NATIONAL HEALTH SERVICE BILL (Hansard, 11 April 1961)

§ LORD NEWTON
My Lords, I beg to move that this Bill be now read a second time. On February 1 of this year, my noble and learned friend the Leader of the House announced the various financial adjustments which the Government proposed for the administration of the National Health Service. They were the subject of a Motion of censure upon the Government and that Motion was debated by your Lordships on February 13. In the course of my speech I explained at length the basic considerations which the Government had in mind in putting forward their proposals, and so did my noble and learned friend the Leader of the House when replying to the debate. On March 9, on the initiative of the noble Viscount the Leader of the Opposition, we debated the new prescription charge, and I again referred to the underlying reasons for all the financial changes. I will, therefore, not weary your Lordships by repeating those arguments this afternoon.
This Bill is concerned with charges for dentures and spectacles, and it introduces no new principle into the National Health Service. There have been charges for appliances under the Service ever since it started. The charges for dentures and spectacles were introduced by the 238 National Health Service Act, 1951, when some noble Lords opposite were in office. Apart from correcting an anomaly in the charge for bifocal and multifocal lenses, this Bill, in so far as it raises charges, does no more than bring the 1951 charges into line with the movement since then of costs and personal incomes and the purchasing power of the pound. If the Bill is enacted, people who are supplied with dentures or spectacles will still get at least as good a bargain under the higher charges as they did in 1951.
It is worth recalling why in 1951 dentures and spectacles were selected for charges to people obtaining them. First, given the financial decision that a limit had to be set to the cost of the National Health Service falling directly upon the Exchequer, the Government concluded that these particular charges would do the least harm of any conceivable charges, largely because they would fall to be paid to a large extent by people who were well in health and able to make their way. Secondly, there was, so far as the dental services were concerned, the aim which has held ever since 1951, to encourage and give priority to the conservation of teeth, and especially the teeth of children and adolescents, as against extractions and the provision of dentures. Thirdly, there was the recognition that, like medical prescriptions, dentures and spectacles constitute a field in which patient pressure is possible, at least to some extent. Indeed, when the then Minister was moving the Second Reading of the 1951 Bill in another place, he referred to the possible deterrence of abuse.
In the debate on February 13, when I referred to this point about patient pressure, the noble Lord, Lord Taylor, questioned the validity of it in so far as it applied to dentures. Well, my Lords, odd though in may seem, there are people who want dentures when they do not really need them. Personally, I am thankful to be able to say of my teeth that they are poor things but mine own; we have been through thick and thin together and suffered a lot in the cause of conservatism, and so I have become attached to them and they are still attached to me, notwithstanding the gloomy warning of my excellent dentist who wants to pull a lot of them out. Nevertheless, there is the opposite point of view which is 239 illustrated by two stories which were told to me by noble friends after the debate of February 13.
One of my noble friends, soon after the announcement on February 1 of the Government's proposals, went to the dentist, and the dentist said to my noble friend, "What the Government ought to do is to charge everybody under the age of 50 the full economic cost of dentures, because so many patients come to us dentists and when we tell them that their teeth need a lot of filling they demand that we extract them and give them dentures instead." The other noble friend met a woman acquaintance in the street with a child, who was crying. "We are going to the dentist," the woman said. "His teeth are very troublesome. Unfortunately, he is too young to have them all out".
As I have said, ever since 1951 the aim has been to encourage and give priority to the conservation of teeth—and, in fact, there has been appreciable success. Immediately after the 1951 Act, which imposed charges for dentures, the annual number of cases in which dentures were supplied sustained a sharp drop; and, since then, it has risen again only to slightly more than the figure for 1952. In 1959, for instance, it was half the number of cases in 1950. On the other hand, and by contrast, the amount of conservative dentistry done has risen steadily, notwithstanding the introduction in 1952 of the charge for dental treatment, and to-day it is nearly double what it was in 1951. Furthermore, and even more important, this increase includes an even bigger increase—an increase of over three times—in the number of courses of conservative dentistry provided for children and adolescents. I feel sure that your Lordships will agree with me that this is a most satisfactory and welcome development. One is bound to conclude that a significant cause of it was the introduction of charges for dentures in 1951; and I say with absolute sincerity that, in my opinion, credit is due to the 1951 Government for the wise, although controversial, decision then taken. I would further say to your Lordships that I believe that the modestly higher charges imposed by this Bill will help to maintain this desirable trend in the dental service.
240 The Bill exempts from charges for dentures the priority classes—that is to say, expectant and nursing mothers, children under school age and children who attend a maintained school. At present, these priority classes can get dentures for nothing provided that they obtain them through the local authority services, but they have to pay statutory charges at present if they get dentures either through the general dental service or as outpatients attending any hospital other than a dental teaching hospital. So this proposed reform in the Bill, which is obviously desirable in itself, also removes an anomaly; and it is also to be hoped that it will be beneficial to the local authority dental services, because parents in the priority class will not have to bother about money when deciding from what source to seek to obtain dentures. So it is to he hoped that this reform will relieve the local authorities of some of their denture work, and will enable them to provide more dentistry of a conservative kind for the priority classes.
I turn now to the actual charges proposed in the Bill and will take dentures first. For a single denture of one to three teeth, the 1951 Act imposed a charge of £2: the proposed increase is 5s. For a single denture of four to eight teeth, the 1951 Act imposed a charge of £2 5s.: the proposed increase is 5s. For a single denture of nine teeth or more, the 1951 Act imposed a charge of £2 10s.: the proposed increase is 5s. For a pair of dentures, the 1951 Act imposed a charge of £4 5s.: the proposed increase is 15s. As for spectacles, it is proposed to raise the 1951 charge of 10s. for a lens to 12s. 6d. for a lens—an increase of half-a-crown. These are modest adjustments to the 1951 Act and, as I say, they do no more than bring the 1951 charges into line with current conditions.
The Bill also makes two other changes as regards spectacles. First, it raises the charge for a bifocal and a multifocal lens from 10s. to £1, and thus corrects another anomaly. These lenses are, of course, more expensive than the ordinary ones, but at present the owner of a pair of bifocals virtually gets two separate pairs of glasses for the charge of one; and it is obviously unfair to somebody who, perhaps for clinical reasons, buys two pairs of glasses, one for reading and the other for long distance, that someone 241 else who buys a pair of bifocals for the same purposes should not pay his proper, fair contribution.
The other change concerns children. At present, under the 1951 Act, children up to 16, or above that age if they are attending school full-time, may obtain both lenses and frames free of charge if, but only if, the lenses are fitted to one of the four standard children's steel frames. Now that provision is unaltered by the Bill; but the Bill also provides that children between 10 and 15, and over that age if still at school full-time, will be able to have their lenses free of charge if they are fitted to any one of the National Health Service frames. This provision is in accordance with the views of the Standing Ophthalmic Advisory Committee of the Central Health Services Council. The frames will be charged for at cost price unless they are one of the four standard steel ones which I have mentioned. This is a reasonable provision, because frames other than steel ones are not necessary from the clinical point of view.
All the changes which I have outlined to your Lordships are contained in Clause 1 of the Bill. Clause 2 enables these charges, and the charge for dental treatment in future, to be varied up or down, or abolished, by regulation instead of by legislation or Order in Council. Those are the main provisions of the Bill, but perhaps I should just add, in conclusion, that the National Assistance Board will continue to pay the charges of those people who are receiving weekly assistance and of those people who, by the Board's permitted standards, cannot afford to pay the charges, either in full or in part, without hardship. My Lords, I beg to move the Second Reading of this Bill.

§ LORD TAYLOR
My Lords, your Lordships' House has already had two debates on the underlying principles of this Bill, and it is not our intention to repeat any of the arguments which we advanced on those occasions. That does not mean that we agree either with the principles or with the details, but we do not intend to vote against this Bill on Second Reading. Indeed, of the various charges which are being increased by the 242 Government these are, perhaps, some of the less objectionable increases.
The noble Lord, Lord Newton, explained what has happened about the supply of dentures over the last nine years, and he attributes the reduction largely to the original introduction of a charge for dentures. But in my view this is by no means the whole story: because when the National Health Service was first introduced there was an enormous backlog of work, particularly dental and ophthalmic work, which had not been done because people could not afford to have their dentistry done. Over the years the teeth of the nation had decayed to such an extent that very often dentists were faced with an honest decision whether to make a total extraction of the teeth in both jaws at the outset, because people just had not bothered about conservative dentistry. I think that a very large factor in the reduction in the demand for dentures, and also, of couse, in the reduction in the demand for spectacles, is that, the initial backlog having been satisfied, people are now behaving much more sensibly. I entirely agree with him that they are behaving very much more sensibly and are much more ready to have conservative dentistry (with a small "c"), and do not exert anything like the same pressure on the dentists which they used to. The noble Lord. Lord Newton, is fortunate in that he has poor teeth, but his own. I have good teeth, but not my own. They are, indeed, National Health Service dentures —and very satisfactory ones, too!
It is, I think, a pity that we should be increasing the price of these dentures, because most people nowadays have dentures only when they have to have them. It is a thing which happens particularly to older people, and it is in some ways sad that only those who are in receipt of National Assistance should now be able to get their dentures without charge.

§ LORD NEWTON
My Lords, unless, of course, they are members of one of the priority classes.

§ LORD TAYLOR
My Lords, yes but I was thinking only of the old people. With regard to the priority classes, I think that this Bill is a very definite advance, because the situation has been that there has been a great shortage of local authority dentists throughout the 243 country. Indeed, in our new town of Harlow, where we have good dental services, we have not a single local authority dentist, and therefore all the children's dental work is done, in general, by National Health Service practitioners. Therefore, it is a good feature of this Bill that this work, both for children and for expectant mothers, should now be available free, and I warmly welcome this particular section of the Bill.
With regard to the question of spectacles, the increases in charge are not very onerous. However, I think that in the case of the bifocals it is arguable that, where these are required for a person's work, that is a reasonable clinical need. Usually they are prescribed only where somebody is doing a job which involves his looking at a near object and then at a distant object. They are frequently prescribed for doctors for that very reason, because they are examining patients and reading notes and have continually to be altering their focus, and it saves their trying to get by with two pairs of spectacles.
I may say, again, that in respect of the children we warmly welcome on a simple clinical ground the proposal that lenses should be available in any type of National Health Service frame. One of the difficulties is to get young girls of school age to wear spectacles, particularly those between the ages of ten to fifteen, when, for cosmetic reasons, they do not want to wear them. If spectacles are supplied with the iron or steel frame, they are extremely unpopular. Therefore, it is a very good thing that in future they should be able to get any kind of National Health Service frame to carry their National Health Service lenses, and get the lenses free. I should have liked to see them get any type of frame, and not necessarily a National Health Service type of frame, because one of the great successes of ophthalmology has been in getting girls and young women to wear spectacles by making them cosmetically attractive, by giving the frames a butterfly shape with a little decoration. If parents are prepared to pay for such frames, as a sort of reward to the girls for wearing spectacles, I cannot see the slightest objection to fitting National Health Service lenses into privately supplied frames. I hope that the noble 244 Lord, Lord Newton, will look at this one particular point to see whether it would have any effect (I cannot believe that it would have any substantial effect) on the cost, because presumably these people will be getting their glasses anyway. Therefore, although we do not feel happy about the principles of the Bill in regard to these increases in charges, we welcome as sensible and reasonable the two concessions which have been made, and we shall not further oppose the Bill.