§ 3.5 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Glenarthur)
My Lords, I beg to move that this Bill be now read a second time.
Nearly every session of Parliament contains a Bill on health or social security issues. This one is no exception, and the Bill inevitably deals with a wide range of subjects. It represents the Government's continuing commitment to promote the interest of the consumer in the health service and to achieve a more rational scheme of social security provision, making the best use of available resources.
The main provisions of the Bill illustrate these objectives. First, we are taking steps to curtail the monopoly granted to opticians and doctors on the sale of glasses and to permit much freer advertising by opticians. This will result in more competition, more choice, and lower prices. It is a change which will benefit nearly everyone who wears glasses. Secondly, we propose to make important changes in the status, accountability, and structure of family practitioner committees. Thirdly, we are proposing to introduce a new benefit—severe disablement allowance—which will replace non-contributory invalidity pension. It will provide a more logical, fair and acceptable form of benefit for people who are outside the scope of the contributory scheme. Fourthly, we propose to rationalise the rules affecting dependency additions to social security benefits. And finally, we are tackling the wholly indefensible position of "franking", which results in a manifest loss for some members of occupational pension schemes.
The Bill also makes minor or technical amendments to existing legislation, which I think (or at least hope) are uncontroversial. I propose in my speech to deal with the main provisions of the Bill. My noble friend Lord Caithness, having been so recently pitched into this complex area, will deal with any points which arise on both minor as well as major provisions when he winds up the debate.
First, I shall deal with optical services, which are covered in clauses 1 to 4. Clause 1 has two objectives. The first is to relax the restriction on competition for the supply of optical services imposed by the Opticians Act of 1958. Achieving this objective enables us to take forward a second one, which is that, given a more competitive market, it will no longer be necessary to persist with the state provision of glasses. A free private market will serve those who need glasses much better than will the present arrangements.
11 Our attack on the restrictions imposed by the Opticians Act had its genesis in the report by the Office of Fair Trading, Opticians and Competition. The study leading to this report followed considerable public disquiet at the high cost of private glasses. Our reform of the Opticians Act tackles two issues. The first relates to advertising. The General Optical Council have the power to make statutory rules regulating advertising by registered opticians. The result has been disastrous for the consumer. A prerequisite of a free market is information. Without comparative information on the range of services and prices of other suppliers, the consumer has no real choice. At present the GOC rules do not allow opticians to advertise their existence, their opening times, what services they provide, what types of frame they stock, or what they charge. They certainly cannot use local newspapers or other normal media to inform the public. The Office of Fair Trading concluded that, in the absence of such information, opticians could virtually set their own prices without regard to the behaviour of other opticians.
Advertising will improve choice for consumers and it will lead to lower prices. Experience in the United States, where advertising restrictions vary from place to place, suggests that prices are nearly 40 per cent. lower in the least restrictive cities compared to the most restrictive ones. We have no reason not to expect significant price reductions here.
I now turn to the question of relaxing the restrictions on who can sell glasses. At present, glasses can be sold only by, or under the supervision of, a registered medical practitioner or a registered optician. This restriction extends, quite illogically, even to empty frames without lenses. The Office of Fair Trading made out a powerful case why this restriction has made glasses more expensive than they need otherwise be. It is the Government's view that a restriction of this kind can he justified only in exceptional cases of public interest. Only in a small number of trades and occupations is it felt necessary to restrict the practice of that calling to those who are professionally registered. We believe that such treatment is justifiable only if the public would otherwise be put seriously at risk by incompetent practice. Expert medical opinion is that "wrong glasses"—that is to say, the wrong types of lenses in glasses—cannot damage adult eyes.
§ Lord Glenarthur
Most people, my Lords, will themselves be able to reach a judgment about their glasses and tell whether they are significantly "wrong". But the Bill ensures that young, developing eyes, which can be damaged by incorrect glasses, are dealt with only by qualified persons. The Bill requires that all glasses sold by non-opticians shall accord with a written prescription following a sight test. This ensures that all wearers of glasses will have a periodic screening for glaucoma and certain other eye and general diseases which can be detected by a sight examination.
The clause gives a power to impose conditions on the unregistered traders who will enter the market. We are already consulting widely on what these conditions should be, to ensure that safe and serviceable glasses are sold. But the best consumer protection of all is a 12 free, competitive market. Those retailers who do not produce serviceable glasses will soon be weeded out by consumer choice. We confidently expect that this reform will increase choice and lower prices, and that it will not lead to a deterioration in the standard of glasses provided.
These reforms of the private market will enable us to tackle the problem of National Health Service glasses. Provision of glasses is unlike most other parts of the National Health Service. New glasses are an infrequent, yet regular, requirement—perhaps needed every two to three years or so—and form an ideal subject for responsible prudent provision by individuals.
The purchase of glasses shares none of the characteristics of services which need to be free at the point of delivery. Indeed, except for a brief period between 1948 and 1951. provision of glasses has not been free. Successive Governments have seen no reason why they should be free. What we are left with, after more than 30 years of the National Health Service, is a range of outmoded glasses which are indiscriminately subsidised by an average of £5 a pair. Most people will undoubtedly get a better overall deal in terms of style, choice and price from the reformed private market than they do from the National Health Service.
But anyone who is on a low income will still be able to get National Health Service glasses. For anyone on supplementary benefit, they will be completely free. If people are above this level, but still of limited means, they will get help with the cost. Children, too, will continue to get their glasses free. No one who is really hard up will have a financial barrier placed between him or her and the glasses he or she needs.
Some transitional arrangements are required and these are covered by Clause 28. For the time being, children and those on low incomes will get National Health Service glasses as now. In the longer term, Schedule 1 gives us the power to substitute financial grants. It is right that once market conditions have stabilised, children and those on a low income also should have the benefits of wider choice. For the small group of National Health Service patients who need expensive lenses, we intend that they will have the option of continued access to National Health Service glasses, at a controlled price. We will not, however, continue to subsidise these lenses indiscriminately. Overall, therefore, we believe that the time is ripe for this antiquated and unnecessary state provision to cease.
I now turn to Clause 5 of the Bill. We intend to publish a Green Paper on future primary health care needs, in order to stimulate an informed debate among the health care professions and the public. Central to any strategy for meeting those needs must be a firm focus for the provision of the family practitioner services. That is what this Bill provides. Our aim is directed at simplifying and strengthening the administrative arrangements for these services by removing the administrative dependence of family practitioner committees on district health authorities and making them fully accountable to the Secretary of State as employing authorities in their own right.
The present arrangements were made in 1974, with the best of intentions. However it has become 13 increasingly apparent that the administrative dependence of FPCs on district health authorities has caused problems of delegation and accountability and has led to the creation of an unnecessarily complicated bureaucracy. In the light of experience we have come to the conclusion that new arrangements are required.
The new arrangements will have three main features: the clarification of lines of responsibility and strengthening of accountability; an increase in administrative efficiency; and improved collaboration between family practitioner committees on the one hand and health and local authorities on the other. It was with that last, important objective in mind that last month we published the report of a joint working group on collaboration between family practitioner committees and health authorities. Copies have been placed in the Library of your Lordships' House.
Its most important message is that the new family practitioner committees which this Bill proposes should broaden and develop their experience and technical capacity in order to make a stronger contribution to the planning of health services. It also suggests an annual programme and a profile and strategy statement every five years as part of the process of calling committees to account.
During the passage of the Bill in another place, the Government have also taken the opportunity to introduce a number of other desirable amendments to existing health legislation. In particular, I should refer to Clause 7, which seeks to put beyond argument the remuneration arrangements for the four National Health Service contractor professions—the general medical practitioners, dentists, opticians and pharmacists. It is long-standing and accepted practice that past inadequate or excessive payments are offset in future payments; this is, in the interests of the professions and the taxpayer. However, the legal basis of the practice has recently been challenged by the body which represents the pharmacists contractors—the pharmaceutical services negotiating committee. Although the High Court ruled against the challenge and in favour of the existing arrangements, we wish to make the statutory position clear beyond any doubt. I must emphasise that this clause does not represent any change in Government policy; it is intended simply to clarify the present arrangements, as they have been understood by the professions and the Government for many years.
I now turn to Part II of the Bill, which deals with social security matters, of which the introduction of a new benefit—severe disablement allowance in Clause 11—is the dominant issue. As your Lordships will be aware, it replaces non-contributory invalidity pension—or NCIP—which has been available since 1975 to men and single women who are incapable of work, but who do not satisfy the necessary contribution conditions to qualify for contributory sickness or invalidity benefit. Married women have been able to qualify since 1977, but only if they are also incapable of performing their normal household duties. This benefit has become known as the housewives' non contributory invalidity pension—or HNCIP.
This additional "household duties" test has long been a source of controversy and discontent both on 14 grounds of discrimination and because of the nature of the test itself. The proposals in the Bill follow a review which was carried out by officials of the department on a recommendation of the then National Insurance Advisory Committee in 1980.
Unlike NCIP, the new benefit will make no distinction on grounds of sex or marital status.Those who become incapable of work on or before their twentieth birthday will qualify on that basis. Those who become incapable of work later in life will qualify if they are also 80 per cent. disabled.
Everyone drawing NCIP or HNCIP, when severe disablement allowance is to be introduced in November of this year, will automatically be transferred to the new benefit. And, in addition, once SDA is fully phased-in, we estimate that around 20,000 more people will qualify over and above the numbers entitled to the present benefits, at an extra cost of some £20 million a year. In the longer term, since some people who would have qualified for NCIP or HNCIP may not qualify for SDA, these figures may be somewhat lower; and it is estimated that after perhaps 30-40 years there will be around 5,000 extra beneficiaries overall.
Much of the criticism of our proposals has stemmed from an understandable disappointment that we have been unable to adopt the straightforward solution of paying NCIP to married women on the same basis as men and single women. However, the Government have never made any secret of the fact that this was not a viable option. The extra costs would amount to some £275 million a year, and money on this scale is simply not available.
SDA will continue to provide an income replacement benefit payable at the same rate as NCIP and on a simple test of incapacity for work to those handicapped at birth or in childhood who are never able to work and build up a contribution record. The additional disablement test for those who first become incapable of work over the age of 20 is intended to concentrate the available resources on the most severely disabled. In effect, this is what the household duties test does at present. We intend to replace it with a much fairer and more objective test using the same principles of assessing disablement as have been successfully used in the industrial injuries scheme since 1948 and in the war pensions scheme since 1917.
I am confident that severe disablement allowance represents a fair solution to a problem that has exercised successive Administrations. The new benefit represents an important improvement in the general level of cash benefits. It is a significant step towards the Government's long-term aim of a more coherent system of benefits for sick and disabled people.
I turn now to the proposals for changes in the dependency provisions of the social security scheme. Clause 13 introduces Schedule 4 and is concerned with dependency additions in respect of children. There are at present two levels of these additions. One is the rate paid with the short-term benefits—chiefly unemployment and sickness benefit—and the other is that paid with benefits for long-term contingencies like retirement and invalidity. As the level of child benefit has gone up, so the rate of the child dependency addition has gone down and we now have a rate of just 15 15p a week by way of child addition with the short-term benefits. At the next general uprating of benefits in the autumn we intend to discontinue the 15p rate so that support for those at work and those not at work because of a short-term contingency will be by way of child benefit, now set at £6.50 a week for each child and free of tax.
Those receiving the long-term benefits get child additions of £7.60 a week—also tax free—on top of child benefit. These are now more readily available because of the changes we have made to comply with the EC directive on equal treatment. We have given some thought to the implications of this change and have concluded that it would be right to introduce a test of child dependency. We intend that where a beneficiary's wife or husband is earning over £80 a week, the dependency addition for one child of £7.60 will be withdrawn and further additions will be withdrawn for each extra £ 10 of earnings. This would only affect new beneficiaries as we shall give transitional protection to those already on benefit when the new rule starts.
There is one further item I should mention about this group of proposals. Several of our dependency provisions are subject to an earnings rule, and we propose in Clause 14 that where a dependant has an occupational pension this should count as earnings in the same way as wages or salary. But I want to make it clear that this will not affect personal benefits and pensions. and, in particular, it will make no difference to the retirement pensioners' earnings rule.
Finally, the Bill contains items which affect occupational pension schemes. Clause 19 facilitates the transfer of accrued rights of groups of earners or their pensions between different occupational pension schemes, while Clause 20 prohibits the practice of franking. Franking is the term used to describe the practice whereby the statutory revaluation of guaranteed minimum pension is achieved by eroding other scheme benefits payable. It is an abuse, and as such it has been widely criticised. In the 1981 report on early leavers, the Occupational Pensions Board recommended that it should be abolished so that:It would thus no longer be permissible for schemes to set the revaluation of the GMP on state scheme benefits against other preserved benefits".Generally, it now seems that there are few who try to defend the practice, and at the conference on early leavers last September my right honourable friend the Secretary of State for Social Services made it clear that we intended to abolish franking as soon as possible. This is the first step in our programme to improve the treatment of the early leaver.
In conclusion, this is a wide-ranging and important Bill which makes a number of significant improvements to health and social security provision. In particular, the provisions concerning optical services, opticians and the sale of glasses demonstrate the Government's policy: to put the interests of the user of the service first. I have concentrated on what we believe are the most important provisions. No doubt other features of the Bill will be discussed in detail in Committee. Above all, this Bill is concerned with securing a better deal for the public, and on this basis I commend it to your Lordships. I beg to move.
§ Moved, That the Bill be now read a second time.—(Lord Glenarthur.)
§ 3.26 p.m.
§ Lord Ennals
My Lords, first, I am sure the whole House will be grateful to the noble Lord, Lord Glenarthur, for his explanation of this highly controversial Bill. Secondly, I should like to congratulate the noble Earl, Lord Caithness, on his first appearance on the Government Front Bench, to wind up this debate. My only wish for him in the mood of sympathy with which I start my speech is that he had a more attractive Bill to defend.
In fact, this is in my view a ragbag of a Bill, with hardly anything to commend it. I intend to choose just the same five items as did the noble Minister, although I have to say that my conclusions on all of them will be sharply different from those he himself reached. Other points, of course, will he dealt with in Committee, and I have no doubt that my noble friend Lady Jeger who will be winding up for us, will have other points to make.
I therefore start with Clause 1 on which I have had, as other noble Lords will have had, a huge volume of representation from professional organisations including the medical and optical professions, consumer bodies and voluntary organisations, especially those concerned with elderly people. There are, of course, two main issues here. First, there is the decision of the Government to deny NHS support to nearly two-thirds of those now assisted by the optical service of the National Health Service. This is a further chipping away at the National Health Service, which is supposedly safe in the Government's hands. One has to ask: why has this action been taken? The noble Lord says that it will make it cheaper for all. Time will tell. I must say that I have not met anyone who believes that that will be the case, except for the noble Minister who said it. I ask, since the Government are proposing to save £17 million according to the financial memorandum: is there any other motive except to save £17 million?
Does the Minister accept that those principally affected will be the elderly? Of the elderly 22 per cent. have some sort of visual impairment and 75 per cent. of all registered blind and partially sighted are over the age of 65. Therefore, the measure that the Government are putting forward in this part of Clause I will particulary hit elderly people. I resent that, and I hope that the House will resent it. Often cataract patients may need three changes of glasses in the 18 months following an operation. These people, unless they are on supplementary benefit, will suffer financial hardship if they are no longer eligible for NHS glasses.
In my view it would be a step backward if visually impaired people were in future required to pay for their disability. It breaches the very principle on which the National Health Service was created; namely, that it is all of us—the taxpayers—who should pay for those who are sick, rather than that the burden should fall on the sick themselves. I believe that the provision is a mean and a petty one.
§ Lord Ennals
My Lords, I am sure that the noble Lord will have his opportunity to make a speech. I want to set out from the Front Bench the many important things that need to be set out. The second issue affects opticians and the public. There is the extraordinary proposal in Clause 1 to end the provision in the Opticians Act 1958 which allows only registered or medical practitioners to sell optical appliances. This proposal has been roundly condemned from all sides. If the noble Lord wishes to point out a side which has not condemned it, of course I will now give way.
§ Lord Orr-Ewing
My Lords, I am most grateful to the noble Lord for giving way early in this debate, because it is desirable. Many of us have had a circular on BMA paper which actually comes from the committee of the ophthalmic group. On following it up, I learn that some of what is contained in it is absolutely untruthful. In fact the full committee of the ophthalmic group has never met since this Bill was published. It has never met since the Bill was published! It is wrong to pretend that the BMA is behind this document. It is not behind it, has not discussed it. and nor has the full committee met. It is true that a few members of the executive of the committee have met under Mr. Gilkes, but it is not right to say that all people condemn the proposal.
§ Lord Ennals
My Lords, this is grossly unfair. The noble Lord has put his name down to make a speech. He ought not to make such a long intervention. If he wishes to say that the BMA does not know its job, that the doctors do not know theirs and that he knows it better, let him say so in his speech. I have here just what the ophthalmic group committee of the BMA said. It represents all medically qualified optical staff. I have this information on the notepaper of the BMA. Noble Lords keep intervening from a seated position.
This document says three things. First:If dispensing by unqualified persons is allowed, there will be no effective control over what is dispensed and no protection for patients if they are dissatisfied with the product".Secondly,The proposed changes could have practical and financial consequences for those with special needs, be they medical (e.g. patients with cataracts or if the prescription is a complex one involving special factors) or social".Thirdly,Since spectacles are a product with a significant health element, we do not feel that it is appropriate for the public to be unduly influenced in their purchase by advertising".I must say to the noble Lord who was intervening that it is not just the BMA which has made representations. It is all the professions involved in optical services. These are people who have spent their lives in that service and who know far better than the noble Lord, Lord Bruce-Gardyne (who is again intervening from a seated position) the needs of their patients. I must ask the Minister, in view of what his noble friends behind him have said, what consultation there was with the professions before the Government took this further backward step. Perhaps he would like to say now what consultation there was. I will give way to the noble Lord; but he does not want to say. I do not believe that there was effective consultation.
18 The BMA has expressed its view. What about the public? The Minister said that the proposal was in the interests of the user. The Federation of Optical Corporate Bodies decided that an independent survey of a nationally representative sample of spectacle wearers provided more reliable information about consumer attitudes towards opticians and their services. A total sample of over 1,000 spectacle wearers was interviewed. The results of the survey showed that 73 per cent. of respondents claimed that they would not want to shop around for spectacles. In terms of factors considered important in choosing spectacles, the most important factor was "professional advice". Twenty-eight per cent. said this was their most important factor; second was "style of frames", followed by "cost". Seventy per cent. rated the overall service from opticians as being "excellent" or "very good", and only three per cent. criticised them as being "poor". Sixty-nine per cent. rated the service received from opticians as being "good value for money". Nearly everyone (98 per cent.) rejected the idea of buying spectacles:from mail order or over the counter without any professional advice".Spectacle wearers have a high regard for opticians—I believe it is right that they should—and the professional treatment received. Correct eyesight is quite clearly regarded as a serious medical requirement, especially among elderly people. The idea that it should go out to the open market, as the Minister put it, is one that most people would find objectionable. I believe that any move towards the supply of spectacles by unqualified sellers will offer cost benefits to some, but they will clearly be benefits dearly won by many others. They will be won by putting eyesight at risk; they will be won at the expense of optimum visual performance; and they will be won by increasing other spectacle prices, as well as by decreasing the general optical service in its vulnerable areas.
Age Concern, with its special interest for elderly people, has set out the case admirably in the letter it sent to the Secretary of State on 2nd February 1984:There is no guarantee that the price of non-NHS spectacles will fall if the Bill is enacted. People who currently obtain NHS spectacles and cease to be eligible and who need to change their glasses regularly, could therefore face financial hardship…the price of NHS glasses could rise if the Bill is enacted since NHS lenses are supplied at below cost and the frames benefit from long manufacturing runs.If non-opticians are allowed to sell spectacles the viability of existing opticians' shops could be threatened and this could lead to a reduction in eyetesting facilities".It could certainly make it more difficult for people in rural areas to go to their optician. It continues:Similarly, the smaller opticians who lack the resources to advertise may also suffer from the competition".I think that those are very strong arguments.
It is interesting that these feelings are expressed not just by one political party. I was very impressed when Mrs. Jill Knight on 2nd May (column 399 of Hansard) in another place—
§ Lord Ennals
Yes, my Lords, she knows what she is talking about on this subject. Perhaps she does not on 19 others, but she really does about this. Her husband is in the profession. She said:It is almost 30 years now since the House, in its wisdom, passed legislation to protect the public from the dangers of allowing persons without expert knowledge to dispense spectacles".She went on to say much more, but time does not permit me to read it into the record. The arguments were there, and I believe that they will be voiced by other noble Lords during the course of this debate.
My next subject is the family practitioner service. I welcome the Minister's statement about a Green Paper on primary health care. Our objective should be to bring the whole of the primary health care services into a closer relationship with the hospital and community services. The Tory reorganisation in 1974 significantly failed to do that. The Minister recognised that fact. The Tory reorganisation in 1982 also failed to achieve integration. The latest proposal would cut them off altogether, presumably to make it easier to make further cuts in primary health care. If that is not so, in this connection may I ask once again in the House whether the Minister who is to reply will say when the Binder Hamlyn report will be published? Why is it being sat on for month after month? Why is the matter not open for debate for those who care about the primary health care services, which I believe are absolutely crucial to the National Health Service in this country?
The new proposal seems to put far more power into the hands of the Secretary of State than ever before. Is it really true that he will himself appoint 3,000 members of the family practitioner committees? How do the Government square that centralised non-democracy with the line that they are taking on democracy in the trade unions? What is the justification for this change which, together with the implementation of the Griffiths Report, is a third Tory reorganisation in 10 years, putting more power to the centre? Instead of this interminable tinkering with the structure, why do not the Government let the National Health Service get on with its job?
I now turn to Clause 7 and professional remuneration in the National Health Service, particularly that of pharmacists and opticians. From my experience gained as Secretary of State, I am only too well aware of the protracted negotiations which take place almost continuously between the Department of Health and these family practitioner contractors who are not fortunate enough to have fixed annual negotiations or a permanent review body. In the case of the pharmacists, the final amount of remuneration due to them is determined according to the best available estimate of their reimbursable costs, such as the cost of medicines, labour, overheads, and so on. But there is no reason in my view why these estimates cannot be replaced by the actual costs incurred at the end of the year in question. Otherwise, what we are doing—and that is precisely what this Bill is doing—is authorising retrospective demands upon the pharmacists. The system requires a more orderly method of annual review in line with the present arrangement for doctors and nurses. On Clause 7, I and a number of noble Lords will table an amendment to limit the retrospective adjustment of remuneration to a period of one year. What the Government are proposing now 20 is a retrospective clawback covering a whole period of three years which I believe is going to have a very serious effect upon many of the pharmacists.
My fourth point concerns Clause 13, which, for the sake of saving, according to the financial memorandum, less than £4 million in a full year. takes away the entitlement of child addition for those receiving short term benefit. Fifteen pence a week does not seem very much. However, if one is living on £25 a week, 15p is something. It reduces financial support for children of the unemployed and the sick by 15p per child per week. We have to put this matter in perspective. As a result of changing the basis on which child additions were uprated in 1980, total child support—that is child addition plus child benefit—received by an unemployed claimant is now £1.70 less than under the rules that my Tory successors inherited from me.
The Government's action is condemned by their own Social Security Advisory Committee. I do not understand what impels Government Ministers to act in so callous a manner against the 4 million unemployed. It is as if somehow or other it was their fault. First the earnings related supplement was taken away. Then unemployment benefit was taxed. Next the uprating of unemployment benefit was set below the rate of inflation. Now child additions are being taken out. It seems as though the Government somehow wish to punish the unemployed for their misfortune. I cannot believe this is true. If that is not true, then why come forward with a clause like that in this Bill?
Finally, I want to refer to the severe disablement allowance in Clause 11, referred to by the noble Minister. I must say that this is an issue on which there is very strong feeling among organisations representing people who are disabled in one way or another. People are disabled in many ways. As I do, they all welcome the proposed abolition of the household duties test. But having said that, there seems to be total unanimity among the organisations who have made representations to me in condemning the alternative proposed in the Bill. I cannot find any organisation representing disabled people which supports the Government on this proposal. If I am wrong and I have missed one out, no doubt the noble Minister, when he comes to reply, will tell me which that one was. I ask: why was there no consultation whatsoever with the major organisations concerned? How stupid it is to alienate organisations which have a detailed knowledge of the needs of disabled people. I am thinking of organisations like the Spastics Society, like RADAR, the Disablement Income Group and MIND. These groups are dealing daily with the problems of disabled people. Did they have an opportunity for consultation? No, my Lords. not a little bit of it.
The proposals for the new benefit were announced on the very same day that the Government's interdepartmental report on the household duties test was published. You might say, "Well, of course time was very short.- It had taken three years for that report to be completed and published, and on the same day that it was published the Bill was published saying what it was going to do instead. There was not any opportunity at all for consultation.
21 I was told by the Disablement Income Group:We think that a debate and consultation of interested parties are essential before such a major change in the social security system is proposed. Had either occurred, we doubt that these most unsatisfactory proposals would have been made…The Bill proposes to abolish the household duties test and end discrimination against disabled married women by introducing a second, and—in many people's opinionsirrelevant test for everyone over the age of 20. Not all disabled married women who would be eligible for the existing housewives' non-contributory invalidity pension will be eligible for the proposed severe disablement allowance"—called the SDA.The Government estimates that about 16,000 disabled married women who are incapable of work, would have passed the household duties test and thus would have been eligible for HNCIP but will not be eligible for SDA.Older disabled students on a course of study compatible with incapacity for work had been able to draw NCIP while studying. Many will now be ineligible for the new benefit and may have to give up their studies and, as a result, perhaps their opportunities to work.Credits towards a pension will be lost by many who will now have to look to supplementary benefit as their main source of financial support rather than NCIP…A test of degree of disablement is wholly inappropriate in the context of a benefit for total incapacity for work. Some people who are merely 20 per cent. disabled may be unable to work on account of their disabilities, whereas some people who are 100 per cent. disabled may be quite capable of earning a very good living.I happen to be 100 per cent. war disabled. I cannot say that the allowances I get at this House are a very substantial financial support but clearly I am able to do, though inadequately, a day's work. There is no correlation between degree of disablement, as measured by industrial injuries or war injuries, and capacity to work and earnings ability. So it is illogical to connect the two, in respect of an incomes maintenance scheme for those whose disability prevents them from doing any work.
This is an issue which has aroused very strong passions. Some of you will have seen what I thought was the very responsible statement by John Cox on behalf of the Spastics Society in the Guardian just a few days ago. He said:In principle, the Society cannot accept an age cut-off point for assessment-free claims, which admits the harsh inequity of the two tier test proposed for older people. Furthermore, we believe that the age cut-off could deter young disabled people from taking up further education or training opportunities.The Society is keen to see any move towards the realisation of a Comprehensive Disability Costs Allowance and Income Scheme, but we do not believe that the SDA is suitable to meet the needs of congenitally disabled people.That is just the same conclusion therefore as that at a recent meeting of representatives of disablement charities, attended by many Members of your Lordships' House. Though I am not committing any noble Lords here, the conclusions reached by the organisations were simple and unanimous. They urged the Government to drop Clause 11 at this stage, to consult with the experts such as those who are involved in DIG, RADAR, the Spastics Society, MIND, and the rest, and to come back again with an agreed solution which actually meets the known needs of disabled people. The Government would not lose face by acting in this way. In fact, they would earn considerable credit for taking the proper route by 22 which conclusions should be reached. A new allowance is very much needed; but, this time, we must get it right.
§ 3.50 p.m.
§ Lord Banks
My Lords, I should like to join in thanking the noble Lord, Lord Glenarthur, for his very clear exposition of the contents of this Bill. There is no one general theme, as he explained, linking the different parts of the Bill together which we can say at once that we are in favour of, or opposed to. The Bill was described in another place as a miscellaneous ragbag of a Bill that artificially combines wholly unconnected issues. Unfortunately, that is true of a good many of the social security Bills that come before this House.
I should have liked to have said that this Bill was like the curate's egg, good in parts; but the good parts are rather difficult to find. However, I can begin with one point of agreement. We support, as did the noble Lord, Lord Ennals, the ending of franking that is provided for in Clause 20. It was wrong that, in a contracted-out occupational pension scheme, the obligatory annual uprating for inflation of the guaranteed minimum pension could be allowed gradually to subsume the balance of the pension.
May I turn for a moment to the child dependency addition. I have made it clear in this House before that we approve the gradual elimination of these benefits so far as short-term benefits are concerned, and that we approve also the substitution of child benefit as the single method of providing child support in these cases. But we have objected in the past, and we continue to object, to the fact that child benefit has not been increased sufficiently to compensate for the loss of child dependency additions, as, again, the noble Lord, Lord Ennals, pointed out. It is also a point on which the Social Security Advisory Committee has commented severely.
Child dependency additions will remain, as the noble Lord, Lord Glenarthur, explained, for those on long-term benefits, but they will be subject to a new earnings rule so far as spouses' earnings are concerned. I think I am right in saying—the noble Earl who is to reply will correct me if I am wrong—that a retirement pensioner with a spouse and a dependent child is subject during the first five years of retirement to three earnings rules. First, if the pensioner earns more than £65 a week, the pension is docked, and the principle is that he is deemed not to have properly retired. Secondly, if the spouse earns more than £45 a week, which is now to include occupational schemes, then the spouse's pension is docked, and that is on the principle that the spouse is not a dependant.
Now there is to be the third test, as a result of the Bill, that if the spouse earns, in the case I mentioned, more than £80 a week, then the child dependency addition is withdrawn. There does not seem to be a principle behind that. It is a means test to ration a national insurance benefit. We should bear in mind that this is not supplementary benefit. It is a national insurance benefit, and it would therefore seem that this is, in fact, a breach of the national insurance principle.
I think your Lordships will agree from the example that I have given that the earnings rules, which are 23 more extensive and cover other cases than those I have mentioned, are complex and confusing. This point was emphasised by the Social Security Advisory Committee in its second report, when it called for simplification and rationalisation of earnings rules. I shall leave it to my noble friend Lord Beaumont of Whitley to comment further on the proposed changes as they affect child dependency additions.
The proposals for family practitioner committees raise two questions. First, is this a move away from the integration at local level of the different branches of the health service? Secondly—and this was raised by the noble Lord, Lord Ennals—does it concentrate too much centralised power in the hands of the Secretary of State? I shall leave it to my noble friends Lady Robson of Kiddington and Lord Kilmarnock to answer those important questions. I wish to concentrate in my remaining remarks on the proposals with regard to optical appliances and on the new severe disablement allowance. First, I turn to the appliances. The Bill, as the noble Lord explained to us, keeps the free sight test by a qualified person. It keeps prescriptions by a qualified person. But, in regard to dispensing and the sale of spectacles, except where children and contact lenses are concerned, it opens the door for a free-for-all.
This has been defended as the breaking of a monopoly. If anyone talks to a Liberal about breaking a monopoly, they certainly get a good reception in the first instance. I can perhaps remind the House that Winston Churchill, in his Liberal days, said that socialism attacks capital but liberalism attacks monopoly. However, when I come to look at the situation here, it does not seem to me that there is a monopoly. Large numbers of opticians' firms are in competition with each other. and there is no concentration of ownership. Is there a cartel? When I come to examine it, it does not seem to me that there is a cartel. This is emphasised by the statement made by the Minister in another place when he said that the same spectacles could be bought for 102 from one optician and for £42 from another.
There is no cartel, but there is a closed shop. We on these Benches are not very keen on closed shops: but we have always accepted a closed shop based on professional qualification where the protection of the public demands it, as, for example, in the case of doctors. Is it necessary to have qualified dispensers? I would say that the answer is: yes, if you want accurate prescribing and some redress if things go wrong. If you look at the subjects that a consulting optician has to study in a three-year course, I think that your Lordships will agree with that.
The question then arises: does it matter if you get inaccurate prescribing? The Government say: no, it does not, because it will not do any damage to sight. However, the noble Lord, Lord Trefgarne, in this House on 27th April 1983—that is just over a year ago—speaking on this matter, said:Standards of dispensing in the United Kingdom are high. If the need for statutory registration was removed and untrained people could enter the field, standards would inevitably fall".24 This was the noble Lord speaking for the Government. The noble Lord went on:Unskilled dispensing is probably not harmful to the eye. However, unskilled dispensing could well result in less than optimal improvement to sight and could perhaps act as a contributory cause to accidents.A contributory cause to accidents! The noble Lord continued:It may well be that this is a very small risk, but I personally would not choose to be driving down the M l behind or in front of somebody who had less than perfect eyesight.He went on to say:I recall also that before I came to your Lordships' House I was a pilot. I had on my licence an endorsement to the effect that I had to wear 'approved correction to defective vision'. I imagine that those of your Lordships, if there are any, who had the misfortune to fly with me would have preferred that the glasses that I was wearing were the correct ones".—[Official Report, 27/4/83; col. 1035.]On a previous occasion my noble friend Lord Winstanley said that incorrectly prescribed glasses would not harm: "You just can't see", he said. That brings us back to the point made so clearly by the noble Lord, Lord Trefgarne. There is sufficient doubt about the possible dangers to convince me that all those dispensing should have a qualification, not necessarily as high as that of dispensing opticians, but sufficient to enable them to know what they are doing.
We on these Benches share the concern about the withdrawal of National Health Service spectacles from all but the poorest and children. We believe that there are many above the limits set in this Bill who nevertheless are still on comparatively slender resources. For example, I think of elderly people with a small occupational pension who will suffer as a result of the withdrawal of these spectacles. The withdrawal reduces the scope of the National Health Service, and on that point the Gloucester family practitioner committee had this to say:To restrict the supply of spectacles to patients other than children and those who receive supplementary benefit will deprive the majority of patients in this country from receiving spectacles through the National Health Service. This proposal is in direct contradiction to the many statements in Parliament that the present Government has no intention to reduce the scope of the National Health Service".That was the view of the Gloucester family practitioner committee.
Some 32 million people per year are affected by this withdrawal and I myself cannot see how the price level is going to fall if one takes out of it the lowest element. To conclude my comments on optical appliances on a less critical note, may I say that we welcome the modification of the restrictions on advertising which are contained in the Bill.
I should like now to turn to the severe disablement allowance. With the noble Lord, Lord Ennals. we welcome the withdrawal of the household duties test for disabled housewives, but we cannot give a similar welcome to the severe disablement allowance. The noble Lord, Lord Ennals, referred to the fact that this appeared to have been introduced without any proper consultation with the disabled or the organisations which represent them. I believe, as he said, that they are all opposed to this proposal. They are opposed to it in the main because it makes the system more complex, because it confuses compensation for disability with income maintenance. As the noble Lord said, someone who is 80 per cent. disabled may 25 be capable of work, whereas someone less disabled may not be capable of work. Some who now qualify for the non-contributory invalidity pension would not qualify, if they were applying for the first time, after the Bill becomes law.
The Bill continues to discriminate against married women. I think that that was implicit in what the noble Lord, Lord Glenarthur, said. The noncontributory invalidity pension is designed to provide for those with no adequate national insurance contribution record. The review of the household duties test states in paragraph 35:The overwhelming majority of people who become disabled while of working age and who lack an adequate contribution record are married women".Two-hundred-and-forty thousand married women are prevented by the household duties test from getting the non-contributory invalidity pension. Some 20,000 extra people are all that will be brought in by the severe disablement allowance.
The noble Lord has told us that £275 million would be the cost of bringing in all those who at present are kept out by the household duties test. The new arrangement is designed to have the practical effect of reducing the numbers of housewives included and keeping down the cost. We on these Benches will continue to press for a disability income which would have two elements—one, an income maintenance element, and the other an expenses allowance element.
May I say in conclusion that while, as I have indicated, there are in the Bill one or two items with which we agree, there is much about which we have strong reservations and much which we strongly oppose. While in accordance with the convention in this House we shall not oppose the Second Reading of this Bill, I think I have said enough to make it clear why my right honourable and honourable friends in another place felt obliged to vote against it.
§ 4.5 p.m.
§ Lord Rugby
My Lords, I wish to address myself to the Opticians Act. The Bill before your Lordships' House is intended to re-examine and amend where necessary an Act which was introduced in 1958 by a Private Member. It was never introduced by Government. Willingness now on the part of Her Majesty's Government to carry out some amendments represents to me at least a chink of light at the end of a dark tunnel. After hearing the speech of the noble Lord, Lord Glenarthur, I regard it as positive sunshine.
From the outset that orginal Bill was a contentious one. It was fought tooth and nail on the Floor of the House of Commons, where, rightly and justifiably, its motivation was called into question. Throughout the 25 years of its operation it has been the subject of committees of inquiry of various kinds as to the manner of its interpretation and numerous abuses which have gone unchecked and have left the customer defenceless in the face of sharp practice.
I use the word "customer" with a certain reservation because that is the correct word where a willing buyer purchases from a willing seller. Indeed, where a willing person seeks advice of a physical nature from a professional expert, the word "patient" is correct. But for somebody who has no desire for medical or 26 professional advice and is more than capable of remedying inconveniences which beset the advancing years and is officially denied a right to a simple aid, then we are in a different ball game. We are in the situation of the alleged Russian who dissents from a discriminatory and unfair law and, because of his dissension, is declared a mental defective. He is subjected to psychiatric treatment and in that instance the relationship involves neither customer nor patient. He is a victim, as is the dissenting presbyope (that is simply somebody with an ageing eye) wishing only to offset a predictable situation with a predictable standard aid, who is denied that right because, in absentio, he has been categorised as a visual defective.
The abuse of Section 21 by the opticians has created many dissidents, many victims. I declare myself to be just such a dissident and just such a victim, and in that I am in excellent company. Recently a shop was opened. It opened its doors to presbyopes like myself, offering a variety of magnifications and frames at realistic prices. The rush to buy while the going was good enabled the owner to open in that short period seven branches.
I said that I was in excellent company and, indeed, I found that leading ophthalmologists were also customers. However, on the specious pretext that the ageing process makes us all visual defectives at some time, and without any shred of justification, many of these branches have been forced to close. I was astonished to hear a leading witness presenting evidence that magnifiers such as presbyopes use are indeed not magnifiers because they are minimal magnifiers and are needed for minimal magnification.
I brought these matters to the notice of this House in an Unstarred Question in 1981. The consequential volume of support for change encouraged me to go the whole hog and seek the repeal of Section 21. At the express wish of Her Majesty's Government I withdrew that Bill, pending an Office of Fair Trading report on the way the Act was working either for or against the public interest. As one would expect, it was a thoroughly researched and a thoroughly professional document. Now, of course, there is a smear campaign, but there is no question that that was an excellent report. There have been many expressions of concern over the years in your Lordships' House which have shown that the fears expressed in that report were fully justified.
Indeed, the report went further by looking at Section 25 of the Act and highlighting the difficulties of the average housewife or pensioner traipsing around trying to discover such simple facts as prices, services offered, speed of service, times of opening and general efficiency. This was further substantiated by a consumer magazine report which highlighted the truly absurd variations in prices—for example, anywhere between £40 and £100 for indentical frames. Such variations are, of course, sustained by an ability to deceive and by nil competition.
Yet another report—this time by the Committee of Public Accounts—highlighted the abuses of value added tax in what was termed delicately as "unintended profits". In other words, under the protective cover of the National Health Service monopoly, there was the practice of buying cheap 27 lenses from the Far East and then recovering VAT in accordance with standard rates applicable to the home-produced goods. This had the double effect of squeezing the home industry and drawing an unmerited subsidy from the taxpayer.
In order to satisfy some doubters in your Lordships' House as to the dangers, if any, of buying reading glasses over the counter, some members of the Repeals Group, to which I belong, funded a small survey on this issue with members of the Ophthalmological Society. We owe a debt of gratitude to the fact that nearly 400 of them replied and of those a one-third majority wanted total derestriction on reading glasses. Bearing in mind that many stood to lose financially, it was a highly significant response.
The Government have now once again brought this Bill into the political arena and it is easy to see why. In so doing they have now to look back to the origins of the Act, because—as I read it—what is said in this Bill empowers the General Optical Council to veto and override anything that they do not like at Privy Council level later on. It brings us back to those days when it was openly stated by those wishing to get control of the market that wearing wrongly prescribed glasses was a major cause for blindness. That would not be accepted today; it would not get past the Trade Descriptions Act. But business is not played according to Queensberry Rules.
The Government commissioned the Crook Report. Their recommendations were intended to be the tablets upon which this new faculty of opticians would find its ethos. The aims are clearly set out, and indeed they were to be the pillars upon which an edifice, akin to the medical profession, could be founded. Central to the whole thinking was that eye-testing opticians and dispensing opticians should be entirely separate. That idea stemmed, of course, from the precedent of the medical profession and the inherent dangers manifested in the earlier days of medicine when professional or quack medicos could diagnose in their consultancies merely in order to sell their own cure-alls. Paragraph 66 of the Crook Report says that the public interest is the main consideration for this all-important directive of separating these two functions. It has never been implemented.
Another fundamental directive concerned the formation of ophthalmic optical corporate bodies. Their remit at that time—a dual role of testing sight and dispensing—was to be terminated as soon as expedient and no new corporate bodies were to be allowed. There can be no room for misinterpretation of those rulings. Also, there were explicit rulings given on partnerships being formed with non-professional opticians, because undesirable pressures could, in that situation, influence professional judgment. The whole tenor of the report was to pre-empt the abuses which would inevitably follow unless strict guidelines were set out for a governing body. The General Optical Council was set up and pledged to adhere to those proposals. The rules have been flouted. Why? Why has there been no attempt to implement any part of them?
After 25 years we still have at the centre the General Optical Council, supposedly the guardians of the 28 public and of their eyesight. It consists of 26 members in all, 22 of whom are opticians; 13 at least—maybe more—represent corporate bodies which, according to the Crook Report, should not exist at all. The biggest of these by far is Dollond and Aitchison, a subsidiary of the American tobacco consortium, Gallahers. With somewhere around 750 retail outlets in the high street—or so I am informed—they have the lion's share. With such muscle power it is beyond dispute that they dominate the entire trade and the General Optical Council is subservient to them. What this body of people did to the Crook Report was to tear it up—or at least the bits which did not suit them—as soon as they got hold of the statutory reins of power or quasi-autonomy as formulated in the word "quango". With such a central autonomous position they have far greater power than the whole of the medical profession put together, and that cannot be healthy.
No member of the public can escape at some time being branded a visual defective. No member of the trade can compete efficiently and provide a service of a competitive nature without running the risk of being arraigned before a secret court and put out of business. Believe it or not, this comes under the heading of "infamous conduct". Under such total power no government can enact legislation which cannot at a later stage, when it suits them—as with the Crook Report—be torn up, buried and forgotten.
So long as this "Trojan Horse" sits within the edifice of the National Health Service, its members representing only their paymasters, the work of this House and of another place will be rendered nugatory. Before any attempt is made to get some measure of reform into the Bill, and in the light of past performance, I would ask the House that the members of the General Optical Council should now be told to stand down and their places should be filled by a representative body—a body which in fact and in truth is seen to represent the public interest and which is identifiable by the public as representing their interests in what are truly matters of vital concern to them.
§ 4.17 p.m.
§ Baroness Faithfull
My Lords, I should like very briefly to speak and ask questions on Clauses 11 and 13. Clause 11, as your Lordships know, concerns the new severe disablement allowance which will be introduced to replace the current non-contributory invalidity benefit and housewife's non-contributory invalidity benefit. While welcoming, as other noble Lords have done, the abolition of the housewife's duties test, the new severe disablement allowance is, for many reasons, cause for concern. I am sure that other noble Lords will pursue this subject—particularly the 80 per cent. test; the age cut-off; and the medical and social implications.
I should like to ask my noble friend Lord Caithness, who is to reply, if it is possible to be given the amount of money that is spent now on the current noncontributory invalidity benefit, and what will be the cost to the country of the new severe disablement allowance. I have not given notice of this question and I appreciate that it will not be possible for him to give an answer this evening. But I would be most grateful if I could have a reply in writing.
29 Secondly, would not the Minister agree that, as it stands at the moment, the Bill's provisions on the child dependency allowances may militate against the interests of families with children? But if, as the noble Lord, Lord Banks, has said, child benefit is going to be raised, then it may be a different matter. Is it possible for the Minister to say whether, in the review of benefits that is to be made by the Secretary of State, child benefit is to be reviewed? If so, then of course a different complexion will be put on this clause.
Can the Minister also say—and here again I would not expect him to reply this evening, but I hope that he will write to me—what is the present position with regard to expenditure and what will be the expenditure if the new system is introduced?
§ 4.20 p.m.
§ Lord Stallard
My Lords, I rise to speak on the Second Reading of this Bill and, as was said by the Minister in opening the debate, I am aware that this is the latest in a long series of social security Bills put forward by the present Administration since the election. What the noble Lord did not say was that all those Bills have had one thing in common, which has been openly admitted by the Government; namely, they have all been aimed at reducing the cost of the social and welfare benefits available to people in this country. This has been openly stated in Committee, and I have had the privilege of sitting on a number of Standing Committees in the other place where, in reply to debates on various amendments, Ministers have regularly said that the main purpose of this or that specific measure has been that it is a nil-cost provision.
§ Lord Glenarthur
My Lords. I hate to interrupt the noble Lord but he is slightly misrepresenting what has been said. What has been said in many cases is that we are trying to achieve better value for money. How the noble Lord can say that we are not spending more money when the SDA is costing another £20 million, I do not know.
§ Lord Stallard
My Lords, I hope that before the end of the Committee procedure I shall be able to give the noble Lord the Minister lots of answers to that. For the time being, I shall not go too deeply into the history, but I can assure the noble Lord that the exact words "nil-cost provision" have figured in many ministerial replies from that side of the Chamber.
As I have said, in previous Bills benefits have been delayed. They have been reduced, taxed and been subjected to clawback devices; they have lost the advantages of linkage with wages or prices, whichever was the highest; and generally all benefits have become so complex that even the experts are now finding it difficult to administer them. The latest example of that must be the unified housing benefit, which is almost totally out of hand.
This Bill, which in my view could easily have been two or three separate Bills, takes the whole process a step further. As one noble Lord has, I think, already mentioned, there is no apparent linkage, as there was in many of the previous Bills. There is no automatic linkage between some of the subjects covered in the four points outlined by the noble Lord the 30 Minister—no obvious link. So this could have been two or three Bills at least, but this Bill takes the whole process of complicating legislation and of the nil-cost provision a stage further.
I should like to comment on just those two aspects, which have already been commented on at length, so I do not have to be too long-winded. I should like to support the views already expressed, certainly from this side of the Chamber, on the effect upon the ophthalmic services. I hesitate to develop that because of the excellent technical address that we have had from the noble Lord, Lord Rugby, and from other noble Lords who have spoken on this aspect. But, because of my close association with Age Concern over a number of years, I, too, felt that they had aptly summed up the problems in the letter that they wrote to the Secretary of State, which has already been quoted in this debate, although I do not recall seeing any reply to it.
However, I was rather worried, and I am still worried, that the Minister and others continue to say that if this Bill is enacted spectacles will become cheaper, that if people are able to buy them from all sorts of outlets, competition will bring down the price, and so on. I imagine that most noble Lords will have received a copy of a document entitled A Dubious Bargain, which has been produced by some members of the ophthalmic profession for our perusal. On page 15 it says:The British UKO lens and frames manufacturing company produced the latest 924 frames for 0.30—'there won't be anything coming in from abroad that will be better value, not for that money', says David Wiseman of UKO.They go on to develop the discussion about the 924 frame and what will happen to it:When the government decided on a new NHS frame which was stylish rather than functional UKO took on 30 extra staff",at their Northern Ireland factory in order to tool up and produce these frames. The document continues:Now they are saddled with the frames because the biggest customer, the NHS, is pulling out after next year.I do not know whether the noble Lord has any better examples of better value for money than the £3.30 frame which has been produced by this firm and which is being made available to the NHS. I think that we should all like to hear about that value for money. I am also worried about the disparaging statements that are coming from all quarters, and which I read in the press, attacking what I have always considered to be the very honourable, highly-trained and highly-skilled profession of opticians and all those connected with the industry. I am worried because it would seem that we are setting the ground for introducing all kinds of semi-skilled, or even unskilled, people to this business of dispensing and providing spectacles.
It is no good people saying that once the test has been taken anyone can dispense spectacles, which was another point raised by a previous speaker. I am also aware of the existence of a machine which literally takes seconds to diagnose the type of glasses required. You simply look into an eyepiece and the operator asks you whether you can see a line; if you say "Yes". he says "Put your other eye there. Can you see it now?" If the answer is "Yes", he presses a button and a small piece of paper comes out, as a bill comes out of a till in a supermarket, and he says, "That is your 31 prescription and you must take it along to someone to dispense it". That frightens me. I know that these machines exist, and I daresay that other noble Lords will have seen this contraption for testing eyes. It takes away the skill from the test. The prescription is then taken to Woolworths, Debenhams or even Marks and Spencer to be dispensed.
Then it is said that no damage is caused to anyone by wearing wrong glasses. It seems that we have all been living under some kind of misapprehension for many years that the testing and dispensing of glasses was an important and skilled job and ought to be done properly. We have all been taught by the same people who are now trying to "unteach" us about the difficulties of eye strain, the possibility of accidents and all the other things that can happen if we wear ill-fitting or badly dispensed glasses.
I am simply voicing the concern of all ordinary people, who are not experts in this field but who are worried if we take away the skilled service and go back to the situation which existed pre-NHS, when spectacles were sold on the market stall, where one went along and picked up one pair after another and tried them on and bought the pair that one could see through best. We thought that we had got rid of market stall spectacles of pre-NHS days. This Bill is taking us right back to that situation, with all the problems that then existed.
But what is worse, and what worries me more than anything, is that that situation is now being supported—in fact, advocated—by people who I should have thought ought to have been a little more careful and responsible about that kind of approach. So I certainly look forward to the Committee proceedings on the provisions of these ophthalmic clauses and what happens to spectacles and glasses and the difficulties and dangers in which we shall find ourselves if this Bill goes through in its present form.
I want to spend just a few minutes on the other point—namely, the question of Clause 11, which has been mentioned by speakers on both sides of the Chamber. The clause contains proposals to abolish the non-contributory invalidity pensions and to replace them with a severe disablement allowance. In practice, these proposals will abolish the additional household duties tests which married and cohabiting women have to satisfy in order to qualify for the noncontributory invalidity pension. That has been welcomed. I recall the discussions during the campaign. I am not saying that it was led as well as it might have been by people on my own side at the time, but I can well recall the campaign against the household duties tests, and a very successful campaign it turned out to be. Therefore, I, with others, welcome the abolition of that test.
But the proposals to abolish it followed a review of the household duties test which was initiated in July 1980 after the National Insurance Advisory Committee had recommended that the test should be phased out if a satisfactory non-discriminatory alternative could be devised. This approach had the support of all the voluntary organisations concerned with the problems and of Members of both Houses of Parliament who take an interest in these matters. But 32 the inference of this approach was that consultation would be necessary if we were to reach this satisfactory non-discriminatory alternative. This was confirmed by the then Secretary of State in a letter to the Spastics Society in March 1982, when he said:We are pressing on with the review in the full awareness that those who have made representations about the household duties test are impatient for results but I canot at present give a date for its completion. When it is, we will, as promised, report to Parliament.That was followed later by the Minister who was responsible in July 1982, Sir Hugh Rossi, Member of Parliament for Hornsey, who had this to say:We intend to publish the results of the review and then to invite consultation.What happened to the consultation? We have been asking ever since. The review was published on 1st December, the Bill received its first formal reading on the following day, 2nd December. and was published on the 5th. Where was the consultation? Did the Government rush the Bill through in order to avoid consultation? Were they afraid that there may be some embarrassing delays. having in mind the EEC directive, and so on, if consultation took place; or is the truth as was suggested by my right honourable friend Brynmor John in the other place when he spoke during the Second Reading debate on 20th December? He said, at col. 339:The only conclusion that we can reach is that the Bill represents the weakest and cheapest scheme that will formally comply with the appropriate European directive".Again, I hope that we shall be able to investigate those aspects when we come to the Committee stage.
My noble friend who led from the Front Bench went into some detail about the objections raised by all the voluntary organisations. I have had a number of meetings with the voluntary organisations and discussed these matters with them. I can only agree with all the criticisms that my noble friend and they have levelled at the Bill. I hope that we shall be able to substantiate these criticisms and convince the Government that the consultation was necessary, that it ought to have taken place, and. I am convinced. would have resulted in an agreed alternative nondiscriminatory scheme. That is still my aim. I hope that as a result of the Committee procedure we shall be able to convince the Government themselves to bring some constructive amendments to achieve that kind of aim.
§ 4.34 p.m.
§ Lord Orr-Ewing
My Lords. I want to concentrate on the optician part of this Bill, as did the noble Lord, Lord Rugby. Before I do that, may I say that I had a message at the beginning of this debate from the noble Lord, Lord Northfield, who has been active in this field for about 25 years. Unfortunately, he is ill in bed with a high temperature and wants to offer his apologies for not joining in. He is one of the most robust advocates of a little more freedom. Coming from the SDP Benches he would have been a welcome addition, and we are all sorry that he is not here for this debate.
I am sorry in a way that this particular aspect was not put in a short Bill without lots of other issues. A short, sharp Bill concentrating on optical matters would have been more desirable, but I know from past experience of seven years as a Minister that the 33 moment you get a Bill a lot of people rush at you and say, "We have been looking for an opportunity, Minister, to tag this along in some Bill. Would you mind if we hang it on? It is only five clauses and three schedules". Of course that is generally the part that gets the most attention and causes the most difficulty, and you miss the wood for the trees.
We have all received many documents in the run up to this Bill. The press have for many years taken a close interest over the possibility of greater freedom. I received the same document which the noble Lord, Lord Ennals, quoted from, and he quoted absolutely correctly. It says at the end:If you have any queries please ring Mrs. Susan Marks.I promptly did so, and I asked, "Though they are on BMA paper, are they actually the views of the BMA? I understand that the BMA have not met on this issue, but of course it has been decentralised to their ophthalmic group, quite understandably." So I then asked, "Has the full committee of the ophthalmic group met?" The answer was. "No, it has not met since the Bill was published. But some members of the executive committee have met".
That is a slightly different view. I am sorry if I interrupted the noble Lord, but he is a straightforward, honest, and honourable chap, with many years' service in this field, and I am sure that he did not want to get too far down that road quoting, as one might be entitled to quote, something that was never really considered by the BMA, or not considered in full by their ophthalmic committee.
§ Lord Ennals
My Lords, will the noble Lord give way? I am most grateful to him, because I felt a reluctance in this regard. The noble Lord will be aware that the issue that had been referred to the ophthalmic group committee of the BMA was one that they had dealt with over a considerable period of time. They had been in correspondence with the Secretary of State for Social Services, and copies were made available to the BMA. The BMA is perfectly entitled to refer to one of its expert committees the handling of that particular field of expertise. I think that the criticism that the noble Lord is making of the BMA is an unreasonable one.
§ Lord Orr-Ewing
My Lords, I did not think that I criticised the BMA. I said that the matter had not come before them. I find it difficult now to be told that they had been careful cohorts with the Minister when the allegation in several speeches has been that there has been very little, or no, consultation at all. What becomes of that argument if we are told that over years they have been in correspondence and have been carefully exercising their minds with the Minister of the day?
§ Lord Orr-Ewing
My Lords, I still think that it is important that specialist committees should at least meet when an important Bill is published. They have never met since this Bill was published. I get the feeling—and this may apply to others who speak in this debate—that some do not know what is in the Bill. 34 I wish to speak to some of the points because I take the view that this Bill, desirable though it is—and certainly it is a good start after 25 years' waiting—ought to go rather further than it does.
It is not liberal enough. How sad I was—and how many old-time Liberals must be revving in their graves—to find the Liberal Party saying that it cannot even accept this mite of liberalisation on a minor issue. It is sad, after the great days of Gladstone and the speeches that lasted three hours, to say that this tiny, little nibble of a Bill cannot have Liberal support.
The two largest optical markets in the free world are in the United States and Japan. In both those huge countries they take infinite pains, as we all know, about health care and eye care. Why is it that in both those markets they allow much more freedom than this Bill is now going to suggest? Why do they find, with all their care over health—and anyone who goes to the United States knows that at the drop of a hat they will give you a test, and probably an enema, too—
§ Lord Orr-Ewing
And an X-ray, and everything else. Why do you suppose that they have allowed freedom, and why in those markets are spectacles so much more easily and cheaply available, particularly for those who, through perfectly normal ageing processes. need some help in reading? I think that the telephone book found me out first. The prayer book also finds you out. if you do not know it by heart, or they change it; and then there is other small print. Maps, by the way, are absolute hell. But I have not got diseased eyes. I have the kind of eyes which half the people wearing spectacles in this country also have. After the age of 45 or 50, whatever it is, you need magnification of small print. This is not a faulty eye. It is perfectly natural.
In other ways our muscles also do not react quite so well. I cannot jump so high. I cannot run so fast. Whenever I play cricket I am always run out nowadays because of what I thought was a safe one to extra cover, but I forget that I cannot go so fast. My muscles do not react. Exactly the same applies to the muscles of every person's eyes. They cannot focus as well as they used to, they cannot be as alert as they used to be, and they age. I am suggesting that this is a perfectly natural process and is not a disease.
I cannot help at this moment saying that all this sad reflection—I must rag the Front Bench Opposition spokesman on this one—is like "granny in the glen" over the British Telecommunications Bill. We were told that everyone was going to suffer; that everyone from now on would have to wander around with a white stick; and that we were all going to he deprived of rights. We are not. If one reads the Bill one sees that we are not going to be deprived of rights or care. Extra care will he taken. Of course. it does exist at the moment—I feel that some of us who would like a little greater liberalisation would like to do what the United States. Japan. Singapore and the Far East are doing and what Sweden is doing. In the days of Sir Harold Wilson, as he then was, we were always used to having Sweden quoted as the "great socialist country". They have liberated their old controls over the sale of spectacles. They have gone the route on which this 35 Government are going a little too slowly. In the Committee stage of this Bill I very much hope that in all parts of the House we shall look after the people who need to be looked after—that is half the customers in this country.
When I go to the States I know that at this stage in my life my eyes are + 3½diopters in each eye. I go into a store and look at the type of glasses that are there. It is rather like a seaside resort where there are post cards in racks I choose the frame that I want and then look down the frame and it says: l–1½, 2–2½, 3–3½diopters. This is perfectly possible. You are never going to harm your eyes—everyone is now agreed about that.
§ Lord Orr-Ewing
I am awfully glad that the noble Lord mentioned that, but are they violently different, because it has been discovered that the human frame. the eye particularly, is far more flexible than people hitherto thought. You can make an allowance. My eyes are slightly different but there is an extreme adaptability. In the States, incidentally, they are doing research because they find that bifocal lenses sometimes cause accidents in that people stumble over a step because they are not looking through the right part of the lens. They now find that it is perfectly possible in some cases—I am not advocating this but it reflects the differences in how adaptable are our eyes—to have the lens in one eye for reading and in the other eye for more distant vision. The adaptability of our eyes and our brain is so great that one can allow for it. Where there is a minor difference it is perfectly acceptable.
This viewpoint is supported by the professional people—the eye doctors, the Ophthalmological Society. The vast majority of them support the idea that the monopoly on sales should now go. Not only would we be bettering the advice of people as qualified as that, but we would be greatly helping the average person. I do not exclude from this the million or so visitors who come to our country. Are they in future to have to carry a prescription as well as their blood groups, their identity cards, their driving licences and their credit cards? Are they in future to have prescriptions because if they break their glasses, as most of us do at some time in our lives, they find it very difficult to get them quickly fixed?
Everyone will benefit if this freedom is allowed. I should like the Government to go a little further and I shall seek to put down amendments and support amendments which show that reading glasses, properly marked, should be able to be bought in multiple stores as they can be in the great majority of countries of this world.
§ 4.45 p.m.
§ Baroness Robson of Kiddington
My Lords, I wish to deal purely with Part I of the Bill as my noble friend 36 Lord Banks has dealt with Part II dealing with the social security provisions. I am delighted that the noble Lord, Lord Glenarthur, has admitted that the Bill is full of different and unconnected pieces of legislation. Before I come to the provisions of the Bill itself, I should like to implore the Government to end that annual production of a Bill dealing with the NHS or with the various aspects of the NHS. The Government have been in power for some time now and they must have come to fairly definite conclusions about the direction in which they want the NHS to move. We would all, I think, welcome a comprehensive Bill clearly setting out the Government's views on the NHS. The present piecemeal fashion of legislation relating to the health service inevitably leaves the Government open to the accusation that they are far from wholehearted in their support of the health service.
Secondly, I also wish that we could have Bills introduced specifically for the National Health Service and specifically for the social security aspects, instead of having them put together in one Bill. I think that both subjects are of such immense importance to the average citizen that they deserve separate treatment.
I return to the Bill. First, I should like to thank the noble Lord. Lord Glenarthur, for his Notes on Clauses and for the very clear way in which he introduced the Bill. I should like also to refer to the statement of the noble Lord, Lord Orr-Ewing, that it must be difficult for a Liberal to come out and speak against the freeing of competition. But may I say that being a Liberal does not necessarily mean that one is laissez-faire and that one does not care about the kind of provision that one provides for people who maybe are not able to discriminate themselves. So, as the noble Lord. Lord Banks, has said, we welcome the relaxation embodied in Clause 1(2) on advertising. We believe that this can only be beneficial to the patient, but we have however grave reservations about Clause 1(1).
Much has been said by various noble Lords about the fact that wrongly dispensed glasses cannot damage your health. I agree that it cannot damage your health but it can cause you enormous discomfort, and I believe can endanger people because they do not see as well as they might. They may not even be aware that they are not seeing as well as they might. There is much much more to the supply of glasses than the actual prescription by the practising opticians.
When you get a prescription and go to your dispensing optician, he has a lot of work to carry out to make certain that those glasses are the right ones for you. He has to measure the width between your eyes so that you focus properly through the lenses. He has to make certain, if you wear bifocals, that the division between the vision is in the right position. depending on the kind of job that you do. All those things require a certain amount of skill. I believe it is essential that people have a certain amount of training before they are allowed to prescribe glasses.
Secondly, in the new system, who is to make certain that the dispenser possesses the right equipment in his premises for the testing and checking of lenses? As noble Lords know, most lenses are produced by prescription houses or laboratories and they are sent to the dispensing optician who then presents them to the 37 customer. He must have the proper equipment for checking and double checking that those lenses are correct to that prescription and are meant for that particular patient. There is nothing in the Bill that will ensure that persons selling glasses will have adequate equipment in their premises.
Thirdly, under the regulations that will be laid down, I understand that in another place we have been given the assurance that only prescriptions up to two years old will he permissible for dispensing. But you can envisage a patient who, having had a prescription two years ago, at the end of two years goes to his optician and has a new pair of glasses made. He could, equally, wear those glasses for two or three years; and in all that time he would not have had an eye test. Among a certain group of people in our society, particularly the elderly, it can be very important to have an eye test every year. That is another danger that I see.
Then, too, I am nervous about how the average patient will get redress in cases of complaint. If the General Optical Council or the FPC are going to be responsible for the provision of services, how can they be responsible if there is not a register of the people who are entitled to dispense glasses? Lastly, I should feel very worried about the orders relating to this clause being passed through this House under the negative procedure. I should much prefer it be under the affirmative procedure.
I will now turn to the family practitioner committees. I should like to turn to Clause 5, which proposes the establishment of wholly independent family practitioner committees appointed by the Secretary of State and accountable to him alone. It has never been my experience that three wholly independent bodies make for better co-operation than that obtained from two independent authorities. The problem of getting agreement from a greater number of independent authorities surely must be more difficult. Both the Royal Commission and the Acheson Report agree that there is great advantage in responsibility for the whole range of services in a given area being discharged by a single authority. Only then would it be possible for the barriers between different parts of the health service to be removed.
I was pleased to hear that the Government are producing yet another Green Paper on primary care. I doubt whether we really need so many Green Papers on primary care. We already have documents that set out the aim of primary care. We are a caring community. What we need from the Government is not more Green Papers or more instructions but a certain amount of finance so that we can introduce primary care. The establishment of a wholly independent family practitioner committee charged with the provision, one presumes, of primary care within the community makes one wonder whether in due time the duty of providing community care will be removed from the health authorities and handed over to the new, autonomous FPCs, thereby slowly returning to the pattern of service that we had before 1974, with complete division between the hospital service and the community care services.
Much has been said in another place during the passage of this Bill about the disproportionate amount 38 of money spent by district health authorities on the hospital service compared with that spent on community services. That comparison does not take into account the money spent on the family practitioner service: it was related only to the funds available to the district health authorities. I am the first to acknowledge the value of the family practitioner service in this country. We are tremendously fortunate in having a devoted service from our general practitioners, and most people see the NHS as their family doctor because, with luck. that is the one and only part of the service with which they will come into contact.
However, because of the division in the service there is much passing of the buck from one side to the other. Under financial constraints, the hospital service has cut down on drug prescriptions for patients, passing the responsibility to the general practitioner. On the other hand, the general practitioners tend to refer to hospitals patients who, in the past, would have been dealt with by them in their surgeries. I came across an example the other day when a mother took her small 4 year-old child to her general practitioner because she had fallen in the playground and slightly cut her chin. The mother and child were sent to Charing Cross Hospital accident department, and the child had to sit there seeing a lot of very badly injured people for the purpose of having one small stitch put in. That does go on; for every general practitioner is not necessarily doing a marvellous job. And when that kind of thing happens, we increase enormously the cost to the hospital service.
It follows that if we are going to have the right kind of balance we need to have the family practitioner service, the hospital service and the community services under one head. I believe that that can happen only when the family practitioner committees are fully accountable to the DHAs and the regions. Regarding the membership of the FPCs. I also have grave reservations. The provision of four representatives of local authorities and district authorities on the family practitioner committees could create great anomalies. In some instances, there could be four representatives from one district health authority on an FPC or there could be only four representatives to represent more than four districts.
Secondly, those of us who have worked in the NHS know how difficult it is to get a good attendance at health service meetings by local authority members, not because they do not want to attend but because of pressure of committee work in their own authorities —work which is increasing under the present economic and financial constraints. A local authority will now be faced with having to produce members of regional health authorities, members of district health authorities, members of joint consultative committees and members of family practitioner committees. I make that quite a large number of local authority members. Where are they to come from? I do not believe that we shall see a better attendance by local authority members on health service committees by increasing the number that they have to provide. I believe that if we are going to have them truly represented we must have for them (just as we have for the pharmacists) permission for a deputy to attend. I think that is the only way that we shall make certain 39 that there is proper representation of the elected representatives of the people on the family practitioner committees or on any other health authority committee.
There are many more aspects of the Bill that are disturbing. We hope that amendments can be agreed at Committee stage to make some sense out of this hotchpotch of a Bill.
§ 5 p.m.
§ Lord Molloy
My Lords. may I first express my apologies to the Minister who is to wind up, as well as to my noble friend Lady Jeger. Owing to a promise that I made, I have to attend a meeting later in the evening. At the time I did not know that this Bill was to be debated today. but I must keep my word so I proffer my apologies.
To a few of us who are left and who have been concerned with the National Health Service from its inception by Aneurin Bevan. it is absolutely amazing to see what has happened over the years. The converts are almost incredible. The vast number of Conservatives who have now been converted to the National Health Service equates with the Chinese general who baptised his troops with a hosepipe. That is always a very good thing.
As a former staff side chairman in the Foreign Office. I wondered whether this measure would be accepted and whether Parliament would throw it out. After the most appalling war in Europe's history, we wondered whether this country of ours could introduce something which the world had never seen before. But we did it, and what is encouraging is that successive Governments have maintained the grand principles which were enunciated by Nye Bevan when he introduced this measure.
However. I am a little worried about this Bill, because it departs from anything that has been done before. With Dick Crossman, my noble friend Lord Ennals and other Ministers in the Opposition, I have scrutinised what has happened since 1947. I am bound to say that, while this Bill is really four Bills in one, at best it is a miscellany of miscalculations and at worst it is a deliberate infusion of rising damp in the National Health Service. It is not an outright attack, but it is slow, invidious and cunning, and when one has been involved for many years generally, as well as specifically, one recognises these things almost immediately.
This Bill mutilates rather than constructs. It is not much concerned with the enhancing of health or social services. The quintessential of this measure is to save around £265 million to £300 million for the Government to hand out in tax reductions later on to the better off. This Bill is more of a bad feudal "means" than the Good Samaritan which Bevan created.
Much of the time will be taken up with the opticians' aspect. I listened very carefully to the most informative speeches of the noble Lords, Lord Rugby and Lord Orr-Ewing, and I am bound to say that I have to agree with much of what they said, though I have to disagree on some aspects. For example, very many people, who may think that they do not need 40 glasses. really need them if only to read the small print on some of the documents of private enterprise insurers in the private sector of the health service, because those who have not read the small print find themselves later on in very difficult situations. It would be much better if they had read the small print and had NHS glasses to do it.
However, I understand that the Government do not intend to include contact lenses in their opening up of freedom to the opticians. If that is the case, may I ask why? Is there any difference in my wearing these glasses, which I look down on, and having lenses inside my eye? All they have to do is make me able to see, so I cannot see what the difference is. No doubt I shall be informed later.
What I want to say loud and clear is what is recognised by ophthalmic surgeons and opticians throughout the world, including the United States of America, Australia, New Zealand, Canada, France and Germany. They have one acknowledgement of which we ought to be proud, which is that Britain provides the best quality lenses in the world. That is important and I am proud to be able to say it, so I hope that this Bill does not detract from that remarkable accolade.
There is another aspect which worries me. I do not understand why no Labour Government or anyone else said that everyone should have the best frames. We are now to move into a situation where National Health Service frames will be restricted to the very poor. They will therefore become stigmatised. Adults who wear National Health Service frames in the future, if this appalling Bill becomes law, will be wearing their badge of being poor in this good society of ours. These are some of the matters which Nye Bevan looked at very closely when he had to fight the BMA and the Conservative Opposition. who fought every line of the Bill at every stage. I am very pleased to say that within a few years they were totally converted.
My fear is that under this Bill that great stand. which was made right through to the 'sixties and 'seventies by Governments of both sides. will now start to change dramatically. To begin with, it seems to me that under the Bill there will be a loss of expert dispensing by opticians and. with the introduction of cut-price proposals by big corporations and multiples. it will be a policy combining callousness with real myopia. It will be bad for the public and what is more—and I am amazed that this came from a Tory Government— it will he so unfair to the small businessman and the small firm dispenser. many of whom have written to me expressing their apprehensions. Does this Bill really mean that expertise does not count any more?
I want to ask one question of the noble Earl who is to reply. Will foreign speculators be allowed to enter this country to compete against the British and to bring with them orders from their countries, so that there will be a wide variety of nice, cheap Japanese glasses as well as good solid British glasses? I want that question answered tonight if that is at all possible.
The apprehension is not confined merely to these Benches. I do not think anyone would say that the Sunday Telegraph is a very hard Left-wing newspaper, but it has suggested that elderly people who are now 41 paying £35 for complicated lenses will probably be paying around £81 because of the Government's proposal in this Bill. We need to take full cognisance of that.
The noble Lord quite rightly quoted the Office of Fair Trading, who have said—and I think I can agree with this—that opticians should be allowed to provide more information about prices. But the Bill flies in the face of other proposals. I can see that there is an argument for opticians being allowed to advertise and to compete within a limited area. I have no disagreement whatsoever with that and it would be an improvement. But what I am gravely apprehensive about is that other aspects of this Bill fly in the face of the recommendations of the Royal Commission on the National Health Service and of the Acheson Report.
I am astounded that the Government had no consultation with the Association of Optical Practitioners, and did not bring the association together with the Office of Fair Trading to talk about this in a sensible way, so that something could have emerged. A proposition from the Office of Fair Trading and from the Association of Optical Practitioners would have been part and parcel of a clause which would have been acceptable to me and to the noble Lords, Lord Rugby and Lord Orr-Ewing.
Why was this not done? Before the Committee stage, perhaps it will be done. There has been a great deal of argument about the view of the BMA. This was quoted in another place by the Conservative Member for High Peak, Mr. Christopher Hawkins. He said:I have no link with the optical industry other than I am a wearer of glasses. But I should like to quote from the British Medical Association ophthalmic group committee, which says: 'While specific harm to the eyes is unlikely to arise from the use or non-use of spectacles, there is firm medical agreement that the correct and appropriate dispensing of spectacles has very significant health implications. The committee cannot accept that after the prescription has been issued optical appliances take on the status of mere consumer durables and feels strongly that when highly skilled and expensive medical or surgical treatment has been provided under the NHS' "—
§ Lord Mottistone
My Lords, I intervene for a very good reason, if the noble Lord, Lord Molloy, will allow me.
§ Lord Mottistone
My Lords, it is out of order to quote what has been said by a Member, other than a Member of the Government. in another place. I think that the noble Lord ought to have been stopped a little sooner.
§ Lord Molloy
My Lords, I am quoting what was said by the British Medical Association. Why are Members opposite so hostile to the BMA? I really cannot understand their attitude, so I had better start again from the beginning. This was said by the BMA. not by a Member of another place. Is this top committee of the BMA not to be heard in this House? As long as I am here, they will he heard.
§ Lord Mottistone
I apologise to the noble Lord. I got hold of the wrong end of the stick. I thought he was quoting a Member of another place.
§ Lord Molloy
I accept the apology of the noble Lord, Lord Mottistone. Since I had almost finished, I shall read just the last part of the statement:'The committee cannot accept that after the prescription has been issued optical appliances take on the status of mere consumer durables'.I should not have thought that one needs to be an optician to accept that point. Everybody would accept it as a matter of simple commonsense. I return to my other plea: that if, as indicated by the noble Lord, Lord Orr-Ewing. and the noble Lord, Lord Rugby, there had been consultation with the BMA and with the opticians, the Government would have gone to the other place last December with a clause which would have sailed through the other place. Their objection is very real indeed. I am not an expert when I go to the doctor with a terrible pain in my stomach, or when I go to the optician because I cannot read. If I were, I should not bother to go; I would give myself the tests. Therefore, it would be wise to speak to these people.
I turn briefly to Schedule 3. As my noble friend who spoke earlier said, the Secretary of State will appoint 30 members of all the family practitioner committees instead of. as is now the case, the family practitioner committees electing locally their own chairmen and membership. As has already been stated, this means that the Secretary of State will personally appoint 3,000 people, so 1984 is here all right: Big Brother will decide all. It is an obscenity to suggest that one Minister should be able to make all of those appointments. When one realises how senior officers in the armed forces are appointed, this kind of procedure is absolutely despicable. It is an affront to those people who wish to indulge in the enterprise of the pioneer. Those people will he discarded. The Secretary of State will replace them by the servitude of lackeys. This, to me, is highly distasteful.
May I now deal briefly with the disabled? Speaking for more than 80 organisations, the Disability Alliance describes the Bill as a "mean and shabby measure". I do not intend to go through the whole list of members of the Disability Alliance, but who is it that says that this Bill is a mean and shabby measure? I merely quote what they say. I have a right to quote what these organisations, representing the disabled, think. That is what Parliament is all about. The leaders of the Spastics Society, the Disablement Income Group, MENCAP and the Multiple Sclerosis Society are all astounded at the Government's proposals. The Royal Association for Disability and Rehabilitation is convinced that, if introduced as it is, the new benefit will prove to be a disaster. Why are they so convinced? I am trying to get the Ministers opposite to understand that not merely the supporters of my party, the Liberal Party and the SDP, but renowned and well-respected major organisations are gravely apprehensive. Once again, why were they not consulted? It is not too late to do so.
Since the last war all parties have joined in the building of a fairer society. Both Labour and Conservative Ministers have defended the National Health Service. Indeed, both Labour and Conservative 43 Ministers have improved the National Health Service. Sometimes they had to fight to do so. The present Minister gives in with an alacrity that is deplorable. The principle of defending the National Health Service no longer applies. Do the Government, in their search for money, really believe that they have got to do what they are doing? I quite understand that they have got to find more money. In order to give tax reductions to the well-off, they look at the big industrialists and say that they cannot touch them. Nor can the Government touch the big people in commerce and industry, with their big cars and fine homes. That might affect their morale. The Government then look at the City—the prosperous bankers, and so on—and say that they cannot touch any of them. Then they suddenly decide that those they can attack are the cripples, the disabled, the hard of hearing, those with poor sight and the sick. I suppose it requires a great deal of courage to do that. How wonderful to have Ministers with such strength of character that they can indulge in that kind of action.
§ Lord Glenarthur
My Lords, before the noble Lord continues, how does he square his vicious attack on this Government's record on the National Health Service with the fact. which he knows as well as I do, that this Government have increased spending on the National Health Service by about 8 per cent. in real terms, from £7 billion to £17.5 billion, since they came to office?
§ Lord Molloy
My Lords, the Minister does not seem to realise that most of the money has been squeezed out of those whose standards of living ought to have been maintained—those like nurses and ambulance drivers. The police and the armed forces have left them way behind. Midwives also have had to suffer in order to make this so-called contribution, which makes it even more unjust.
§ Lord Glenarthur
My Lords, the noble Lord's challenges are so excessively wild that I must ask him to sa,, how they have been affected in the way that he suggests.
§ Lord Glenarthur
My Lords, can the noble Lord justify his charge that nurses, midwives and others have been affected in the way that he suggests?
§ Lord Molloy
I have been doing so for three years, my Lords. Where has the noble Lord the Minister been? Some of my charges have been directed at him. I have been trying to educate him for at least two years. What a waste of time that has been! After that intervention, I am bound to say that it might be more truthful to say of this Government, O tempora! O mores!, because they are pretty hopeless. Over the past four years this House, despite the fact that there is a Conservative majority, has developed a new reputation. It scrutinises more. This Chamber has shown more understanding and, because it scrutinises better and more freely, because it is free of the whipping system, it has shown greater concern. It has 44 developed an image which I believe to be remarkable. if not wonderful. This Chamber has become the acknowledged guardian of the people. Perhaps that is right and proper, for it was the barons who forced King John to sign Magna Carta. When we are in Committee therefore I hope that we shall deal this Government a reminder of Magna Carta.
All parties should acknowledge the fact that we have been groping for many years—and this is under all Governments, including Labour Governments against Tory Oppositions and Tory Governments against Labour and Liberal Oppositions—towards a general consensus on improving the great articles of state. such as education and the National Health Service, in the national interest. It would be a great shame if that kind of principle was in any way spoilt by the present attitude of this Government.
I hope that when we are in Committee we shall endeavour to change a number of aspects to this Bill. This House may not be able to influence or gain the support of the ordinary British people. but it can remind the world of the lead given by Britain in shaping and fashioning a civilised society. Despite all our political differences in the past. we have moved forward by doing just that. It now seems that. under this cunning little Bill, we shall be departing from that great principle. I hope this House will ensure that that principle will be returned to when we embark upon the Committee stage.
§ 5.21 p.m.
§ Lord Suffield
My Lords, I wish to refer today only to that part of the Bill relating to the Opticians Act. While I have sympathy with the object of the Bill—namely, to ensure a reduction in the price of spectacles—I have certain reservations regarding its ultimate effect on both the price of spectacles and the standards of eye care in this country.
When free eye examinations and the provision of spectacles under the National Health Service cease. the availability of a large range of spectacle frames will also cease because manufacturers will stop making them. In the past. supply to the National Health Service has been subsidised by the private sector, and therefore it is quite true that the price of private spectacles should fall—at least. certain of them.
I am informed that the present price of spectacles in this country is among the lowest in Europe and that no other Western country provides spectacles to National Health Service standard at a comparable price. However, although the simple and cheaper private spectacles may become cheaper still, the more complex prescription lenses will probably cost more. Even now, these can cost double the National Health Service charge of £32.
The unregistered supplier of frames and lenses will be interested only in supplying the simpler and more profitable of these: the qualified optician will be left to supply the more complicated and expensive. To this must be added the cost of the eye examination. And what will be the position regarding VAT? If this is to be charged. it will be based not only on the retail price of the spectacle frames but also on the cost of the eye examination and the prescription lenses. How w ill those on low incomes—not. I understand. those on 45 supplementary benefit—who require the more complex type of spectacles be able to afford them?
In America, the effect of advertising has been to move the supply away from professional opticians to commercial firms which have a lower standard of patient care. This may lead, in this country, to a change in the pattern of supply away from privately-owned practices, thereby denuding rural areas of ophthalmic facilities.
Although prescriptions will still be provided by qualified registered opticians, the same prescription can be made up in frames in many different ways. They have to be suited to the particular needs of the individual. This care is unlikely to be provided by the large suppliers. Although I can confirm that no medical damage is done to the eyes, incorrect fitting and adjustment can lead to headaches or, in the worst cases, to double vision. The noble Lord, Lord Banks, has already observed that one needs no imagination to appreciate the dangers to drivers and to industrial users where this occurs. Is it not possible to introduce a British Standard for spectacles?
The sale of ready-glazed lenses—not sunglasses —without prescription is illegal under the Act, but their importation must be prevented by banning the advertising of them. Some are now entering the country by mail order. There is also an attempt to outwit the law by calling them magnifying glasses. Advertising by both the profession and by commercial firms should be governed by the rules of the Office of Fair Trading. This point has been mentioned already.
My final question is this: what method is open to a dissatisfied client to obtain redress? The only means at present would seem to be through the Sale of Goods Act. But if the eye examination is carried out by one person, the supply of frames by another, and the lenses by a third, it will he difficult to say who is responsible. Litigation to recover the sum of £30 or £40 would hardly seem worthwhile. That is all I have to say, and I hope that the noble Earl will be able to provide some of the answers.
§ 5.25 p.m.
§ Lady Kinloss
My Lords, I am greatly concerned about the effects of parts of this Bill on certain sections of the population; effects which appear to me to be adverse. As I have been given to understand, the Government now propose to permit persons with no optical qualifications to engage in ophthalmic dispensing—also, to sell and supply ophthalmic frames and lenses to adults. There are 6,179 registered ophthalmic opticians. There are also 2,879 registered dispensing opticians in the United Kingdom. In almost every city and town, there are several opticians in competition with one another, and no chain which has anything approaching a monoply.
I would ask the Minister this question: what advantage would accrue to myself or to any other individual in this country in going to an unqualified person to purchase a pair of spectacles? I would ask the Minister also: would he himself be prepared to do so? I have no desire to labour these points to the Minister but it is on ground of simple common sense that I question the Government's apparent policy. I can see every argument for securing spectacles more cheaply, 46 but surely there are means of doing so available to the Government other than by allowing unqualified persons to dispense.
This Bill also limits the provision of National Health Service spectacles to children up to the age of 16. to students in full-time education up to the age of 19, and to people receiving supplementary benefit. I am sure the Government know that the majority of undergraduates are aged between 18 and 22. Why add one more item of expense to the budget of those supported by student grants? I may add that I wear National Health Service glasses and I do not come within any of those categories. As the Bill stands, a very large group to be excluded will be retired people—many of whom are on small fixed incomes and small pensions. No financial assistance will be given to those people unless they are in receipt of supplementary benefit.
The Minister of State for Health in another place has said that the Government recognise that there was a problem with certain sections of the public and have been considering what should be done to help those people. I was therefore very glad to hear the Minister say that those with the need for special lenses will he able still to have National Health Service glasses, if they wish, if they are in financial need. I urge the Government to consider particularly the needs of partially-sighted people.
With regard to the dispensing of spectacles, I understand from people with a knowledge of this subject that the dispensing of spectacles is very important—especially so with bifocal lenses which require further measurements. These may be small points but they are very important to the health of those people requiring spectacles.
I turn now to Clause 1 1, which concerns the severe disablement allowance. It is 10 years since the introduction of the non-contributory invalidity pension payable to people incapable of work and who have not, for whatever reason, paid sufficient contributions to qualify for sickness and subsequent invalidity benefit. A major problem has been that married women have had to show that they are incapable of normal household duties. Although I welcome the end of the household duties test as being discriminatory against women, for the past seven years this test has been under review. The last review was conducted by the DHSS, and successive Ministers have agreed to a debate on any eventual proposals. However, I understand that the Government published this Bill on the day after the DHSS report. So, far from being able to consider the report, the Bill must already have been sent to press.
I believe it has not been fully realised that this Bill takes away from men and single women a right they have had since 1975. No longer will incapacity for work for a period of 196 days qualify people for benefit. If they are over 20 they will have to show that they are 80 per cent. disabled. MIND has estimated that over 26,000 people with mental disorders will. over a period, lose entitlement to benefit. RADAR has calculated from Government figures that 1.280 additional married women claimants each year will fail to obtain SDA who would have qualified under the former household duties test. This would he because of the 80 per cent. test of disablement and the great 47 difficulty in applying it to people suffering from multiple sclerosis or epilepsy—let alone mental health. I am worried that it can seem that too little thought has been given to these proposals. Many voluntary organisations would have liked constructive discussions with the Government on possible alternatives to solving these problems. I cannot say that I feel happy with the Bill as it stands.
§ 5.30 p.m.
§ Lord Rea
My Lords, it has been no easy matter for me to understand this disconnected Bill, even while wearing my bifocal National Health Service magnifying glasses, which I gather are shortly to become an extinct species. I do own another pair with expensive frames. I was persuaded to get them, against my better judgment—an appeal to vanity, or something—but I have had much more trouble with them. The National Health Service lenses keep falling out of the expensive German frames. It is another example of how the public-private mix does not always work.
I do not think that those who have pressed for an end to the opticians' closed shop, and thus initiated this part of the Bill, ever had this in mind—the ending of the National Health Service provision of glasses. The Government have slipped in this one. The Government are agreeing to pay, as outlined in Schedule 1. for glasses needed by children and those on supplementary benefit. However, as my noble friend Lord Ennals said, I do not think this is a wide enough provision by any means. For example, I consider that it should apply to all pensioners, many of whom, as has been said, have complicated eye conditions such as glaucoma or cataracts where frequent lens changes are necessary. This is an area which I certainly hope can be improved in Committee.
This whole aspect of the Bill—getting rid of a service which was everybody's right without restriction and without means testing—is in every way regressive and I am totally opposed to it. But we have to do what we can to try to improve it until better days come along.
My main concern is the change in the status of the family practitioner committees. Independent status as an employing authority with direct remuneration from the Department of Health and Social Security is regarded as a promotion by the family practitioner committees and, as such, has been largely welcomed, particularly by the BMA which considers that this move will benefit primary health care. Ostensibly the status of primary health care receives a boost to its morale by this change. Until now the family practitioners have definitely had a subordinate role to the area health authorities, as they were, and which are now the district health authorities; although they have had the great advantage of not being cash limited. Ninety per cent. of the expenditure of district health authorities is on the hospital sector which therefore has been their main preoccupation.
At this stage I should like to give your Lordships some of the views of the British Medical Association on this change. It states:
The DHAs are often prepared to transfer responsibility for patient care to the primary sector, but conscious of their own 48 pressing needs they are reluctant to match this transfer with adequate resources. FPCs have been unable to initiate this kind of resource shift and to achieve the resulting savings in total NHS expenditure because they have been subordinate in these matters to the policies of their local DHAs.This point is well illustrated by the pattern of care for the elderly. The costs of maintaining elderly patients in long term hospital care are high (at least £40 per day per patient). At present 94 per cent. of the elderly population aged 65 years and over live in the community, whereas the remaining six per cent. are in institutional care. A small increase in the 94 per cent. of the elderly living in the community could yield substantial savings in expenditure on geriatric institutional care. thus freeing resources for other uses. But the transfer of long stay elderly patients to the community (or more realistically, a reduction in the number being admitted to hospitals and other institutions) does require a commitment of resources to community health services, including local authority services and family practitioner services.It is natural, because of the level of involvement of DHAs in the hospital sector, that an increased role for primary care in the NHS would only be achieved if it were given direct responsibility to act through its own health authorities. The new FPCs would be able to present the case for family practitioner services both within the NHS and outside it. They would be able to contribute to the planning of growth of primary care in partnership with DHAs, using their own ear-marked funds for developing its contribution to the NHS. In short, they would be able to serve as catalysts, stimulating the expansion of the most cost-effective sector of the NHS. Through their agency local government could he propelled into making a serious commitment to community health services. There is a range of opportunities for change, and this includes accommodation for the elderly/infirm, home helps. meals services and laundry services".Having said that—and I respect those views—I wonder if that is the best way of integrating hospital and community care. It was only in 1979 that the Royal Commission on the National Health Service recommended that the family practitioner committees should be abolished and that their functions should be assumed by the district health authorities as a step towards integration. During the last parliamentary Session when this same question was being debated in this Chamber—I think during the Committee stage—the then Minister the noble Lord, Lord Trefgarne, in reply to my noble friend Lady Jeger (who had been consulted prior to the decision to separate the FPCs from the health authorities), wrote to her listing 633 organisations which had been approached. Fifty-six per cent. of the replies favoured a solution as in the present Bill and the Minister implied that that virtually clinched the matter. In fact, most of those who were consulted prior to the decision were statutory or professional bodies working in the professional organisational mould and were, therefore, likely to have an interest in the continuation of the status quo of the FPCs.
The Royal Commission on the National Health Service, which advocated the abolition of the FPCs, made its recommendation on the basis of consultation with 1,300 named organisations and a further 650 individuals—a much wider spectrum than that on which the present decision of the Government to make the FPCs independent is based. It is a pity that when the opportunity for change arose in 1982 the narrower rather than the wider view was taken. I consider also that it is an insult to the work of the distinguished members of the Royal Commission that a decision was taken which flies directly in the face of their recommendations. The Royal Commission was set up by the previous administration, but one must ask whether that is a good reason for overturning such authoritative and well-informed advice.
49 However, the family practitioner committees have had their way and it could be that this vitally important branch of the health service should have special treatment and encouragment. I can only say that the family practitioner committees do not enjoy a very good reputation among community health councils and other health workers who have been trying to build up good community health services. They have a reputation for being inward-looking and for self-interest. I can only hope that their better status will be reflected in magnanimity to other branches of the health service, as suggested by the excellent working party whose report was referred to by the noble Lord. Lord Glenarthur, in his opening remarks. I also hope that the hand now being offered directly from the DHSS to family pracititioner committees does not turn into what many fear will be an icy grip, which will, first of all, gradually impose cash limits and, finally, result in a second-rate service.
§ 5.40 p.m.
§ Earl Attlee
My Lords. I will, if I may, start off on a slightly different tack. On Monday last week in your Lordships' Chamber it was said in so many words that it is not easy to forget the disabled; we do not get a chance to. That is true, but it is wrong in implying that the disabled have made their point and enough is enough. What was said was true because, since I have been attending your Lordships' Chamber regularly (that is, since last October), we have had two Bills on disablement, we have had the Telecommunications Bill, the Housing and Building Control Bill and the Rates Bill—all with a high content about the disabled. At present we have the London Regional Transport Bill going through Committee. Again today we have the Health and Social Security Bill—on which. incidentally, I shall be restricting myself to Clause 1 I . Yes, it has not been easy to forget the disabled in this House, but the reason is very simple. In Bill after Bill the Government have neglected to pay attention to the specific needs and requirements of the disabled.
Also last Monday the noble Baroness, Lady Lane-Fox, in talking on the London Regional Transport Bill, said:
much as we value the help and advice of able-bodied people, we know that there are vital points on the travelling needs of disabled people that the able bodied simply do not comprehend".—[Official Report, 14/5/84; col. 11601The noble Baroness was right. Who but the blind can comprehend what it is like to he blind, and who but those confined to a wheelchair for life can comprehend what it is like to he so confined? Those of us who speak up for the disabled have in mind their best interests, even though we do not really know what it is like.
My noble friend Lord Kilmarnock, who will be winding up for the Alliance, warned me that social security matters are always very complicated and. oh, was he right! I have read and re-read Clause 11, and I have compared it with the section of the 1975 Act that it is to replace. I have read the copious briefings from which so many noble Lords have been quoting, and I have listened to talks by the experts. Quite honestly, I am not sure that I am not now more bemused than I was before I heard anyone say anything. However, bemused or not, I must say that there are certain 50 aspects of Clause 11 that are perfectly clear, even to me
I should like to take first the severe disablement scheme. This is an arbitrary percentage test of disability and will be an additional hurdle towards the incapacity benefit. As I understand it, if the DHSS decides to remove somebody's mobility allowance, that person will have to pass the 80 per cent. test if he is not to lose his SDA. The 80 per cent. test is modelled on the industrial injuries and war pension scheme, which at present operates a graded system of benefits. Your Lordships will note that it is a graded system. For industrial injuries that may be fair, as it means that nobody except those at the very bottom will lose out completely. However, as the noble Lord, Lord Ennals, so cogently said in his opening speech, there are many people totally incapable of being able to work who would fail the 60 per cent. test, let alone the 80 per cent. test, and there are many others who would pass the 100 per cent. test with case but are perfectly capable of working.
The fact is that the industrial injuries scale is inappropriate for assessing degrees of disability in people suffering from a diverse range and mixture of handicaps. It is not only inappropriate. but the doctors operating the industrial injuries scheme have little or no experience of dealing with 80 per cent. disability claims. I have worked out from the figures that I have read that the majority of their assessments average no more than 30 per cent. Here we are asking them to adjudge on something quite different, which is not industrial injuries and works on an 80 per cent. basis. We must remember that it is 80 per cent. It is not 79 per cent. or 794 per cent. It is 80 per cent. unless there is a cut-off.
Apart from the obvious drawbacks, the new system will discriminate among different groups of people on grounds of percentage loss of faculty. age at start of claim and existing entitlement and between deserving and undeserving disabilities. The major discrimination remains against those who for a variety of reasons have become disabled through illness or accident when in full-time further education, in training or when unemployed. They will lose out. With regard to the unemployed, the current high level of unemployment among young people means that many will be at risk even before they have had the opportunity to work and so to meet the first condition of sickness benefit, which is to he in employment. As for the proposed cut-off point, this ignores the growing trend towards early retirement and forced redundancy in middle age, and the severe hardships that would result in people not signing on—for work which is non-existent—and thus becoming incapable of work but being unable to pass the 80 per cent. test.
But apart from any other considerations, the 20-year cut-off is far too low, and the provisions and requirements of SDA could act as a disincentive to youngsters to stay on in full-time education, to enter a training scheme or to work beyond the age of 20. But equally the 20-year cut-off could act as a deterrent to employers. It is difficult enough as it is for the young disabled to get work, but if an employer knows that, if he takes on a young disabled person, within a very short time that person has to make up his mind whether or not he will continue in employment, that is 51 a great inducement for him not to bother giving employment to that person in the first place.
I am a trustee of the Countrywide Workshops Charitable Trust. Countrywide workshops markets exclusively products made by the blind and the disabled. I was reading through a draft letter which the trust was going to send out. This is what I read:
another aim is to encourage the young disabled, by example. By showing what can and is being achieved, I hope that they too will want to try and do something for themselves, and not just be discouraged by the very few job opportunities available to them in the present economic climate".When I read those words, an alarm bell rang in my head. 1 may be wrong—and if I am perhaps the noble Earl will tell me so when he replies on behalf of the Government—but as I read Clause 11, by encouraging the young disabled to stay on in full-time education beyond the age of 20, and/or encouraging them to learn a trade, and then encouraging them at least to try to find work, we may actually be doing them a disservice, because financially, regardless of their self-respect, it will now be in their best interests to give up and allow the state to look after them for the rest of their lives.
It has been and is being suggested in certain quarters that the Government have been sly and underhand in this Bill especially in respect of married and cohabiting women; that they have tried to give the impression of ending the patent discrimination in the old Bill, while perpetrating it in the new Bill under a heavy disguise. Let me say that we on these Benches do not believe this. The fact of the matter is that the Government have set itself certain parameters in respect of the amount of money they will spend on disability allowances and pensions. All they have done in this new Act is to try and devise an equitable scheme, which will not exceed the financial ceilings or targets they have set themselves. They have done this but I do not believe that they have done it equitably. The fact that the end result is a clause that has hardly anything to commend it. does not in our view warrant the charge of duplicity in the Government.
Because this clause is not equitable. we would urge the Government to withdraw Clause I 1 and substitute an enabling one. This would give them and the organisations representing the disabled breathing space in which to discuss methods of meeting the Government's financial guidelines in a way that would be most equitable to the greatest number of disabled people with the greatest need.
In conclusion, I should like to quote from St. Luke, Chapter 14, Verse 21:
Go out quickly into the streets and lanes of the city, and bring in hither the poor, and the maimed. and the halt, and the blind".To which we should add, if Clause 11 is allowed to stand part in subsequent stages. that their ages and national insurance contributions may be checked, so they may be given the 80 per cent. severe disablement test.
§ 5.52 p.m.
Lord Campbell of Croy
My Lords, I seek to take part in this debate in order to express concern about Clause 11. Therefore I shall address myself only to 52 Part II of the Bill and to the changes proposed for severely disabled people. In two of the principal changes, the Government's intentions seem admirable. What is worrying is the way in which they propose to carry out those intentions. Clause 11 introduces the severe disablement allowance replacing the non-contributory invalidity pension. This would have the effect of abolishing the household duties test for disabled housewives.
I of course welcome that proposed abolition. Indeed. it would be churlish of me not to do so, having been in print on the subject several times. I have reminded myself that it was three years ago, in writing the book commissioned for the International Year of Disabled People, that I was pointing out that the test was quite arbitrary: that many of the cases in which the individuals had been rejected were then successful on appeal; and that the test discouraged a housewife from trying to carry out her household duties and was therefore a disincentive to rehabilitation. Further, I was pointing out that the national insurance advisory committee had, in the previous year, 1980, recommended abandoning the test.
Last December, the announcement came that the Government had decided to abandon the household duties test. However, at the same time the Government published their internal review and this Bill. Apparently no time was given for consultations with the organisations specialising in different forms of disablement before the Bill was published. That is what the organisations have been telling me and no doubt others in your Lordships' House.
There was no doubt contact between the Government departments and individuals or some of these organisations but we do not know to what extent. They certainly feel that they did not have the consultations which they would have expected before the Bill appeared in print. I suggest that one year less spent on the review and one year more on consultations would have produced more workable results. I concede that this is a very complex subject. It is not easy to construct an alternative system of tests, which will apply fairly to different categories, for example. to disabled housewives, and to different forms of handicap. I submit that because it is complex the Government should not have deprived themselves of the opportunity to obtain good advice in consultations with organisations who specialise in these matters.
In my opinion, the second matter on which the Government are to be commended on their good intentions is that they are attempting to identify severely disabled people who need special help. Again it is the way in which it is proposed to carry out that intention that does not, regrettably. stand up to close inspection. For some time. several of those who are prominent, both in Parliament and outside Parliament. in taking leading parts in this field, have been seeking a definition of such a category of severely disabled persons. After all, those are the disabled persons upon whom we should be concentrating our attention.
For years there has been a percentage system for classification of war disabled and those who have been disabled by industrial injury. Then the Amelia Harris survey, in the four years from 1967 to 1971. 53 introduced categories of their own when they were carrying out the sampling of all kinds of disablement. That was really the first attempt to place severely disabled people in a category.
The Government are now in this Bill proposing that the category should be 80 per cent. and above, as assessed in the war and industrial injuries examinations. That form of assessment cannot of course be simply and directly applied in other cases for several reasons. First, the medical tests in war and industrial injuries cases do not deal with sufferers from, for example, cerebral palsy or multiple sclerosis. Nor do they deal with any congential impairments such as being deaf and dumb. Hitherto, these tests have dealt with war injuries and industrial injuries and with the effects of military service and the effects of conditions of work.
Another consideration is that the capacity to do a job is not directly related to the percentage of disablement. Someone who is 50 per cent. disabled may be quite incapable of carrying out any job for which he is suited. We all know of cases of people with very high percentages of disablement, by the scales to which I have been referring for war or industrial injuries, who are able to carry out certain jobs successfully.
Another point is that the war disability percentage classification system has not had to consider whether the person is successfully doing a job or not—and rightly so, for the purposes of that kind of examination. Accordingly, considerable extension and adaptation of the existing percentage system will be necessary. I regard these proposals in the Bill as still at a rudimentary stage. I urge the Government to import flexibility into Clause 11. I understand most readily—and applaud what the Government are doing—that having taken the decision at the end of last year, they wanted to proceed immediately and not to lose any more time. Moreover, this Bill was there and was a suitable vehicle for the purpose.
In my view, however, that will be proved to have been shortsighted. It would have been better to have obtained some general agreement on the changes among the organisations representing severely disabled people. What can be done now? We could leave more to be worked out in consultations and brought forward later to Parliament, perhaps in subordinate legislation. I know that this is an unsatisfactory way of proceeding because orders cannot be amended and have to be approved or rejected. However, there are arrangements now in Clause 11 for regulations to be made by Ministers that will no doubt have to come before Parliament later in some form.
Perhaps I may summarise. In my opinion the Government deserve praise for tackling these problems, for deciding to make changes that have been generally advocated as needed. Some of us are worried, however, that a new system is being proposed in the Bill that has not yet been fully thought out and which may simply replace the present system with a fresh set of anomalies.
§ 6.1 p.m.
§ Lord Prys-Davies
My Lords, I wish to apologise to the Minister for the fact that I was not in the House 54 when he introduced the debate. I was caught up in traffic difficulties on my way to the House. The Bill consists of 29 clauses and eight schedules: but, as noble Lords have mentioned time after time, it lacks a single theme. I propose to address myself to two or, if I have time, three clauses, Clauses 1, 5 and 11. I appreciate that the ground has been well covered, and I shall do my best not to repeat arguments already advanced.
It seems to me that when a Government are introducing substantial changes to the NHS we would do well to judge those changes by reference to the principles involved in the basic legislation. The founder of the NHS—or, rather, his vision— encompassed a number of principles. Two of them are very relevant to a discussion of Clause 1. Bevan always advocated that there should be adequate training compatible with responsibility; and that a financial barrier should not be placed between a patient and the skilled services that are available to him. Clause 1 is in breach of the first principle to which I have referred because it will permit non-trained. unqualified persons to be engaged in dispensing spectacles to adults.
Under present regulations, I understand that the course of study lasts for a minumum of two years, together with another year of practical training. Last year, 313 students began this course of study. It seems to me that the Bill devalues professional training. Many of us are worried about how the changes will affect, particularly, the provision of services in rural areas. If non-opticians are allowed to sell spectacles, will this not affect the validity of the smaller opticians in rural areas? If that were to happen. it could lead to a reduction in eye-testing facilities available locally. It may be that the Minister can tell us something about how the Bill will affect the rural areas.
We appreciate that unqualified persons are not to supply spectacles without prescription, and that they are not to supply spectacles to children. But how are these prohibitions to be enforced? The non-qualified optician will not be a member of a professional body, so the professional body cannot take disciplinary proceedings against him. I have searched the provisions of the Bill, but I see no reference whatever to a penalty that can be imposed if the non-optician is in breach of these two important prohibitions.
Clause 2, in the case of many people—I accept not in the case of everyone, but in the case of many—will also be in breach of Bevan's second principle, that there should be no financial barrier placed between the patient and skilled services. I, for my part. accept that the average price of the simplest glasses in the private sector will probably be reduced. That is the Government's hope. Even a Government are allowed to have hopes. But it is almost certain that they will not be cheaper than NHS glasses.
There is considerable evidence—indeed overwhelming, evidence—received not just from the opticians but from voluntary organisations with a special interest in this field, that the price of complicated glasses will increase. We have heard time after time this afternoon that, as a group, old-age pensioners will be the largest single category to be adversely affected by the provisions of Clause 1. Just over a quarter of all elderly people have a visual impairment of some sort. That figure gives us an 55 indication of the size of the problem. Often, they need stronger and more complicated lenses. and they will need to change the lenses more often.
There are many elderly people with small occupational pensions and little or no capital, and who do not qualify for supplementary benefit, who can ill-afford to buy glasses in the private sector or to change their glasses as often as they should. We should not be complacent. Many will be vulnerable. That is the considered opinion of Age Concern. If the Government insist on denying NHS glasses to elderly persons generally, then we ask that they should widen the exemption category.
I wish now to deal with Clause 5. The primary health care services have been described as the linchpin of the NHS. The thinking on which the relevant parts of the 1974 legislation were based was that the process of co-operation between the general practitioner services and the hospital services would be speeded up when the general practitioners, clinicians, nurses and others were side by side in the same authority, and when that same authority builds the health centres, runs the ambulances and employs the nurses, clinicians and others. If there was one theme running through the 1974 Act—a theme that was reinforced time after time by the department and by Ministers—that theme was integration. It was agreed that what was required was one decision-making authority to cover the whole field of health care in every district. and with one budget. By Section 5 of the 1974 Act the family practitioner services were brought within the unified local administration, although retaining a degree of independence.
However, we are now asked to assume—I underline the assumption—that the co-operation intended by the 1974 Act has been less than was hoped for because of the degree of unification introduced by Section 5 of the 1974 Act. Is there any firm evidence that because of the 1974 reorganisation purpose-built health centres. the quality of doctors' waiting rooms and the general practitioner services generally have had to compete unfavourably with the tasks and demands that have assailed the local health administrations? Is there any direct evidence, valued evidence, that the structures in the districts created in 1974 have made it more difficult for clinicians, GPs and others to give a higher standard of care to patients? I have come across no such evidence. And even if the evidence were to show that the building up of primary health care facilities has not been as successful as was hoped for, that may he because the 1974 reorganisation itself was far less than integration.
We appreciate that the general medical practitioners fully support the proposals in Clause 2 of the Bill. I value very much the contribution of the family practitioners. and obviously one values their judgment in this connection. But I suggest that the only reliable inference which the Government should seek to draw from that support is that there has been difficulty in planning and monitoring the service in the districts in a way that retains the confidence of the general practitioners and general administrators. That is why earlier on my noble friend referred to the general practitioners welcoming this proposal because it was a boost to their morale. So the evidence perhaps draws 56 attention to a difficulty inherent in the task of building up community services and to the fact that hitherto that difficulty has been underestimated.
I understand that the Minister referred to the Government's intention to produce a Green Paper on the primary services. I hope very much that it will address itself to those questions. to those difficulties, and how we can overcome those difficulties. Certainly the evidence cannot be used to provide a case for setting up general practitioner authorities independent of the district health authorities. The total separation of these services could lead to a more fragmented service. I did not hear the Minister's opening speech, but in the other place we heard very little—indeed, we heard nothing—from the Ministers about the risks of fragmentation of the service. We on these Benches consider that integration has considerable potential and that we should strive to make it work.
I turn now to the severe disablement allowance. It is a matter of considerable regret and disappointment that the Government did not consult with the main disablement organisations before rushing into legislation. Time after time this afternoon bodies have been named. They contain men and women with first-hand knowledge of the needs of the disabled. They know better than Government to what extent statutory measures designed to meet the needs of the disabled succeed or fail or are likely to succeed or fail.
These are the organisations which are respected for their vigorous examination of proposals, policies and actions intended to meet the requirements of the disabled, and they all challenge the concept of the severe disablement benefit which is embodied in this Bill. Again, I know of no disablement organisation which supports the proposal. Is not this in itself evidence that the Government have not got it right and even at this late stage should think again? However, if they are sticking to the line which they have adopted. then we are sure that the validity of this provision will be tested in the European courts.
§ 6.15 p.m.
§ Lord Mottistone
My Lords, I thought the noble Lord. Lord Molloy, expressed surprise that the Conservatives had been converted to the National Health Service. I put it to him that it can be the other way about. I admired the National Health Service from the word "Go" because I was a very poorly-paid naval officer with a large family which had to grow up and the National Health Service was absolutely vital. However, because of the performance and policies of the Labour Party, not least in not paying me very much when they were in power and I was in the Navy, I found myself converted to the Conservatives. So your Lordships can take it that it is the other way round—a national health supporter has been converted to the Conservatives rather than the way round the noble Lord put it.
I must apologise to all three noble Lords on the Front Bench and to the noble Lord, Lord Rugby, for having been otherwise detained at the beginning of this debate and arriving in time only for the last one-third or so of the speech of the noble Lord, Lord Rugby. I am sorry that that should be so. Having missed the opening speech of my noble friend the Minister, I find it difficult to contribute to those sections of the Bill on 57 which I have heard consistently "anti" speeches without having heard his undoubtedly very clever "pro" speech, which I look forward to reading.
I propose to concentrate on the section relating to spectacles, where I in part support the Government. For example. I trust that the Government will stick to their position. in particular with regard to the need for up-to-date prescriptions based on a free eye test. I would hope that during the passage of the Bill the House will be able to persuade the Government that they should retain qualified dispensing.
I believe that the structure of the present optical service stems from the wish in the 1950s, 1960s and, indeed, the 1970s to create and strengthen professional bodies. This led to a country-wide acceptance that only a qualified person could do a whole range of activities, in many of which long experience is often of as much value as high qualifications, if not more. I think it is possible that as a result the optical service is more specialised than it need be.
However, we now have the present system and all the opticians I know and who have served me, as it were, are thoroughly dedicated to a first-class professional performance; they are to be congratulated for that. Any moves to change the system we have got now must be made with great caution so as not to destroy what is good in that present system.
As I see it, the changes the Government are proposing are that there will be cheaper glasses for some people and that will he offset by more expensive glasses for others. Nobody quite seems to know who is going to benefit and who is not, but clearly some will not. There is also a question of greater risk to some people, and my noble friend Lord Suffield gave some good and interesting details on important points in this connection. Perhaps that will be offset by the availability of cheaper spare glasses for others, but in many cases with poorer visual performance, especially if they are dispensed by an amateur.
As I seem to have a bit of time, perhaps I may explain briefly my own experience with spectacles, which brings out several of these points. I have had spectacles like this since I was in the mid-40s, because I was a naval officer and had to have perfect eyesight to begin with. To that extent I am exactly the same as my noble friend Lord Orr-Ewing and, as he said, about half the population. These specs are the most suitable because they give one a wide rim for reading. However, there was a happy occasion when my right honourable friend the Prime Minister was made the leader of the Conservative Party. I attended a meeting in this House and had to sit at the back of the room. To my horror, I could not see clearly who was my new, splendid leader, because my eyesight was not good enough.
§ Lord Mottistone
My Lords, I cannot tell your Lordships how much I admire my right honourable leader and how much benefit bifocal spectacles have been to me. I went to the optician and he said that I needed bifocals and he gave them to me. I then found that I was able to see noble Lords opposite more clearly, too. However, your Lordships will notice that 58 I am not wearing them at the moment because the trouble with bifocal specs is that one cannot read quite so readily because they have such a small reading lens. In any event I think that I know most noble Lords opposite quite well enough without having to look too closely at them.
However, this aspect has a more serious connotation. I am talking of seven or eight years ago when I acquired these specs. I have only had to have one other pair in the interim. Initially, I used them hardly at all. But I then found that I needed them for watching television. I found that they were absolutely ideal and they still are ideal. I am using the same pair as I had about four years ago. I then found—and this is really important—that these spectacles, which fit me perfectly because they have been properly dispensed, are also the ones that I have to use for driving. When driving down to the Isle of Wight from here on the motorway without wearing spectacles and certainly not having had a drink, I found that I tended to go to sleep. That was very dangerous. It alarmed my wife; it sometimes alarmed other motorists and it certainly alarmed me. It then occurred to me that if I needed bifocals for watching television. I would do well to wear them while driving. Since I have adopted that habit within the past six months, I have never felt sleepy at all. I believe that it is very important not only to have absolutely the right glasses. but also glasses that fit properly.
I suspect that if people are allowed to buy their specs over the counter—even within the Government's present rules—there is a very serious risk that only lip service will be paid to the need for recent prescriptions and the need for accurate dispensing. My noble friend Lord Orr-Ewing described how he was sometimes in a hurry to get a pair of specs and he said that it took a long time to get them if one used the other method. I am not saying that my noble friend would do this, but I can see that there would be certain people who would bully the shop assistant—who would not be a qualified person and who therefore could not produce a qualified answer—and would say, "Come on, give me these specs. They look all right". The shop assistant would ask for the prescription and the customer would produce one which was way out of date, and would say that it was all right and he would go off with his specs. That type of thing is much more of a risk to the rest of us—quite apart from the people concerned, who may be bad drivers—than the type of risks about which I heard the noble Lord, Lord Rugby, talking at the end of his speech. So I honestly think that the Government ought to take another look at the business of dispensing. It really is the most important aspect.
The other aspect that must be borne in mind is that of cost. A lot of people say that they can get their specs cheaper. As I understand it, the simplest type of National Health specs now cost £1055. No doubt bifocals cost a good deal more. Of course they will cost even more again because under the new rules they will go up by, for example, another £5, or 50 per cent. or something like that. If we are talking around the £10 or even £20 mark, we are talking about spectacles which cost between one and a half and two and a half bottles of whisky. If you are a normal chap like me and like my noble friend Lord Orr-Ewing, who only has to have new specs every three or four years, you are 59 talking—whatever the system may be—about the cost of, say, a couple of bottles of whisky every three years. If you cannot give up drinking for about three days in Lent in order to spare that amount, then surely we are getting the whole matter right out of proportion as regards all the arguments about added costs or not, as the case may be.
Even if one has a complicated pair of specs like those of my noble friend Lord Suffield, which probably cost nearer 100, we can also judge them in terms of bottles of whisky. It is the equivalent of, for example, 16 bottles of whisky spread over two or three years. Really, it is nothing. I chose whisky because that is my favourite luxury. Other noble Lords can choose other luxuries. We must get the cost aspect into perspective. We must ask the Government again to think very seriously about this dispensing business. I shall be right behind anybody who puts down an amendment on that matter.
§ 6.26 p.m.
My Lords, I do not often oppose the noble Lord. Lord Mottistone, but today I am afraid that I am going to oppose him completely because I support the case made out by the noble Lord. Lord Rugby, and the noble Lord, Lord Orr-Ewing. I am a little distressed to see that the noble Baroness, whose name appears on the list of speakers to reply for the Opposition. is not in the Chamber at the moment. She was not present when either the noble Lord. Lord Rugby, or the noble Lord, Lord Orr-Ewing, spoke, so she will not know the strength of the case which those two noble Lords put across.
I am speaking in my capacity as chairman of a repeals group which we formed some two or three years ago to look at legislation which we thought might well he repealed. One of the earliest matters we looked at was Sections 21 and 25 of the Opticians Act. We came to the conclusion that the whole of those two sections ought to be repealed. We helped the noble Lord, Lord Rugby, produce his Bill, which he was invited to withdraw and which he did withdraw because the Government had decided to send the case to the Office of Fair Trading.
We waited a very long time for the report of the Office of Fair Trading. When it eventually came out we still did not know for quite a long time what the Government were going to do. Meanwhile, we decided in our group to hold a ballot. We balloted the 654 United Kingdom members of the Ophthalmological Society. We received 357 replies—equivalent to 55 per cent.—which was not too bad. We asked them a question:Should the present statutory monopoly for opticians (or doctors) to sell simple reading spectacles be repealed?Of the replies. 189 said "Yes"; 145 said "No"; and 23 could not make up their minds.
When we sent out that ballot paper we asked the people whom we were balloting to make their comments. We received a lot of very interesting comments. Let me first give your Lordships a selection of the comments made by those who were against repeal. The most important point that was made concerned the importance of the early detection of 60 glaucoma. I think that about 50 per cent. of those against repeal made that point. They also referred to the importance of the prescription and the skill of the profession and they also—and this point was made by the noble Lord, Lord Ennals—referred to the fact that different lenses are often required for each eye. But many of those people stated that prices in any event were too high.
Then those who were for repeal said that the present system was far too expensive and that exorbitant profits were being made; they said that there were many charlatans in the business and that false confidence can often be given because opticians often fail to detect glaucoma. They then continued:Prior to 1958 [we] came across no cases harmed by over counter sales".At the end some of them suggested: why not, have a health warning similar to the one on packets of cigarettes?
So I believe that there is a case for relaxing the monopoly on the provision of reading glasses. I do not want to contest what the noble Lord, Lord Mottistone, said about his experiences, but I also wear bifocals. I believe that they are only for presbyopia, which is a natural condition which affects all of us at a certain age. I found that I was unable to get my bifocals on the National Health Service. Whether that was someone telling me a wrong story I do not not know, but they cost me quite a lot of money. The result is that I do not have my eyes tested every two years; I think that the last time I went was about four years ago, and I believe that my present glasses are perfectly satisfactory.
I conclude by telling the Minister that some of us are likely to put down amendments to Clause 1 to try to relax the restrictions which are at present contained in it.
§ 6.32 p.m.
§ Lord Beaumont of Whitley
My Lords, it has been said that this is three or four Bills in one. Judging from the debate, it is certainly two very separate Bills on two separate subjects and I wish to move the debate slightly away from the optical side, about which we have been hearing in the last few speeches, from the side which can possibly be dealt with by, according to the noble Lord, Lord Mottistone, the non-consumption of a bottle of whisky in three days or the non-consumption of 16 bottles over two years, which seems to me to be a much smaller rate of consumption—I suspect that if he grossed it up he would find it was rather different. I want to deal with the other part of the Bill, which moves to a very different world indeed, a world where there are no luxuries and not even the ability to go out for an evening to a pub among the kind of families about whom we are talking.
Some of the provisions in the clause dealing with social security are unacceptable. Tonight I want to speak as an officer of Church Action on Poverty, a body which is composed of concerned people in all the Christian Churches in this country. I want to make just a few remarks on Clause 8. Clause 8 deals with the final phasing-out of the child dependency additions. At present these are only 15p and, according to the Government. affect only "about 212.000 children", 61 and in saying that I would point out that I quote from the proceedings in another place. However, 212,000 children is a great many children, and that number is arrived at by the application of the means test, which, as my noble friend Lord Banks has said, is a breach of the insurance principle, for otherwise the number would be higher. But 200,000 children are worth talking about, and that is what I shall talk about this evening.
There is fairly wide agreement among a large number of people that these particular payments should be phased out. Certainly the party of which I am a member, as my noble friend Lord Banks has said, agrees with that. Church Action on Poverty is not particularly concerned with that problem. What it is concerned with is the result—that poor families will suffer. This appears to be what will happen. No one is against administrative tidying; the trouble is that in the adjustments of the living standards of the already deprived, it always appears to be rounding down which occurs and never rounding up.
The agreed principle is that child benefit should replace CDAs. That is fair enough. But in effect at the end of these adjustments children will be at least 1.70 worse off than they would have been if the old scheme had continued from the very beginning, and some of the spokesmen in another place put it slightly higher than that. The Social Security Advisory Committee, which has already been quoted in this context, in its first annual report said of this scheme:
the objective is a sound one only if there is no loss of income in real terms to families dependent on the scheme".There is such a definite loss. Our very real concern about this is heightened by the Government's approach to the whole problem. In Standing Committee A in another place on 6th March 1984 at col. 442, the Under-Secretary of State for Health and Social Security said:
It has never been the perceived view in this country that it is the state's business, even for those on supplementary benefit, to expect to meet from state benefits or through taxation the full costs of bringing up children".I find that a most extraordinary statement. If people are unemployed and have no financial resources—and these are the people about whom we are talking—where else will the money come from to bring up those children? This is a specific quotation on which I would ask the Minister who replies to this debate to comment. I have not given warning of it; frankly, I do not think I need to have given warning of it. It is a general proposition and one which has been put forward by a Minister of the present Government. I think it either needs to be reinforced, in which case it opens an even greater debate on poverty than society is having already, or it needs to be withdrawn.
Of course the state must support the families which find themselves in this position. That is certainly our view, and one which surely must have universal backing. We are not just talking about the 15p; we are not just talking about the technicalities of moving from one system to another; we are talking about real poverty, real misery and, in the course of the technicalities to which we are driven in discussing this Bill, let us not forget that.
I now quote from an article published in the Methodist Division of Social Responsibility News 62 Supplement headed "Focus on Poverty". It is an article by Bob Holman, who is in fact a social worker for the Church of England Children's Society. Before he became a communtiy worker, he was Professor of Social Administration at the University of Bath. He says:What are the main effects of poverty on children? There are five main ones. 1. Some children in poor families are now in serious physical want …2. More generally, the children are enduring a climate of family anxiety. 3. The children face the contrast of their emptiness amidst the plenty of others. 4. "—and this is the only one where I shall quote from the expansion on the sentence—
Poverty means that children suffer adverse parental treatment.I think it is a point worth making that poor parents are no worse than other parents but they have a very great deal more to put up with, and research has shownthat the strains of social deprivations force parents unwillingly to adopt child rearing practices which inhibit the social, emotional and intellectual growth of their youngsters.Finally:the nearly 100,000 children in public care are disproportionately drawn from the families of the poor.They are the very families which are going to be hit by the changes which have been made, and are now being completed by the changeover in this Bill, and by this clause of this Bill.
We believe that this matter of the responsibility of the state for the poverty of children and families, which was repudiated by the Under-Secretary in that Committee stage in another place, must be covered. Indeed, if we cannot have a pledge that the money will be made up one way or another—presumably through child benefits, if we are going to go on with this particular reform—we hope that noble Lords will oppose, or seek to amend, this clause when it comes to Committee stage.
§ 6.42 p.m.
§ Lord Colwyn
My Lords, I must apologise for missing some of the opening speeches of our debate this afternoon, particularly to my noble friend the Minister and noble Lords on the Front Benches opposite. However, I think it is unlikely that anything that I am going to say will have been said before. As a practising dentist who spent 15 years working within the National Health Service, I strongly support the Government's plan in this Bill to give family practitioner committees responsibility for their own administrative arrangements. Those practitioners working within the family practitioner services are independent, and it seems to me wholly appropriate that there should be health authorities specifically for this sector of the health service where such a different approach to planning and management is needed.
Having said that, health services need to be planned as a whole. This is true of my own field, dentistry. Health service administrators and planners are not always popular people, but in dentistry we simply have not had enough planning, not enough thinking about what is needed and how we can best achieve it, taking the dental services as a whole. With this in mind, I also welcome the new DHSS working group report on planning collaboration between FPCs and DHAs, especially the emphasis it gives to dental planning.
63 It may be asked: what do we need to plan in dentistry? The answer is: all the usual things—services for children, for the elderly, for handicapped people and for people who are housebound: but for everyone else as well including the parents of the children and the children of the elderly. They need National Health Service dental services, too.
Let me concentrate on just one aspect of dental planning which matters for all patient groups. This is the location of dental practices. In general dental practice, unlike general medical practice, there are no central controls on practice location, so general dental practitioners, as I did, have to work out themselves where their services are likely to be needed. This is a sound policy for a profession of independent contractors, but it is becoming more difficult to identify the areas of need as we train more dentists and as more areas have dental services at an adequate level. We need help, and this help is going to have to come from the FPCs and DHAs researching local needs and making the information available to dentists so that the can make more soundly-based decisions on practice location and development.
So then I look at the composition of FPCs, shown in Schedule 3 to this Bill, and ask myself whether these new FPCs are really likely to take this sort of problem seriously. I have to say that I am doubtful, because out of 30 members and 15 contractor members. only three will be dentists. My noble friend the Minister will say that this is the composition now and that it has worked well, but I would disagree and say that it has produced committees which generally have not taken much interest in broader dental issues. They will keep the names of dentists on a list; they will investigate any complaint made about any aspect of treatment; they will ensure that superannuation contributions are paid: but in many areas that is as far as it goes. What I am saying is that I believe dentists are underrepresented on FPCs. They always were: but it matters more now that the FPCs are being asked to broaden and develop their planning activities. FPCs are going to be developing new working methodssub-committees, or whatever—to carry out their new functions, and the dental members are going to have to be involved. If they are not, essential dental matters will not receive the attention they need. The present three dental members are going to have their work cut out.
But there is a particular problem for dental practitioners serving on NHS committees of this sort, which normally meet during the day. Dentists working within the NHS are paid for the items of work they do. To take time off to attend a committee meeting could cause serious financial problems. The income stops, but daily practice overheads still have to be paid for at an average rate of something like £100 a day. So taking part in expanded FPC work is going to be a real problem for most of the dental members.
This problem could be considerably eased by a simple proposal which I hope my noble friend the Minister will consider sympathetically. I suggest that an additional sub-paragraph should be inserted in Schedule 3. paragraph 12. after sub-paragraph (6), to the effect that there should be one deputy dental member of the FPC so that the load can be spread and 64 to improve the chance of a dental voice being heard at all appropriate times in an FPC's deliberations. I hope that this will be seen as a relatively uncontroversial measure in the face of a real problem. It is not an ideal solution, as I believe that dentistry is badly underrepresented with only three dental members.
In Gloucestershire, where I used to practise within the NHS. there are 60 per cent. more doctors on the FPC list than dentists. Yet the medical profession has eight members on the FPC and my own profession only three. Ultimately I am sure that there will have to be changes in the numbers balance between the professions in Schedule 3. I am not proposing this at the present time. but I hope that the Minister will give serious consideration to my suggestion, and perhaps even give me an encouraging answer this evening. If he is unable to help at this stage. I shall feel under an obligation to my profession to come back with a suitable amendment at Committee stage.
§ 6.48 p.m.
§ Lord Pitt of Hampstead
My Lords, one of the advantages of speaking late is that much that you would want to say has been said before, and you can scratch out a lot of your notes. I am in that happy position. However, I want to comment on the Bill on two sections in Part I and perhaps for a little longer on Part II. All the sections I shall comment on have been commented on by other people.
There are two serious aspects of the section dealing with ophthalmic services which are to be deplored. The abolition of the availability of National Health Service spectacles for the vast majority of the population is regrettable. As has been said before, it will cause hardship. particularly to the elderly, but it will also cause hardship to the poorer sections of the community. In the case of the removal of the control over the sale of spectacles. this could have unpleasant results. In my view, the results may be felt most in the poorer sections of the community.
The Minister waxed eloquent about the free market. I am afraid that I do not share his enthusiasm. There are many unpleasant consequences that can flow from the free market. In fact I agree with the opinion of the noble Lord. Lord Trefgarne, his colleague. which was quoted by the noble Lord, Lord Banks. earlier. I hope the Minister and the House will pay great attention to the speech that was made by the noble Lord, Lord Suffield from across the way. It is all very well to be willing to have a free market in the sale of spectacles but there is need for some control and there is a need to maintain standards.
I am sorry that the noble Lord, Lord Orr-Ewing. is not in his place. I was a little surprised at his outburst. When all is said and done, he is accustomed to organisations. Most organisations delegate powers to their specialist committees. And, in effect, when a decision has been made on principle, it is normal for the committee to deal with it or it can be dealt with at a lower level by a sub-committee or by the officers of the committee. I cannot see that there was any need for the song and dance about whether the whole of the Ophthalmic Services Committee of the BMA had met before this letter was written.
I hope that during the Committee Stage we shall improve Clause 1. Unlike my noble friend to my left. 65 I welcome the independence of family practitioner committees. I strongly endorse the views of the BMA which were read out to the House earlier. Primary health care is the most cost effective sector of the National Health Service. Its expansion would benefit patients by increasing the range and accessibility of services and also reduce overall costs of the National Health Service. Until FPC administrators have the same standing as district health authority administrators and the funding of the family practitioner services is separated from the health authority budgets, effective planning is not possible.
The development of the primary care sector requires the establishment of an independent administrator wholly committed to its growth. The FPCs as now established can do this. With their newly acquired status they will have an equal standing in their dealings with health and local authorities, with which they will be able to make at first hand the case for important developments in community care.
The DHAs, as has been said earlier, are, quite rightly, heavily influenced by the hospital sector, because it accounts for the great bulk of their expenditure. As a consequence, it is not as easy as it ought to be for the expansion of the primary care service to take place. It is all very well to talk about integration, but it is wrong to try to integrate services by making one subordinate to the others. The new FPCs will be able to present the case for family practitioner services both within the National Health Service and outside it. 1 think that that is of the utmost importance. As I see it. only the Secretary of State can stand in the way of the needed expansion and improvement of primary care. I really do hope that the Minister will recognise the importance of doing this particular job and give the primary sector the support it deserves.
I end up where I began, by pointing out that the primary care sector is the most cost effective sector of the National Health Service; that it can be expanded; that there can he a shift from hospital to community care, but it must be planned and it must have the necessary resources. If that is done, quite a lot of benefit can flow to the service.
I welcome the proposed Green Paper. I hope it will lead not only to some worthwile discussions but to worthwhile action. I hope that the Government are not merely putting out another Green Paper in order to be able to fob us off with some platitudes.
I turn to Clause 11. I am worried about this clause and speak about it today as a practising GP. Like many other noble Lords, I have received innumerable representations against this clause. At first I did not grasp it as fully as I should but when I subsequently had it explained to me by one of my colleagues who understood it better, I began to share the concern. I understand that it is the need to withdraw subsection (2) of Section 36 of the 1975 Act which made this clause necessary. I believe that we must look at what we are going to lose. The non-contributory invalidity pension has proved a valuable benefit to everyone else except married women and those who have stayed at home to look after their families. I have seen no criticism of its major role in supporting them to justify our submitting them all—because we are doing that 66 Vol. 452now—married and unmarried alike, to an additional test which, frankly, has only one purpose—that is, to exclude certain people; people who do not reach this arbitrary 80 per cent. disablement on a specific schedule which, in fact, is more concerned with industrial injuries than with sickness.
I find myself unable to explain this 80 per cent. severe disablement allowance to myself. I find it difficult to explain to myself. Because I cannot explain it to myself I shall not be able to explain it to my patients. I shall have to tell them, for example, that if, when they produce my statment on their incapacity to work to their local DHSS, it is found that their contribution record is insufficient for an invalidity pension. they will have to have another examination which I believe is to be done by two doctors from the DHSS. I shall tell them that they will then have to answer a lot of questions and be medically examined to establish levels of amputation, blindness, deafness, severe disfigurement, none of which happen to be the likely cause of their incapacity because most of the people I deal with come from civilian life.
Another problem I have is that, whether they are qualified by having 80 per cent. disablement or not, they are unable to work. I am satisfied about that—that is why I gave them a certificate in the first instance. Yet I must tell them that the fact that I have given this certificate is perhaps only a way of starting the process; that it is not going to enable them to get the benefit; that they have to have this additional examination—and have to have it with the likelihood that a large percentage of them will fail it.
I have to ask myself this. Do I tell them not to apply for the benefit?—because, in effect, by giving them that certificate, I may well be subjecting them to hardship, embarrassment and stress, which is not very good for them. These are the problems that I find as a doctor which concern me and about which, therefore, I am quite unhappy. What is more. I am not entirely sure that today it is true, as it may have been in the past, that the man goes out to work and the woman stays at home, runs the house and looks after the children. What is more true today is that both parents, the man and woman, the husband and wife, go out to work, and if they are an agreeable couple, in the sense that the man is willing to do his share of the work, both will do the housework. If he is a male chauvinist, then the woman will go to work and when she comes home she will do the housework.
The approach therefore needs to be changed. In effect, I think that the Government have changed it to some extent. For example, no longer do we have the lower-rate insurance. A married woman who is working now has to pay the full rate. As I see it, therefore, the numbers of people who are affected by the present household duties test will gradually diminish and, in fact, in the future, the number of people who do not have contributory pensions and therefore need the non-contributory pension, could be considerably less than today.
I hope that the requests which have been made earlier will be accepted by the Government. I believe that this is a clause that the Government need to look at again, that this is a clause about which the Government need to consult a little more. I hope that. 67 when we come to the Committee stage and we ask them to do so, they will agree.
§ 7.3 p.m.
§ Lord Cullen of Ashbourne
My Lords, noble Lords who have taken part in the debates on opticians for the last four or five years will, I am sure, share with me the feeling of relief that the end appears to be in sight. It has gone on for a very long time and, even though I do not agree with everything in this Bill, I am very glad that we have got to this point. There is no doubt that there are parts of the Bill about which opticians are not happy, about which doctors are not happy and about which many Members of another place were unhappy; and about which, from the debate this evening, it appears that many of your Lordships are unhappy. My own views have not changed substantially since the period when I had the honour of being the spokesman in your Lordships' House for the DHSS; that is to say, I fully support the Government in opposing the rather extreme view propounded by my noble friend Lord Orr-Ewing today and frequently propounded in the past by the noble Lord, Lord Rugby, to legalise the sale of ready-made spectacles.
I should like to make one or two comments about the speech of the noble Lord, Lord Rugby. He mentioned the composition of the General Opticial Council, and I think suggested that something like 18 out of the 22 were opticians. I do not have the figures with me. but I know that is incorrect and I look forward to my noble friend Lord Caithness correcting that, because I think it gives a false impression. I can also confirm that the Dollond and Aitchison Group are not represented on the General Optical Council and nor for that matter are even the Federation of Optical Corporate Bodies. So I think that one should clear that up.
The noble Lord also referred in his speech to the seven eye shops opened by a company which employed Peter Risdon, an out-of-work actor, as a frontman. What the noble Lord did not say is that on Monday last Peter Risdon was fined £100 and ordered to pay £500 costs. His activities are not only illegal now but would be so after the Bill if, in its present form. it were enacted. At the conclusion of the case, the noble Lord was reported in the Daily Telegraph as having said that,The decision was disappointing and meant that the price of a pair of reading glasses would remain at £80 or £90".That is misleading information. In fact, properly prescribed reading spectacles are now available (and for some considerable time have been available) at prices round £10 to £14; although anyone can pay more if they wish.
§ Lord Rugby
My Lords, would the noble Lord perhaps say what the delays are in being able to obtain reading glasses, which sometimes can be as much as three weeks so that people have had to buy private ones? They have been cajoled into buying private ones, at a figure of round about £80 or £90, simply because they cannot wait for that period of time.
§ Lord Cullen of Ashbourne
My Lords, I have no doubt that the situation varies from place to place and 68 from optician to optician. What the noble Lord is suggesting is that everybody has to wait three weeks for their glasses—and that is by no means true.
§ Lord Monson
My Lords, is the noble Lord, Lord Cullen, aware that at this very moment I am wearing a pair of Mr. Risdon's glasses which cost me £8.50; and that they are perfectly satisfactory in every way?
§ Lord Cullen of Ashbourne
My Lords, I am very glad to hear that the noble Lord is satisfied with his glasses, but I imagine that he is also concerned that others less educated than himself are not misled by people selling glasses who do not actually know what they are doing.
Perhaps I should again declare my present interest in the Bill as president of the Federation of Optical Corporate Bodies, as a result of which I have somewhat increased my knowledge over the last year or so. I appreciate that the Government no doubt take the view that they are steering a middle course between the extreme view personified by the noble Lord, Lord Rugby, on the one hand, and the views held by the optical profession. In fact, I think the Government have been very astute. In listening to the arguments today, they seem to get somebody to agree on one bit and somebody else to agree on another bit and one or two to disagree on other bits. However, I believe that the Government's proposals to allow unqualified persons to engage in ophthalmic dispensing is itself an extreme proposal put forward without any real justification; and I will come back to that later.
First. I should like to make it clear that, together with many other noble Lords. I fully support the Government's proposals to relax the present restrictions on advertising by opticians, so long as there is no advertising of the professional function of the testing of sight and provided that provision is made to ensure that advertisements of the prices of spectacles are not misleading to the public. For that reason I think it will be important that any price advertisement by opticians should indicate precisely what it refers to—whether it is only the frames, whether it is the frame and lenses and whether it includes any professional fees or charges. Subject to those important qualifications, I know that the federation are willing to accept price advertising in future—and the magnitude of this change and the effect that it will have on competition should not be underestimated.
Secondly, I am prepared to support the Government's proposed changes for the ending of the general provision of spectacles under the general ophthalmic service, subject to satisfactory safeguards to protect the visually disadvantaged. The Government have already hinted at some willingness to provide financial assistance to those requiring more complex lenses, and I hope and expect that we might have some more definite statement from Her Majesty's Government tonight.
The main reason why I am able to support the NHS changes. which I realise some members of the Opposition are concerned about, is that this will end the distortion of the optical market and do more than advertising or any other single measure to reduce the average price of private spectacles, which have in fact already been reducing since the Department of Health 69 and Social Security, after years of delay, increased NHS fees. It is often not appreciated sufficiently that approximately 80 per cent. of all lenses are supplied under the NHS at state-controlled prices and approximately 50 per cent. of all frames at cost price. What a loss leader!
I believe that the ending of the NHS provision will enable progressive opticians to provide the public with a better and wider range of budget priced spectacles at costs very comparable to those at present charged under the NHS service. No longer will private spectacle prices have to subsidise NHS work, as has been necessary in recent years, so private spectacle average prices will fall. Perhaps then criticisms of opticians will cease. Even the OFT supported the views of the two Price Commission reports that opticians had not been making excessive profits.
It is my conviction that, if Her Majesty's Government had limited their proposals to allowing opticians to advertise prices and to the changes in the general ophthalmic services, they could achieve both their main aims of increasing competition and achieving a reduction in prices, together with a wider choice of attractive budget priced frames and lenses for the public.
Regrettably, the Government have chosen to swallow completely the superficial arguments presented in chapter 9 of the report of the Office of Fair Trading. Accordingly. the Government are proposing in Clause 1(1) of the Bill to permit unqualified persons to dispense—provided that it is against a recent prescription issued, the Government say, in the previous two years—and those two years we shall have to look at in Committee.
I think it is objectionable that the Government had no proper consultations with the organisations representing dispensing opticians after the OFT report was published, although such consultations were not only requested from but promised by Ministers. Instead Ministers have preferred to rely upon the advice of the Office of Fair Tradng, which was concerned only with the competition issues and had no one on its team with any optical or medical qualifications.
Furthermore, it had been made clear, when the then Minister of State for Consumer Affairs, Mrs. Sally Oppenheim, announced the review, that the report was not expected to come to conclusions on matters affecting the public interest. I believe that the Government's proposal, based on the shaky foundations of the OFT report, to permit unqualified persons to dispense spectacles is very much a matter affecting the public interest.
It is not only dispensing opticians who are concerned about unqualified people being allowed to practise dispensing; ophthalmologists have expressed their concern as well. The chairman of the Ophthalmic Group Committee of the British Medical Association has said:While specific harm to the eyes is unlikely to arise from the use or non-use of spectacles, there is firm medical agreement that the correct and appropriate dispensing of spectacles has very significant health implications. The Committee cannot accept that after the prescription has been issued optical appliances take on the status of mere consumer durables and feel strongly that when highly skilled and expensive medical or surgical treatment has been provided 70 under the NHS the final rounding-off of such treatment with spectacles or an optical appliance must also be provided by skilled or qualified personnel".Her Majesty's Government wish to break what is known as the opticians' monopoly and I was very interested in the remarks made by the noble Lord, Lord Banks, who I thought analysed the situation extremely well. This monopoly consists of some 2,900 dispensing opticians and 6,200 ophthalmic opticians, all in competition with each other. It is therefore the case that no optician and no optical company has anything approaching a monopoly. What is so curious is that Her Majesty's Government happily follow the advice of the Office of Fair Trading to allow unqualified and unregistered people to dispense, despite the other suggestion of the Office of Fair Trading that motor mechanics and installers of double glazing should be qualified and registered.
One of the problems when debating these matters is that there are many people, including some noble Lords and, I am afraid, the present Government, who have largely misunderstood or failed to understand the function of a dispensing optician. Some people do not appreciate the difference between a prescription and a specification. Certainly the Government have shown little sign of understanding the difference. My honourable friend the Minister of Health seems to take the view that, since it is normal for prescriptions issued by an ophthalmologist or an ophthalmic optician to be sent to a prescription house where the spectacles are made up, then there should be no problem so long as they are made to British Standards. That sounds very plausible, but it is by no means the full story since it omits the essential stage of dispensing.
What actually happens—and the noble Baroness, Lady Robson, tried to explain this—is that the dispensing optician, after discussing someone's employment, way of life and hobbies, advises on the type of lens form and frame that will be suitable for his prescription. Careful measurements are taken to ensure that the lenses are properly centred and that the spectacles fit the patient's face. A great many more technicalities are involved in ophthalmic dispensing, but I think that this outline is sufficient for my purpose. The dispensing optician then adds all the dispensing details and measurements together with the prescription on the specification, and it is the specification or order which is forwarded to the prescription house or workshop. To send a prescription alone would be quite useless; and, of course, the optician has the final responsibility for the accuracy and fit of the spectacles.
While it may have been excusable for the OFT to fail to understand the importance of ophthalmic dispensing and the training and experience which are necessary, despite all the evidence which it was given on this subject, I find the same failure on the part of the DHSS quite extraordinary and inexcusable. I notice that quite a number of noble Lords are wearing spectacles, and if those wearing bifocals want to get the message about this business of careful dispensing they should move their spectacles just a little bit away from their eyes or a little bit sideways or up and down, and they will find that if they stay like that for a minute or two they will be feeling quite uncomfortable. That is perhaps the best way of getting this point over.
71 I believe that the Government, in their boundless enthusiasm for increasing competition, have made a serious mistake and if unqualified persons are allowed to dispense spectacles there could be grave consequences. In a recent letter. my honourable friend the Minister of Health has written that Her Majesty's Government rest their case on two irrefutable facts. The first is that wearing wrong spectacles does no permanent damage to the eyes. While I am not able to judge the weight of medical evidence in this regard, although I have heard it said very frequently, perhaps my noble friend Lord Glenarthur could let me have by letter the full medical evidence on which the Government rely in this regard. The second is that anybody who was supplied with the wrong spectacles would be aware that they were wrong. That is not true in the case of anybody who has had an eye operation, such as a cataract operation.
During the later stages of the Bill I shall urge your Lordships to leave out subsection (1) of Clause 1, unless I can persuade my noble friends on the Front Bench to reach a sensible compromise. What I urge them to do is to proceed as rapidly as they may wish with the removal of any unreasonable restriction on advertising by opticians and implement the general optical service changes, and then judge the effects on competition and prices of these two very major measures over a period of from 12 to 18 months. In the meantime, the proposal to allow unqualified persons to dispense should be withdrawn or put in cold storage. If. as I confidently expect, the prices of private spectacles continue to fall, there will be no need to incur the risk of a general fall in standards of ophthalmic dispensing by unqualified persons.
Finally, I should like to pose a few questions. With regard to enforcement, how do Her Majesty's Government propose to ensure that unqualified spectacle vendors observe any or all of the so-called conditions and safeguards to be laid down by Order in Council? How, for example, will the Government ensure that these unqualified persons do not in fact dispense, except to a recent prescription? How will they ensure that these unqualified persons will not be dispensing to children? Are they perhaps considering the appointment of an optical ombudsman? If the Government's reply is simply that they will be relying on the present law, that hardly seems likely to be adequate.
My second question to Her Majesty's Government is whether there is any other country within the EEC, with the possible exception of Denmark, which does not currently license or regulate ophthalmic dispensing? Thirdly. may I ask whether there is any country in the world which, having once established a system of regulation, has then proceeded to deregulate ophthalmic dispensing? Fourthly, how do the Government propose to enforce the application of British Standards by both registered opticians and unregistered spectacle vendors? Fifthly, I should like to ask Her Majesty's Government whether, in their opinion, permitting unqualified persons to dispense will in any way raise standards for ophthalmic dispensing? Sixthly, do Her Majesty's Government accept that standards of ophthalmic dispensing are a matter affecting the public interest? And I should also 72 like to ask why they should be prepared to envisage lower standards than we have at present? Finally, how do Her Majesty's Government intend to prevent the importation and sale of cheap spectacle frames from Taiwan and the Far East made of cellulose nitrate, which, as I am sure your Lordships will know, is highly inflammable.
Unless Her Majesty's Government can provide satisfactory answers to these questions and to the other concerns which I have expressed, at the Committee stage of the Bill I shall wish to propose certain amendments, including an amendment to require any order made under subsection (3)(a) to be made by Affirmative Resolution of each House of Parliament. However, I hope that this will not be necessary and that Her Majesty's Government will have second thoughts and will withdraw that particular subsection. The most important role which this House can play is, I believe, as a revising Chamber, and the very first subsection in the Bill is in serious need of revision.
§ 7.24 p.m.
§ Lord Kilmarnock
My Lords, we are reaching the end of an interesting but rather disjointed debate. I can understand that it is convenient to the Department of Health and Social Security to get its annual Bill. It might be more convenient for the rest of us, as the noble Baroness, Lady Robson of Kiddington, suggested, if in future we had separate Bills, for health and social services on the one hand and for social security on the other.
May I begin by congratulating the noble Earl. Lord Caithness. on his promotion and by congratulating also the rank and dignity of Earldom as a whole in achieving such prominence on the Government Front Bench, to which I am sure the latest noble Earl to join it will bring additional lustre.
I shall refer only briefly to Clause 1 of the Bill. to which a number of noble Lords have already devoted large parts or, in some cases, all of their speeches. I must say at once that in my view a no doubt praiseworthy zeal for the destruction of monopolies, with which I agree in principle and which is a cherished Liberal tenet, seems in this particularly sensitive field to be leading to unfortunate results for large numbers of our neediest citizens, unless of course the Bill is amended in order to protect them at the Committee stage. It cannot possibly be right that something like 3.2 million people, or 64 per cent. of those at present receiving support for the purchase of ophthalmic services, will lose that support under the Bill as at present drafted.
The object of breaking monopolies is normally to protect the consumer's interest against the producer's, and I accept that many people with uncomplicated prescriptions—the kind of people referred to by the noble Lord, Lord Orr-Ewing, the average user of reading spectacles—are likely to benefit under the Bill. But in this case the interest of some consumers is not the same as that of others, and I must state my special concern for those with complex prescriptions who, it seems, will be paying up to three times as much as they did before the removal of National Health Service support. This point was made by the noble Lord, Lord Prvs-Davies.
73 The noble Lord, Lord Glenarthur, spoke of the promotion of consumer interest in the Bill, but I have to tell him that the National Consumer Council do not agree with him. They speak of the need fora safety net for those consumers who have less common sight problems and who are unlikely to benefit from more competition because of the small size of the market for the lenses they need".A little later they say:We are particularly concerned about the effect that the removal of the NHS subsidy will have on people requiring special or complex lenses. There is unlikely to be much competition in the supply of such lenses because of the relatively small number of people involved and the individual nature of the lenses they require, so prices of complex lenses will rise when the NHS subsidy is removed".I find that to be a matter of deep concern.
Furthermore. the noble Lord, Lord Ennals, mentioned cataract operations. It is well known that cataract operations sometimes require as many as three changes of glasses in the 18 months after the operation. This could put an intolerable burden on elderly people at the lower end of the income scale and might indeed mean that they simply could not afford the aids which would assure them of reasonable vision, with a consequent huge decline in the quality of their lives and, indeed, a corresponding rise in the hazards they would be a prey to through diminished vision.
At Second Reading in another place on 20th December 1983 the Secretary of State said at col. 297 of Hansard:it has been argued that there are those with the very poorest sight who need complicated and more expensive lenses and I am certainly prepared to consider the evidence on that to see whether they can have continued access to NI-IS glasses".But by the time the Bill reached Report stage nothing had been done. A wider amendment to entitle all pensioners to purchase lenses and frames under the provisions of the general optical service was defeated, and I find nothing in the Bill as it stands to exempt even the partially sighted. The noble Lord, Lord Glenarthur. spoke briefly of the possibility of a controlled price for complex prescriptions. This was an area about which the noble Lord, Lord Cullen of Ashbourne, also showed concern. May I ask the noble Earl whether the Government will bring forward an amendment at the Committee stage on this point. Unless the Government can give us substantial assurances this evening, this is something which we shall have to take very seriously at the Committee stage. In this respect, the Bill cannot he allowed to go forward as it stands.
On the question of advertising, this is supported by the National Consumer Council. We are not against advertising, provided that there is proper quality control; but such control will not necessarily be maintained by the Government's very proper insistence upon qualified prescribing if there is little or no control over the quality of dispensing. This is something about which the noble Lord, Lord Mottistone, is worried.
Another worrying aspect of this Bill is that it appears to contain no safeguards against negligence resulting in damage or injury. What happens if someone driving a vehicle while wearing wrongly dispensed spectacles causes injury either to himself or to another person? I can find no provision in the Bill for such a contingency. The noble Lord, Lord Banks, offered a 74 rather telling quotation from the noble Lord, Lord Trefgarne, who, at an earlier stage in his ministerial life, was concerned that this might be a contributory cause to accidents.
I believe that I have said enough to indicate our grave disquiet over certain aspects of Clause 1 of the Bill and to warn the Minister of a hefty raft of amendments at Committee stage. I hope that when we come to that stage the Government will listen carefully to what we have to say and will show themselves to be somewhat less inflexible and opinionated than they have been on some recent occasions. Sight is a precious gift, and in the case of the elderly it is doubly so, for as the other faculties necessary for active physical participation in daily life decline, the capacity to participate in the world around by means of observation becomes a priceless asset. I trust that the Government will not seek to sacrifice that asset for the sake of getting their Bill through unamended, or virtually unamended. That would be an inexcusable exercise of political machismo.
I turn now to family practitioner committees, which are the subject of Clause 5. This is a subject we have debated on a number of occasions. I confess that I remain of the opinion expressed by the noble Baroness, Lady Robson. that it would have been preferable to bring the FPC services together with the hospital services under the umbrella of the DHA, as is the case in Scotland. I do not often disagree with the noble Lord, Lord Pitt, but I am afraid that I do in this particular respect, although I agree with him on the outstanding importance of primary care. It must be remembered that one of the main aims of the 1974 reorganisation was to create a more integrated National Health Service, and this clause is a long stride in the opposite direction. However, we have to be realistic and it seems unlikely that we shall succeed, at this late stage in the argument, in converting the Government to our point of view. In all probability, FPCs will achieve their independent status. Having accepted that, it becomes a matter of urgency to ask whether the Government have really thought the consequence through. I want to express my alarm in regard to a number of points and to ask the noble Earl some questions.
First, although the representatives of the medical committee, the local authorities, the dental committee, the pharmaceutical committee and the opticians are to remain the same in number, there are now to be seven free-wheeling appointments in the gift of the Secretary of State. The method of appointment of all members is to to be changed. In future, all members will be appointed by the Secretary of State from persons nominated by the various bodies rather than being directly appointed by those bodies themselves. Furthermore, the chairmen will no longer be elected by the members but will also be appointed by the Secretary of State. This means that local influence on the committees will be further diminished and the power of the Secretary of State will be further increased. I believe someone mentioned a patronage of 3,000 places. I wish to record our fundamental disagreement with this proposal and our intention to come forward with amendments on this score at Committee stage.
75 There are other points which give rise to disquiet. As the noble Earl will he better aware than anyone, the strategic plans of RHAs for the next few years envisage a significant shift of resources from the acute sector to community care. How will this be administered, and what pattern of primary care do the Government envisage after this further reconstruction of the service? Concern has been expressed in some quarters that this Bill will open the way for FPCs in the future to employ directly nurses, midwives, health visitors, community specialist nurses for the mentally ill and mentally handicapped, and perhaps other types of professions in the community health field. Is this what the Government intend to do? If so, there are two points to be made.
The first is that any reversal of the 1974 objective of greater integration would carry with it the danger of creating two overlapping spheres of responsibility and two rival bureaucracies. The second point concerns the role of the nursing profession. Nurses would want to see included in the Bill—quite naturally, in my opinion—a facility for nurse membership of FPCs as a distinct category similar to that which exists currently for health authorities. It would of course be possible for nurses to be appointed within the DHA quota in Schedule 2. Part II, paragraph 6(3)(h) or under 6(3)(g), within the seven nominations directly in the Secretary of State's gift. But neither category gives any guarantee of nurse representation, and unless the noble Earl can provide an assurance that such a provision will be made I shall have to return to this matter at Committee stage.
This brings me to the administrative aspect. Clause 5(3) on page 7 of the Bill would seem to pave the way for FPC chairmen to be paid on the present lines of payment to RHA and DHA chairmen. Is this the Government's intention? The responsibilities would not seem to be comparable. Also, will there be a special grade of FPC administrator? If the new system is to work, it will obviously need to attract people of real ability. Would the noble Earl not agree that such people are unlikely to be attracted unless there is a unified, administrative career structure for the whole of the National Health Service, and unless those in it are able to move between FPCs and other types of health authority? Would this not he essential to the preservation of some dialogue and mutual understanding between the two branches of the service? The Royal College of General Practitioners is strongly of the view that unless there is a unified career structure, whatever benefits the Government expect from the new structure will certainly be lost. May I have the noble Earl's comment on that?
On the financial side, can the Government cross their heart and say that they do not envisage a substantial increase in costs to follow the establishment of FPCs as health authorities in their own right, with powers to engage their own staff! Have they never heard of Parkinson's Law? Where is the money to be found, if not at the expense of other branches of the NHS? It is also relevant to ask: what are the recommendations on control of GP spending in the Binder Hamlyn report? The noble Lord, Lord Ennals, asked about this. Why does the report remain 76 unpublished? Does it contain some recommendations uncongenial to the Government? Or does it contain recommendations that might be uncongenial to the rest of us? Why all this secrecy? What it there to hide?
What about the Green Paper on primary care? The noble Baroness, Lady Robson, questioned the need for another Green Paper. If the Government decide that there is a need, is it sensible to introduce legislation in advance of consultation? The Government's record in this respect is rather bad. They have received a lot of flak tonight from all sides of the House. The noble Lord. Lord Stallard, was one of those who mentioned this point. I myself feel that the Government should order some embroidered samplers to be hung in every Minister's office, which should read "No legislation without consultation". They are going down the opposite road.
I believe that I have said enough to indicate my believe that the Government have not thought their proposals through. There are other questions, but I shall keep them for Committee stage. However, there is one final question I cannot refrain from asking now. What are the Government's real, underlying motives in relation to this part of the Bill? Perhaps I have a suspicious mind, but I cannot help surmising that fully-fledged independence for FPCs could—just could—be a paving step towards reprivatisation of the general practitioner side of the service and conversion at some time in the future to an item-of-service basis of payment, underpinned by a mutual insurance system covering 80 per cent., say, of the doctor's charge, as in France. That may be pure fantasy, but I shall be relieved to hear from the noble Earl that it is not even a gleam in the Government's eye. I see the noble Lord, Lord Glenarthur, shaking his head, and I am much relieved to see that.
I turn briefly and finally to Clause 1 I of the Bill, which introduces a new special disablement allowance. My noble friend Lord Attlee has already spoken in some detail and very effectively on this point, particularly on the discouraging effect this Bill may have on the young disabled to continue in education and training with a view to securing a job. I will not go into the matter in any depth at this stage. Certainly we welcome, as does the Social Security Advisory Committee, the abolition of the household duties test for married women. This is obviously right in principle. But there are two main provisions in the Bill which. understandably, have excited much adverse comment. These are the cut-off at the age of 20 of automatic entitlement on a simple test of incapacity for work, and the very high threshold of 80 per cent. disability which has to be surmounted to qualify after that age.
Presumably the Government have erected these hurdles in order to make the change to the new benefit cost-neutral, or as nearly so as possible. These are the financial parameters referred to by my noble friend Lord Attlee. But, not unnaturally, a number of voluntary organisations have voiced concern about the effect of these rules on the particular sector of disablement which they represent. From the many statistics and estimates elicited by Written Questions in another place, two figures stand out. The first is that some 16,000 housewives who currently qualify for HNCIP will be unlikely to clear the 80 per cent. 77 hurdle. Can the noble Earl comment on what support he envisages for them in the future, and on how much they will lose?
Then there is the staggering revelation—at least, it staggered me—that of the 143,000 claimants of NCIP, 81,500 (or 57 per cent.) are suffering from mental disorders. Of these, it has been calculated—this is, of course, an estimate—that as many as 26,500 will not qualify for the new SDA. If this is true it can be seen only as a severe setback for the Government's proclaimed policy of care in the community. How can the closure of large, old uneconomic hospitals be speeded up, or take place at all, if these people are deprived of the therapeutic earnings at present allowed to them under NCIP? Can the noble Earl tell me how the Government's declared policy is to be implemented if the income of many of those struggling to live in the community is actually reduced? I fail to understand that. This seems to be yet another instance of a direct conflict between the highly desirable concept of care in the community and the Government's actual legislation.
There are many other points, but the evening is drawing on. One of great importance is that the criteria for assessing disability are wholly inappropriate for considering disablement through mental disorder. We shall want to bring forward proposals on that at Committee stage. For example, MIND suggests:A possible approach to the level of disability of a mentally disordered person would be for an independent multidisciplinary assessment by a panel including a psychiatrist, social worker and other competent professionals with experience of mental health problems".That is something we shall certainly have to come back to. The proposed system is totally inadequate as at present written into the Bill.
Our colleagues in another place voted against this Bill on both Second and Third Readings on account of its many flaws, which were not corrected in another place. I understand that the Government are planning to have only two days for the Committee stage. If the debate this afternoon is anything to go by we shall need, I am sure. more time.
§ 7.42 p.m.
§ Baroness Jeger
My Lords, I have listened with great interest to this debate. Perhaps I may say especially to the noble Lord, Lord Spens—who has only just returned to the Chamber—that I may not have been here for every minute but I seem to have been here for a lot of minutes. I should like to say how happy I am to see the noble Earl, Lord Caithness, on the Front Bench opposite. I hope he will enjoy his new appointment and that we shall enjoy many interesting arguments as time goes by.
The most important statement to be made about this Bill, before one goes into details of the clauses, is that it is another rag-bag of a Bill. It consists of wholly unconnected issues, and this has happened before under the present Government. This is really four Bills in one. I submit to the House—and I say this in no party sense because it is, I think, a constitutional point—that it is very bad to put four Bills into one. It is no way to legislate. We have four Bills masquerading as one. It is undemocratic and disrespectful to Parliament. From a constitutional point of view it is 78 much better that the Bills which come before this House should be homogeneous and should deal with single issues. A Bill like this which deals with everything from spectacles to disability and the family practitioner committees is not the way to legislate intelligently in this House.
It is also a bad Bill because it just tinkers once more with the National Health Service. It tinkers again with social security. We have had successive changes in detail which are confusing, expensive to administer, and which often create even more anomalies in the health and welfare services. We understand that the Secretary of State is undertaking four reviews of the system, but it is not clear whether there will be any public discussion or consultation about those reviews. Any radical beneficial changes must also involve the Treasury and broad principles of public expenditure finance, including taxation and contributions as well as benefits. There seems to be no focus at present for this wider political public debate, which must be about philosophical as well as fiscal attitudes. So tonight we have just another example of shifting around old problems and creating new problems without any coherent beneficial policies.
The Bill does nothing effective to resolve the poverty trap or the unemployment trap. It leaves confusion worse confounded. It leaves untouched the hardships resulting from the Government's policy of taxing unemployment and sickness benefit, the collecting of national insurance contributions from people on sick leave, and it leaves the blind allowance at £1.25 a week. When I asked in a Question on 21st March what should be the blind allowance if it was upgraded in conformity with inflation I was told that it should be £8.21 a week. We are leaving blind people with an allowance of £1.25 when even the Government admit that taking inflation into account, and not for any other reasons, it should now be £8.21. I make no apology to your Lordships for talking about blind people, because we have had a great discussion about spectacles and the ophthalmic services. My goodness! I am worried about how many more blind people will be left with this inadequate allowance.
The Government maintain the abolition of the earnings related supplement to which thousands of workers have contributed. They have introduced a disastrous policy of housing benefits. The Government's own Ministers have had to acknowledge the need for a review of that after 18 months. Applicants are made to feel that they are means-tested mendicants. The Government pay them about £4 billion a year while the Government give nearly £3 billion a year in tax relief on mortgages, however well-off the applicants might be. The Government hesitate to make essential increases in child benefits above the present £4.2 billion but give away £3 billion in married men's tax allowance, whether or not they have any children at all.
Therefore, it is necessary to set this context for the Bill we are now discussing. It is apparently the last legislation this Session on social security and the health service, but it omits one of the most urgently needed changes—the provision of long-term benefit rates for the long-term unemployed. The Government's own Social Security Advisory 79 Committee, which surely cannot be accused of electioneering, said in its 1982–3 report:We continue to regard as our main priority the extension to unemployed claimants of the long-term supplementary benefit scale rate.On page 2 the report states:We make no apology for repeating our firm conviction that the poorest and most vulnerable people in our society should be protected whatever sacrifices have to be made by the rest of the community.So what do we get tonight instead of these urgent and beneficial changes? We get a Bill which puts the optical services into the market place. We understand that the Government expect to save about £17 million a year by doing this. If the Government are saving £17 million a year that means they are taking £17 million a year away from people who need the services. The proposals before the House might be cheaper for some, but they will inevitably be dearer for those who are now paying about £ 12 for their spectacles.
This is a question which has been discussed in great detail. I do not propose to detain your Lordships long on this aspect of the Bill, but I must ask the noble Earl about pensioners. It was said in another place that there was not to be an exemption from charges for pensioners because not all pensioners were poor. I have to ask the noble Earl whether that is the first step towards the Government changing the prescription exemptions for National Health medicines so that pensioners no longer get their prescriptions free. If they cannot get their glasses free on the basis that not all pensioners are poor, perhaps soon we shall not be able to get our prescriptions free on the same basis.
Will the next step be that prescriptions which come from doctors do not have to go to pharmacists? Will we be able to take our EC10s, or whatever they are now called, to the department store on the ground that that is good competition—we should be able to shop around and pharmacists should not have a monopoly? Is that the way we are going? I note that the noble Lord, Lord Glenarthur, for whom I have a great respect, is shaking his head. I very much hope that he can prove me wrong. I must tell him that many people share my anxieties about this.
I must ask the noble Earl also how we are going to police this situation. Someone with a prescription may go into a shop and get some sort of glasses which are then found not to be convenient and not to be useful. These traders are not accountable to any professional body. Will the patient be able to take those glasses back? Is there any arrangement whereby they have to be changed if they are not satisfactory? Can the noble Earl give us any further information following the statement made on 20th December in the other place? .A question was raised about elderly people with serious eye problems such as cataracts and postoperative problems. I quote from column 297:there are those with the very poorest sight who need complicated and more expensive lenses, and I am certainly prepared to consider the evidence on that to see whether they can have continued access to NHS glasses".That was on 20th December, and I think that it would be useful for your Lordships to know whether that statement has been taken any further.
80 I will not go into many details of this debate, because I think that there have been a number of interesting propositions put to your Lordships to which we shall come back at the Committee stage, but I must refer especially to Clause 11. This provides a severe disablement allowance of £20.45 a week for people continuously incapable of work for 28 weeks on or before their 20th birthday or for people continuously incapable to the extent of 80 per cent. disablement. I wonder whether the noble Earl can tell us why the age of 20 has been fixed on? What is there that is magic about 20? It is not the age of citizenship; it is not the age of consent. I do not know what there is about 20 that makes it the age in this Bill.
I also have to ask the noble Earl, why is there the 80 per cent. limit? What is 80 per cent. disablement? Is it two legs off, one leg or one arm? Can the noble Earl explain to the House the point about this 80 per cent. disablement being continuous? Those of us who know something about the problems of disabled people realise that there are circumstances (for instance, when someone has multiple sclerosis) when there may be a remission. The person can get better for a bit. perhaps do a little job for two or three weeks and then have to have a rest. Are we to pin on people an 80 per cent. disablement label, which will mean that they are stuck with that? Surely they must be allowed to try to get better. We are trying to get all these technological aids for disabled people so that they can do a little job. They surely do not have to be either one thing or the other. The 28-week rule will be a disincentive for people to take on a job for a little while.
I want also to ask the noble Earl whether the Government propose to raise the weekly £20 disregard for therapeutic work to help disabled people to do little jobs which are of great benefit to them and to society. What are the Government's intentions regarding the £4 disregard for people on benefit who are able to work for 35 hours a week? I submit that these are fair questions to a Government who have pledged themselves in their last two manifestos to abolishing earnings rules.
The severe disablement allowance replaces the noncontributory invalidity pension. I am glad that it abolishes the household duties test for married women, but let us not congratulate the Government too much. We know that that arose from an EEC compulsory resolution which said that it was unlawful to discriminate between men and women in social insurance provisions. Will there be people who are receiving the present benefit who will be disqualified from this new benefit? I ask this question—I really have done some homework—because on 16th December in another place the junior Minister said, at col. 629:it is estimated that about 16.000 married or cohabiting women currently receiving the HNCIP would not qualify for severe disablement allowance".What is to happen to them? Are they to lose their allowance, or will they be enabled to go on with a preserved right to benefit?
What consultations have the Government had with disabled organisations in order to try to work out some of those things? Many of us, in no party sense at all, have been having discussions with representatives of disabled organisations. I shall quote only one sentence 81 from the Royal Association for Disability and Rehabilitation:The new benefit would prove a disaster".I am sure that the Government do not want it to prove a disaster, so why has a situation arisen in which the organisations which are talking to many of us feel that it is a disaster?
I will just quickly go on to Clause 13 with Schedule 4. I am sure that many noble Lords will be surprised to know that some families get a dependency allowance for their children of 15p a week. As I understand it, that is to be discontinued under the Bill. The idea is that these dependency payments should be subsumed into child benefit. Of course that would be absolutely right. The Social Security Advisory Committee said that the proposal to replace the child dependency additions by child benefit:is a sound one only if there is no loss of income in real terms to families on contributed benefit".But there is no evidence in this Bill or in the schedules that that will happen. It seems to us that these families will lose that mean little 15p a week without getting any additional benefit under the arrangements for children.
There is then the question of a spouse, who should not be earning over £80 per week. That is another earnings rule from a government who are supposed to want to abolish earnings rules. Then in Clause 19 we get the proposed taxation of occupational pensions. Occupational pensions are now, according to this Bill, to be regarded as earnings. That their pension should be regarded as earnings for taxation pensions is something which will be unacceptable to many people of all parties and of all attitidues in this House. I am only mentioning a few points to show what a ragbag of a Bill this is, as one goes on from one point to another.
I should have thought that the main objects of any Government should be to try to abolish the poverty trap and to try to abolish the unemployment trap. But now we are going to have a situation where we have a breach of the insurance principle, because these occupational pensions were paid by people's contributions. Now we are going to have this weekly earning limit of£80, plus £10 for each child. I must ask the noble Earl whether this £80, which is written into the Bill, is gross or net. Will it include housing benefit? Will it include family income supplement, taxation, savings and building society interest? Surely the Government are again bringing in a means test for people who should expect their benefits as of right because of their contributions. The Social Security Advisory Committee also said that the idea of replacing the child dependency additions by child benefit:is a sound one only if there is no loss of income in real terms to families on contributed benefit.There are many other faults in this Bill which I know we shall want to take up at Committee stage. I feel that I have said enough today to suggest to your Lordships that there really must be considerable time and effort given during Committee stage to this Bill, which is a disaster as far as the most hard-up and vulnerable people in this country are concerned.
§ 8.3 p.m.
The Earl of Caithness
My Lords, we have come to the end of a very interesting debate on this Bill. I am grateful to the many noble Lords for their contributions. Before turning to the more detailed points which have been raised on the various aspects of the Bill, I should like to make some general remarks on the provisions upon which much of the debate has concentrated--namely those contained in Clauses 1 and 11.
Opposition to these clauses has, I think, in general centred on three matters. The first is the liberalisation as regards those who can sell glasses. Secondly, there is the withdrawl of state provision of glasses to most people. Thirdly, there is the the proposed new severe disablement allowance.
With regard to the sale of glasses, I must reiterate that medical opinion is firm that the wrong glasses cannot cause any damage to adult eyes. It is also a fact that most people will be aware if their glasses are incorrect in some way. Faced with these facts. we feel able to relax the total ban on sales of glasses other than by qualified opticians. This does not mean we favour or encourage wrong dispensing. Indeed, the clause makes it a statutory requirement that glasses sold by non-opticians would have to conform to the prescription given by a doctor or ophthalmic optician. We believe that glasses, like most other products, need to be safe and serviceable. However, requiring glasses to be correct does not mean that we need to legislate upon those who can sell them. Many products which are potentially more dangerous than glasses are sold and used.
As an example, I invite your Lordships to look upwards, because you are content to sit under a roof held up by scaffolding. No one has advocated a scaffolders' Bill or a scaffolding council to restrict scaffolding to those registered. I do not want to tempt fate but I believe your Lordships face a greater risk from the scaffolding falling down than from unqualified dispensers. In such cases, safeguards are attached to the products or workmanship not to the sellers.
Nothing I have heard tonight shakes our conviction that this proven way of conducting business cannot be applied to glasses. We are consulting widely with consumer and professional bodies on the content of the orders which will govern sales by non-opticians. We are convinced that conditions can be attached, which will ensure the objectives sought by many of tonight's speakers including my noble friend Lord Suffield and the noble Lord, Lord Molloy—that is, safe and serviceable glasses. One safeguard we already have in mind is to require glasses to conform to appropriate British Standards. Fears of an influx of dangerous, substandard goods. including dangerous frame materials, are therefore unfounded.
I turn to the ending of NHS glasses. It has been suggested that this will no longer permit many people access to affordable glasses. We are sure that this fear is totally unfounded. Many people already pay the full cost of their frames and nearly all the cost of lenses. The average subsidy on lenses is £5. Glasses are changed about every two to three years. Consequently, the proposals contained in Clause I mean that we are 83 withdrawing a benefit worth perhaps five pence a week from most people. This benefit is at present totally indiscriminate and is given to all who choose "NHS brand" lenses.
We have heard much about pensioners. I should make it quite clear that pensioners as a group have never had free glasses. Many need simple glasses. Simple glasses are subsidised by about £2. Some pensioners losing £2 once every two years hardly constitutes the destruction of the NHS, despite what some noble Lords would appear to think.
I acknowledge that there is a small minority who are subsidised by greater amounts for special expensive lenses. About 1 per cent. of users receive over £15 per pair. Even this represents a mere fourteen pence a week. There is a fear, however, that the cost of these special lenses may rise disproportionately; that opticians will cut prices of simple glasses and load the cost on expensive ones. We doubt that this will happen. Nevertheless we are proposing to ensure that this minority does not suffer such a fate by allowing the users of expensive lenses to continue to get them through the NHS. Our negotiating strength will be put to their use to ensure a controlled price for these special lenses. To the extent that users of such lenses are on low incomes, they will also qualify for help towards the cost. Many old people needing such lenses will get them free on income grounds or have much of their charge remitted, and, of course, the higher the charges the greater the remission. We believe that no one will be denied access to the glasses they need on income grounds.
I hope I have sufficiently disposed of the rather extravagant suggestion that the new provisions portend the dismantling of the NHS. Perhaps I can also set your Lordships' minds at rest on another erroneous idea that has gained some currency: that free sight tests will be put at risk by this Bill. This is not the case, my Lords. The requirement to provide NHS sight tests is contained in the NHS Act 1977. The Bill contains no provision for a change. Charges could only be introduced by primary legislation. There is nothing in this Bill which affects that position.
Before concluding my remarks on the optical provisions in the Bill, I should like to add a few words on a matter which I know many of your Lordships will be concerned about—and rightly so. That is the question of enforcing the requirement on unregistered dispensers to dispense according to a prescription. Anyone breaking conditions contained in orders made under Section 2 I of the Opticians Act will be in breach of that section. They will be subject to a fine off 1,000. It is open to anyone to lay information before magistrates where they believe an offence has been committed. By the very nature of these offences, they cannot be committed secretly by the trader. They require the active collusion of a member of the public. We believe the risk of breaches is minimal. Traders have started to break the present law because it is clearly too restricting and has lost the necessary credibility with the public which all laws need if they are to be effective. We believe that the vast majority of people will benefit from the package of proposals.
84 Moving on now to our proposals for the introduction of the new benefit, severe disablement allowance, there is no intention for there to be any correlation with regard to the incapacity. The first condition for SDA is the incapacity for work. The additional 80 per cent. disablement test is simply intended to direct resources to the most severely disabled. On the question of consultation, the Government accepted the recommendations in the official review, and we therefore thought it right to bring forward legislation as soon as possible to remove the dissatisfaction generated by the present household duties test that has been universally condemned today. None of the other options identified was practical and affordable. A delay in order to consult on the details of the scheme could have meant losing the opportunity of introducing legislation this Session.
My honourable friend the Minister for the Disabled has been consulting for some months. and debates in this House and another place formed part of the scrutiny. None of the orgnisations that have criticised this measure has come up with positive proposals for an alternative to SDA, NCIP or HNCIP other than straightforward abolition of the household duties test. As my noble friend has said, this would cost £275 million. Even if resources were available, I am far from convinced that spending them in this way would be the best means of improving the lot of disabled people. Those who criticise our proposals have made no real attempt to face the issues within present financial constraints. The fact is that we must live—all of us—within the means that the economy can afford.
Suggestions have been made that the age 20 rule should be extended in various ways. SDA, like NCIP. is intended to be an income maintenance benefit primarily for the congenitally handicapped or those disabled in childhood who never have the opportunity to work and build up a contribution record. Given this priority, the logical cut off point for the easier qualifying condition is age 16 rather than 20. We feel that we could not legitimately make a special concession for the over 20s in full time education without making similar concessions for other groups: for example, the unemployed or those looking after children or elderly relatives.
In assessing the level of disablement, we propose to apply criteria which have been successfully applied to both physical and mental disabilities in the industrial injuries and war pensions fields over many years with general public acceptance. In building on the long experience of those schemes. I am confident that the well-tried 80 per cent. disablement test will provide a much fairer and more objective basis of benefit provision than the present household duties test for HNCIP.
On the wider front, contrary to what some noble Lords have suggested today. we estimate that the introduction of SDA will initially bring in an extra 20.000 beneficiaries and that the number who will qualify each year in the future on the 80 per cent. disablement test will be some 10 per cent. higher than the number who presently qualify for HNCIP. I am sure, and I hope that the noble Lord, Lord Ennals, will agree, that these are considerable steps forward at a time when resources are severely limited. The extra cost of this will be £20 million a year.
85 Turning now to other and additional matters raised by your Lordships, I shall try to respond to the main points, but if I overlook any of the issues raised, I can promise that I shall check the Official Report and write to those noble Lords I have not answered. The subject of family practitioner committees was debated at length in the spring of last year and many of the questions raised tonight were answered in debate. I shall endeavour to mention them briefly again. Our proposals are not a fragmentation of the primary care service. That criticism, we believe, is a misconception of what we are about. The committees already exist and have done so in one form or another since the inception of the NHS. Our object is to make them accountable to Ministers by directly appointing them and, secondly, to make them more efficient by enabling them to employ their own staff and to become responsible for their own administrative budgets and, as necessary, called to account. The appointment of all members of FPCs by the Secretary of State is designed solely to ensure that accountability.
The Earl of Caithness
My noble friend, Lord Colwyn, mentioned the question of dental deputy members for FPCs. It is a long established principle adopted in respect of deputies that provision should be made for only one where the profession or other group has a single representative on the FPC. To go beyond that would be to open up the possibility of deputies for all parties. This would obviously have undesirable results so far as continuity of experience is concerned.
Certain of your Lordships believe that our proposals will make collaboration between the districts and the FPCs more difficult. We do not believe this. On the contrary, it is expected that FPCs and DHAs will continue to collaborate closely in the provision of primary care as the Bill makes it a requirement for them so to do. Additionally, the Bill provides for automatic FPC representation on local joint consultative committees. Family practitioner committees in Scotland are administered by the health hoards. However, the situation in England, with its much larger number of patients and practitioners and generally higher population densities than Scotland, is different and admits to a solution that we have adopted. Some points have been raised about the membership of the comittees. I should like to remind noble Lords that we have taken powers to enlarge membership of committees in certain circumstances and after consultation.
Moving on to the child dependency addition, the point has been raised by the noble Baroness, Lady Jeger, that the proposed earnings rules for long term child dependency additions are simply a back door way of means testing national insurance benefits. That is not the case. There has always been an earnings rule to determine entitlement to the extra benefit for an adult dependant.
With regard to occupational pensions, I should make it clear that the Government do not wish to impose a full-blooded means test, and we do not wish to penalise the thrifty. We wish simply to draw a distinction between pensions for which a past 86 employer has substantially contributed, and which probably featured in the conditions of employment, and income deriving from voluntary investment.
The noble Lord, Lord Ennals, and my noble friend Lord Cullen of Ashbourne asked what consultation took place with the optical profession before the introduction of the Bill. All organisations involved were consulted. They were invited to a meeting with my right honourable friend the Secretary of State for Social Services on 8th November 1983. Since the Bill has been published, there have been consultations at official level.
The noble Lords, Lord Ennals and Lord Banks, my noble friend Lady Faithfull and the noble Baroness, Lady Jeger, raised the the short term CDA problems. They expressed concern that withdrawal of the short term CDAs would hurt the poorest and most vulnerable. However, the withdrawal will take place at a time of up-rating and no one will be worse off. In addition, two-thirds of those who will lose the short term CDA are in receipt of supplementary benefit. The withdrawal of the CDA will simply mean more supplementary benefit.
The noble Lord, Lord Ennals, asked which groups supported us when it came to the SDA. The Social Security Advisory Committee, for example, generally welcomed the proposal. I should also like to illustrate the age 20 rule. Between the ages of 16 and 19, a young person will be prevented from drawing SDA only where he is undergoing normal full-time education. Beyond that age, further education will only be a bar to entitlement if the type of course being followed is inconsistent with the finding that he is incapable of work. The noble Lords, Lord Ennals and Lord Kilmarnock, raised the question of when the Binder Hamlyn report will be published. I can only tell them that it is expected to be published at the same time as the Green Paper.
The Earl of Caithness
In the future, my Lords. The noble Lords, Lord Banks and Lord Beaumont of Whitley, raised the question of the introduction of an earnings rule as a means test for the long-term CDA. I covered this point a moment ago. There is no intention of means testing national insurance benefit. There always has been an earnings rule to determine entitlement to the extra benefit for an adult dependant. The proposed earnings rules for CDAs simply ensure that the extra benefit for a child goes only to those beneficiaries for whom it was intended. I am sure we would all agree that that is very laudable.
The noble Lord, Lord Banks, asked why there are three earning rules for pensioners. The earnings rules are for different purposes. The £65 personal earnings rule is to establish that the pensioner has actually retired. The £45 earnings test for a wife is to establish that she is really dependent on the pensioner. The new £80 rule is in line with the concept of defining dependency hut at a higher level. To put the proposal in perspective, a family consisting of a pensioner, his wife and a child could have earnings of more than £100 before affecting the entitlement to the personal pension and the adult and child dependency addition.
87 The noble Lords, Lord Banks and Lord Kilmarnock, referred to the speech of my noble friend Lord Trefgarne. At the time the speech was made my noble friend was speaking against the total repeal of the safeguards in the Opticians Act. The Government are keeping registration of opticians to give an informed choice of supplier. They are making it a requirement that all glasses sold accord with a recent prescription. Lord Trefgarne was speaking against self-selected glasses. The Government are not proposing this, although some noble Lords have suggested that we should. We are also consulting widely to ensure safe and serviceable glasses. This was my noble friend's objective and it is still the Government's objective.
We are grateful to the noble Lord. Lord Rugby, for starting a public debate on the matter of glasses. He raised a point with regard to the GOC. The GOC is concerned mainly with the education and registration of opticians. In respect of its rules on publicity it has strayed into areas where it has affected competition. We believe that it is necessary to regulate its activities in this area. We do this in the Bill. However, we believe that in other work it can safely be left to regulate the profession.
The noble Lord, Lord Stallard, raised the question of what we call the 924 glasses, saying that these will disappear. Of course, they will not disappear, and other NHS frames that are popular will not disappear. If they are good value for money, there is no reason to suppose that they will not hold their own in the free private market.
My noble friend Lord Orr-Ewing and the noble Lord, Lord Ennals, referred to the letter of 15th May from the BMA. 1 have seen the letter to which the noble Lords referred. They may well be correct that the letter does not represent the views of all BMA members or even all 'ophthalmologists. However, the Government judge all such representations on their merits. It is not whether the views are those of the BMA or of just a few individuals which influences us, but rather whether there are any substantive arguments which need to be considered.
The noble Lord. Lord Molloy, raised the question of the Secretary of State's appointments of all the FPC members. Although local authorities will no longer appoint four members, four of the lay appointments will be made from their nominations, and similarly in the case of DHAs. Some of the other seven lay members may also be chosen from local authority or DHA nominations, especially where more than four such authorities respectively are involved.
The question of contact lenses and the need for special treatment was also mentioned by the noble Lord, Lord Molloy. There is virtually unanimous support for the view that, unlike glasses, badly fitted contact lenses can damage the eyes. This is why we are proposing in Clause 2 to strengthen the law.
The noble Lady, Lady Kinloss, asked why NHS glasses should not be available for those over 19 years of age in full-time education. NHS glasses have only ever been supplied free to those under 16, or those under 19 if in full-time education. Those over 19 in full-time education have always paid for their glasses unless they were on low incomes. If persons over 19 in 88 full-time education are on low incomes they can be assessed and get their glasses either free or at a reduced cost. This will continue.
The noble Earl, Lord Attlee, suggested that SDA was a disincentive to employers to take on disabled youngsters. We believe this to be wholly speculative. Disabled youngsters capable of work obviously want to work, and experience, particularly after the International Year of the Disabled in 1981, suggests that employers are not discriminating against them.
The noble Lord, Lord Beaumont of Whitley, mentioned a comment in Standing Committee A in another place. I can take this opportunity of saying firmly that there has been a misprint. It was either a slip of the tongue or a misprint. The word "even" should have been "except". The quotation should now read:It has never been the perceived view in this country that it is the state's business, except for those on supplementry benefit. to expect to meet from state benefits or through taxation the full costs of bringing up children".My noble friend Lord Cullen. the noble Lord, Lord Kilmarnock, and the noble Baroness. Lady Jeger, raised a problem relating to cataract patients. Cataract patients are treated by hospitals. It is customary for hospitals to lend glasses to those who need frequent changes of prescription. There is no need for an amendment in relation to the problem of expensive lenses, as this can be tackled in regulations.
I am grateful to my noble friend Lord Cullen for letting me have advance notice of the points he raised. His point about standards of dispensing was raised also by the noble Lord, Lord Ennals. We do not believe that permitting unqualified dispensers in itself will raise standards. However. competition between qualified opticians and other retailers will have this effect. Competition is the best enforcer of standards. We do not accept that permitting unregistered retailers to sell glasses will lead to lower standards. New entrants may not be trained to do all the things a dispensing optician can tackle. However. this does not mean that they will not perform adequately the jobs they have agreed to tackle.
As I have said, I will write to other noble Lords who have raised points. I would conclude by reiterating what my noble friend said earlier. This is a far-reaching and significant Bill, which represents the Government's continuing commitment to promoting the interests of the consumer in the health services and to achieving a more rational scheme of social security provisions. Therefore I have great pleasure in commending the Bill to your Lordships.
On Question, Bill read a second time, and committed to a Committee of the Whole House.