Eye Test Charges (Hansard, 22 April 1991)

§ Mrs. Alice Mahon (Halifax)

Sadly, nothing illustrates the Government's real intention towards the national health service more than the disastrous decision in 1988 to abolish free eye tests. The Government simply ignored the warnings that abolition would have a serious effect on the health of large numbers of our nation. The then Secretary of State for Health refused to believe Labour Members when we told him that if he stopped paying for free eye tests, opticians would have to start charging.

Last week, in the debate on the national health service, my hon. Friend the Member for Livingston (Mr. Cook) reminded the House that the right hon. and learned Gentleman could not have been more wrong. In November 1988, the right hon. and learned Gentleman assured the House: the charge for the eye test will steadily disappear … that is my strong personal opinion."—[Official Report, 1 November 1988; Vol 139, c. 927.] He has certainly been proved wrong, because today every optician charges between £10 and £17 for an eye test. As a result of that charge, hundreds of thousands of people face an increased risk of going blind or developing other serious diseases as they are deterred from visiting the optician by the cost of the eye test.

It was not just the Labour party who warned the Government about the potential serious situation that has now developed. The main professional body also advised against abolishing the free test and stressed its worthiness. A survey conducted by the British College of Optometrists in 1986 showed that of the 2,194 referrals made as a result of the eye test, older people—who formed a large group of those questioned—were particularly at risk from cataracts, macula degeneration, glaucoma, diabetes and other serious medical conditions. The college concluded that such people would be at risk if the free test were abolished as the charge would deter them from seeking such a test. Despite the survey and other early warnings, the Government refused to exempt pensioners from the charges. Since 1986, various surveys have been conducted which confirm the Labour party's fears that there would be widespread resistance to charges, particularly from the elderly.

In June 1990, the Consumers Association conducted a survey on eye testing and its findings were published in Which? The survey covered 1,094 adults who represented the public. It discovered that two in five people would go for an eye test less often once the charges were introduced, that two in five of those exempt from those charges thought that they had to pay and that nearly half those over 40 who were exempt from the charges also thought that they had to pay. The latter evidence was particularly worrying, given the increased incidence of eye disease in that age group.

The Consumers Association findings took into account the 7 per cent. increase in the number of eye tests as people rushed to beat the charges. However, even comparing the number of eye tests conducted in the year to April 1989 with those conducted in the year to April 1988, it is clear 877 that tests were down by about one fifth—more than 2.5 million in England and Wales—which represented a great reduction.

The survey concluded that, given that about one eye test in 20 results is a referral for medical examinations for eye disease or other medical conditions, that drop in examinations may have led to 125,000 fewer referrals with consequent repercussions for the early detection of diseases and possible increased long-term burden on the national health service. Therefore, the rather mean and irresponsible decision to charge for eye testing has not just caused untold human misery and pain—it has also been an economic mistake. Someone with an advanced disease is likely to cost the NHS far more than someone whose disease is diagnosed early.

Recently, there has been more evidence that the decision was bad. On 12 April, the Association of Optometrists published the findings of a major MORI survey on eye testing, which showed that the number of eye examinations had plummeted by one fifth since 1988. The survey, in which the Economists Advisory Group sampled 252 practices of members of the association, said: In comparing survey data on each quarter in 1988, 1989 and 1990, the … study estimates that eye examinations during 1990 were 20.9 per cent. fewer, on a national basis, than during 1988. It stated that, in particular, there were an estimated 3.6 million eye examinations in the first quarter of 1989, just before the Government abolished universal free eye examinations. It said that, in the second quarter of that year—after charges were introduced—the number of estimated eye examinations shrank to 2.4 million, down nearly 32 per cent. Subsequently during 1990, estimated eye examinations have averaged 2.5 million a quarter, almost 21 per cent. down on the 1988 quarterly average of 3.2 million. Those are alarming figures.

A second survey, conducted at the same time and by the same group arid commissioned by the Association of Optometrists, showed that a majority of the public believed that eye examinations should be free to all, It is commendable that the public take such a good social attitude. The survey updated trend information spanning seven years and was carried out to establish public attitudes to eye examinations. It was conducted among more than 2,000 people aged 15-plus throughout Britain, and it concluded: The Government's decision, in April 1989, to abolish universal free eye examinations is not popular amongst the public. Nearly three-fifths (57 per cent.) of those interviewed said 'everyone should be able to have a free eye examination'. A quarter (26 per cent.) said free examinations should be available only to those groups currently eligible, namely children under 16, students aged 19 in full time education, those on income support or family credit"— many of whom are currently entitled to free eye tests— those registered blind or partially sighted, those with glaucoma, those aged over 40 who have a close relative suffering from glaucoma, and those suffering from diabetes. As might be expected, the public were socially aware and were concerned about the abolition of the free tests.

The British College of Optometrists, which carried out the work, said that in the two years since fees were imposed about 4 million fewer people had had their eyes tested. That represents a drop of about 8 per cent. per year. Any health Minister worth his salt would take those alarming figures seriously. Some 400,000 of those would have been referred for further medical attention and half of those referred would have been suffering from a major eye 878 disease such as cataract or glaucoma. Thousands more would have shown early warning signs of illnesses such hypertension, heart disease, diabetes and, in extreme cases, brain tumours.

When I looked to my constituency for a local angle, I worked out that, based on those figures, 10,000 of my constituents in Halifax would have gone without tests, and perhaps 1,000 of them would have missed important medical detection. That statistic is unforgivable, alarming and unnecessary in view of the amount of money that the Government have saved.

Today, I received a letter from Age Concern, which argues forcefully for the annual free test to be reinstated for elderly people. It is important to hear the opinions of the various groups concerned with vulnerable sections of society. Age Concern states in the letter: Older people may need encouragement to visit the optician as they tend to 'make do' with spectacles which are ill-fitting or which no longer correct their vision effectively. Eye test fees impose an extra barrier to older people who need to seek help. There are many myths about who can and cannot receive free tests. Age Concern makes the important point: The Government has repeatedly argued that it aims to target help on people most in need, and that people on income support, and some priority groups, continue to receive free eye tests. Although older people whose incomes are just above income support levels can receive help, they have to put in a claim. Many older people are reluctant to fill in what are often long and complicated forms, and around one fifth of older people do not claim benefits to which they are entitled. We know that that is often the case with elderly people.

The letter continues: The recent increase in the state pension means that married couples under the age of 75 now receive 10p over the income support limit and are therefore no longer automatically eligible for free eye tests. Age Concern is obviously concerned that that problem should be solved.

Local opticians in my constituency, and those of other Members—I am sure that the Minister has been lobbied over this—have called for free eye tests for all over 65. That confirms the point that I have made, and that has been made so forcefully by others, that people in that age group tend to have the most problems with their eyes. It is important to stress that that age group is not automatically excluded. As Age Concern stated, because of the recent increases in state pension, many of them will not be.

The Royal National Institute for the Blind makes a similar plea in a letter that it sent me when it knew that I had this Adjournment debate, and which I received today. It states that all pensioners should be exempt and that research overwhelmingly shows that that group of people are those most vulnerable to eye disease. It quotes Professor John Marshall of the Institute of Opthalmology, who estimates that about 78 per cent. of the 78 to 85 age group have major eye disease. That is an important point.

The Royal National Institute for the Blind also states—this may pre-empt something that the Minister may say in his defence—that it commissioned a survey last year, which I believe the Government have used to support their claims that the issue was not important. The survey showed that people had been deterred from eye tests, but it also showed that a high number of people claimed to have had eye tests. It stated that the figure was similar to that in the Government's survey. We know that the 879 Government conducted a survey. My hon. Friend the Member for Livingston challenged it in a debate after the eye test charges were introduced.

The institute states: The Government have seized this information to support their argument. We believe the figure is a substantial overestimate. The Government itself accepted that its survey had produced some degree of overestimate. It is also worth comparing what the Government survey claimed to have happened on NHS tests with what actually happened. 2.05 million adults claimed to have had an NHS test in the first quarter of 1990, but the records show the Family Practitioner Committees only paid for 0.624 million tests. Although some of this discrepancy might be explained by confusion as to the difference between NHS and private tests, it casts doubt on the credibility of the Government's survey. I believe that, too, and I hope that the Minister will seriously consider that forcefully made point.

In the light of the overwhelming evidence from all sources, it is time for the Government to admit that they made a serious mistake in abolishing free eye tests. Abolition is leading to serious diseases going undetected. The Government must accept that thousands are at risk because of the cost deterrent. They are not being given medical care when they need it, and that cannot be in their interests. That makes a cruel nonsense of the purpose of the NHS, and it represents a false economy that can only lead to human misery.

Some of these diseases are very painful, and human beings are suffering needlessly. Some may even suffer early death as a result of their condition not being detected early enough. I urge the Government immediately to restore the free eye tests. It they do not, we can only assume that the impression that we were given when the Government changed their Prime Minister—that we were to have a more caring Government—was only a mirage, and that they are following the tradition of the last Prime Minister and her Administration, in whose hands we could not trust the NHS.

I promise the Minister and anyone who may take note of this debate that we shall keep pressing for free eye tests, which any socially aware and civilised society should provide for its citizens. If the Government do not restore them, on the election of a Labour Government we shall soon restore them. They are vital diagnostic tests which provide an early warning system for serious diseases. I urge the Government not to wait for the next Labour Government and to show that they really do care.

§ The Parliamentary Under-Secretary of State for Health (Mr. Stephen Dorrell)

I agree with the hon. Member for Halifax (Mrs. Mahon) that this is an important subject, and the House therefore has reason to be grateful to her for initiating this Adjournment debate, which allows us once again to test the arguments for the stance that the Opposition have adopted on the issue and the arguments that the Government deploy in defence of their position.

I wish to restate the policy that the Government have pursued and to set it in context. There is no disagreement between the Government and the hon. Member for Halifax, or between the Government and the optometry profession, about the importance of eye tests. The Government remain fully committed, as they have been throughout, to quality eye care and to ensuring that those 880 who go to opticians receive a high-quality professional service. That is why, in July 1989, the Government tabled regulations that set out factors that should be taken into account, by law, when a patient has an eye test. The law requires that a patient have a refraction test to measure the degree of correction required for good eyesight, and that patients be given a full examination of their eyes. That requirement was put on the statute book by the Government because we are committed to the principle that a regular eye test is an important part of health care.

The hon. Lady is concerned principally not with high-quality eye care but with who pays in most instances for such tests. Experience proves that on average the cost of a test is £12 or £13, and the Government believe that, for the great majority, it is entirely reasonable that the individual citizen should pay that sum for himself or herself. I suggest that it is inconsistent to argue, as many do, that taxpayers, and citizens in general, would be prepared to pay another 1p in the rate of income tax if the proceeds were directed entirely to health care. If the rate of income tax were to be increased by 1p, something in excess of £50 a year would be the yield from a man on average earnings. Yet that same person is not prepared to pay £12 every two years for an eye test.

The Government accept that people are prepared to pay an additional charge to ensure high-quality health care. For those who are in a position to do so, the eye test is a perfect example of an opportunity for people to make a contribution to their health care, recognising as the Government do the importance of a fully qualified person conducting an eye test. That does not detract from the Government's commitment to ensure that there are free eye tests available to those who can establish a need, either on the ground that they are adults with low incomes, or are children or students aged under 19 years, or to those who on health grounds attach an especial importance to regular eye tests. That is why free tests continue to be provided for the blind and partially sighted, for those who suffer from diabetes and for those and their families with a history of glaucoma.

Those who benefit from free eye tests on the ground of low income and those who so benefit on health grounds constitute 40 per cent. of the population. I accept that by and large the public would like to have the opportunity to contribute more to expanding the resources that are available for health care, and the eye test system provides exactly that. It seems entirely consistent with the Government's commitment to improve the quality of health care that is available and to ensure that the maximum value is squeezed out of the budget that is available to the national health service.

It is sometimes suggested that the free facilities amount in some sense to a concession that has been drawn from the Government under protest, but our record gives the lie to that. My hon. Friend the Minister for Health devoted considerable effort in the early spring to promoting the importance of eye tests and the availability of free tests to those who will benefit from them. It is not a matter of 40 per cent. having an entitlement and the Government taking no further steps. We have undertaken a promotion campaign to ensure that those who are entitled to a free test have that fact brought to their attention.

The hon. Lady has said that an incoming Labour Government would restore the universal availability of free eye tests. That commitment, blithely given late on Monday night in the House, would cost such a 881 Government more than £100 million a year. The question that the hon. Lady and her hon. Friends must answer is whether an extra £100 million a year available for improving and expanding the resources of the national health service would be best used in the way she described or whether it would be better used to improve the quality and availability of health care elsewhere in the national health service. I find it hard to believe that the highest priority for a marginal £100 million in the national health service is the restoration of free eye tests.

The only evidence that the hon. Lady used to substantiate her case this evening—her speech was entirely consistent with speeches made by Opposition Members ever since the change was made—was a series of surveys on which I shall comment briefly. The hon. Lady suggested that I should not get involved in an argument about which survey we embrace, and she sought to argue that there was some doubt about the credibility of one of the surveys that one of my right hon. Friends relied on in the past. I am content with that. I shall take the surveys published on 12 April by the Association of Optometrists on which the hon. Lady placed the greatest weight.

There were two surveys. The first was carried out by MORI which, not surprisingly, concluded that given the choice between paying for eye tests and getting them free, the British people would prefer to have them free. The hon. Lady considered that to be socially aware. I disagree. If someone offered me the choice between having something free and paying for it, I would choose to have it free. That is simply to ignore the reality of the choice and the importance of priorities in the use of resources within the national health service.

882 The other survey published on 12 April by the Association of Optometrists was undertaken by the Economists Advisory Group which sought to demonstrate that the take-up of eye tests has been substantially cut since charges were introduced in April 1989. I believe that that survey is subject to severe shortcomings. First, only 56 per cent. of the optometrists to whom it was directed responded to the survey. That leaves me wondering what evidence the other 44 per cent. would have produced. Secondly, the statistics that were quoted compared the period immediately after charges were introduced for the first time with the period immediately before the change—the last period during which they were free. It is not surprising that there was a boom in demand for eye tests just before the charges were brought in, and that there was a slump just after they were introduced.

If the hon. Lady reads the press release, she will find one piece of evidence that was not highlighted in the text. In the last two quarters measured by that survey, there was a sharp increase in the take-up of eye tests. In the third quarter of 1990, eye tests were up by 9 per cent. on the equivalent period in the previous year and in the fourth quarter of 1990, take-up was up by 16 per cent. over the same period in the previous year.

I do not accept that the evidence is conclusive that the change in funding has led to a long-term decline in the demand for eye tests. I agree with the hon. Lady about the importance of eye tests and we shall certainly continue to stress that, but I do not accept that her conclusions can be based firmly on the statistical information at her disposal.