currently reviewing the form to find out how it can be improved. I stress that people receiving income support or family credit get free treatment automatically and others on low income can claim help.
The hon. Member for Southport also asked about the sight tests being provided through British Home Stores at £2.50 for pensioners. He asked whether they were proper sight tests. I understand that they include a full eye examination, so what my right hon. and learned Friend said to the House appears to be taking place.
A number of points were raised by the hon. Member for Southport, the hon. Member for Strathkelvin and Bearsden and my hon. Friend the Member for Macclesfield (Mr. Winterton) about the deterrent effect of charges. It is not accepted and never was throughout the debates on the Health and Medicines Act that charges will have any deterrent effect. When the supply of NHS spectacles ended it was argued that people would be deterred from going to the optician. That has not been the case and spectacle sales and sight tests have increased. My hon. Friend the Member for Ryedale (Mr. Greenway) stressed that point in respect of dental examinations and charges. That did not persuade my hon. Friend the Member for Great Yarmouth (Mr. Carttiss) or my hon. Friend the Member for Macclesfield who were concerned about the apparent contradiction between bringing in charges for dental examinations and our clear commitment to preventive medicine.
The dental examination charge is in no way contrary to the philosophy of prevention set out in "Promoting Better Health". It still pays to visit the dentist regularly. Moreover, the charge will help to release some £50 million, as my hon. Friend the Member for Ryedale pointed out, for positive measures to encourage the prevention of dental disease, including fluoridation, improved and more widespread vocational and postgraduate training for dentists and a new programme to promote dental awareness among young people. It will also help to finance preventive measures in other primary care services.
The hon. Member for Southport asked about backlogs and the use of discretion for late claims for refunds. He is quite right that there have been some delays in processing claims for help with NHS costs. However, I am pleased to say that from a peak of more than 9,000 cases, the agency benefits unit had reduced the stockpile to about 2,500 cases on Monday and had cleared it completely by this morning. People who have incurred NHS costs while waiting for their claims to be assessed will be able to claim a refund and will include those who have purchased glasses or contact lenses following a sight test. The normal one month for claiming a refund will not apply. I hope that that meets the hon. Gentleman's point.
My hon. Friend the Member for Great Yarmouth asked about the cost of dental and sight tests for the unemployed. The unemployed people who are receiving 1031 income support, as most unemployed people are, get free dental and sight tests, free dental treatment and full-value vouchers for glasses as well as free prescriptions.
The hon. Member for Preston (Mrs. Wise) complained about the design of the forms which have been issued. The first two batches of forms from the printers did have reversed prescription details. That error has now been corrected and the forms which are due for delivery to family practitioner committees next week are correct. The hon. Lady was also concerned about a delay in issuing instructions. Revised instructions were issued to health authorities and family practitioner committees to arrive no later than 21 March. That gave them sufficient time to issue them to their practitioners, but I understand that some delayed issuing them until Friday 31 March.
The hon. Member for Birmingham, Hodge Hill (Mr. Davis) complained about the regulations amending the scheme for helping people with low incomes and about incorrect instructions being issued. The amending regulations simply ensure that the scheme for help with NHS costs is kept in line with the income support scheme on which it is based. The hon. Gentleman asked about the number of people who had been affected because for part of the year 1988–89 the agency benefits unit was not assessing claims strictly in accordance with the 1988 regulations. The cases concerned will be reviewed and we will be writing to the people concerned to find out whether they have paid more than they should have done
§ Mr. Terry Davis
Given that the letter admitting that the incorrect instructions had been issued was sent to me by a Minister three months ago, surely the cases should have been reviewed by now
§ Mr. Forsyth
If the hon. Gentleman would like me to I shall ensure that I write to him to explain the background. It is a complex matter and I am sure that he will understand that every effort is being made to identify the people who may have suffered and to ensure that they are properly treated. I shall certainly write to the hon. Gentleman if that will be of assistance to him.
§ Mr. Forsyth
I understand that about 15,000 claims were affected by the error, but that does not mean that that is the number of people who will lose out. The hon. Lady should be concerned, as I am sure we all are, with the particular circumstances of those affected and I can give her an assurance that everything is being done to put matters right
§ Mr. Terry Davis
The Minister would have had more time to obtain the information for which we are asking if his hon. Friend the Under-Secretary had given way during his speech because I would have put some questions to him which might have saved us all some time. The Minister has told us that 15,000 people have been affected. Can he tell us how many cases have been reviewed during the three months since the Government admitted to me that they had made a mistake? After all, it took them 10 weeks to write to me with that admission
§ Mr. Forsyth
I have already explained to the hon. Gentleman that we will be writing to the people concerned to find out if they have paid more than they should and that we will ensure that the matter is put right. I would have thought that he would accept that.
My hon. Friend the Member for Ryedale asked about the new dental contract. I can give him the assurance that he sought. Negotiations will begin soon and I can repeat the assurances that have already been given to the profession about that. I am sure that he will welcome that.
I think that I have covered all the points raised in the debate. The regulations ensure that proper exemptions are made and that a balance is reached between obtaining a proper contribution from those who are able to afford it and those who are not. I commend the regulations to the House.
§ Question put and negatived