HL Deb 08 November 1988 vol 501 cc550-89

3 Clause 13, page 13, line 18. leave out subsection (1).

The Commons disagreed to this amendment but proposed the following amendments to the words so restored to the Bill:

4 Page 13, line 26, leave ma from 'requirements' to 'or' in line 27.

5 Page 14, line 41, leave out front 'person' to 'and' in line 44 and insert— '(a) whose sight is tested by a person 1,12; provides general ophthalmic services'.

6 Page 14, line 45, leave out from beginning to 'above' in line 47 and insert— '(b) who is shown during the testing or within a prescribed time after it to jail within subsection (1)'.

The Commons proposed the following consequential amendments to the Bill:

7 Page 15, line 25, leave out from beginning to 'give' in line 27 and insert— '(3) The Secretary of Stale mar by regulations—

  1. (a) provide for himself or such authority established under this Act as may be prescribed to contribute to the cost of a testing of sight which he or the prescribed authority accepts as having been incurred by a person whose resources fall to the treated under the regulations as exceeding his requirements by only by an amount calculated under the regulations,
  2. (b) provide ,for payments to be made by him or by such authority established under this Act us may he prescribed to meet, or to contribute towards, ant' cost accepted by him or by the prescribed authority as having been incurred (whether by way of charge under this Act or otherwise) for the replacement or repair in prescribed circumstances Of optical appliances for which a prescription was given in consequence of a testing of the sight of a person of a prescribed description' and
  3. (c) direct host' a person's resources and requirements are to be calculated and, without prejudice to the generality of this subparagraph,'.

8 Page 15, leave out lines 33 to 40.

Lord Cullen of Ashbourne

My Lords, I beg to move that this House do insist on their amendment numbered 3 to which the Commons have disagreed and do disagree with the amendments numbered 4 to 6 proposed by the Commons to the words so restored to the Bill and to the Commons consequential amendments numbered 7 and 8 to the Bill

The only reason that I had any doubts about moving this Motion today was as to whether there was any constitutional impropriety in so doing. I asked the Clerk at the Table and I have been told that there is no constitutional problem whatever as regards Clause 13. I later saw my noble friend the Chief Whip who did his best to explain to me why Commons privilege attaches to Clause 11 but not to Clause 13. I must admit that I am woefully ignorant about constitutional matters as may also be some other of your Lordships. I hope that during the course of this debate some noble Lord well versed in this subject will explain the position as regards this clause in as simple a way as possible in such a complex area.

I am sure we would all agree that it would be unfortunate if your Lordships voted differently from what they would otherwise have done without this complication if it turns out to be more of a red herring than a grey area. As I understand it, if the Government are defeated today it is possible that when the Bill returns to the Commons the Speaker might or might not invoke Commons privilege. If he did so, that would be the end of the matter.

The reasons that I am on my feet are, first, that after extraordinarily strong pressure in another place from the Whips, the Government overturned your Lordships' amendment which was passed by a majority of no less than 26 votes. This they did on a slender margin of eight votes. There can be no doubt what the result would have been had there been a free vote in another place. Secondly, in spite of the widespread opposition to their proposal the Government have not seen fit to make any concession except at the margin.

Perhaps I may once again declare my interest. Soon after becoming spokesman for the DHSS in your Lordships' House 1 was invited to become president of FODO, the Federation of Ophthalmic and Dispensing Opticians, and I still am president. The views I hold today are those which I was convinced were right when I was at the DHSS. It is the views of the department or of the health Ministers that have changed. My views are strongly supported by the BMA, the RNIB, Age Concern and many other professional institutions. I have had endless supporting letters from these and other institutions, but today is not the time for long speeches and I shall resist the temptation of reading out of any of those letters.

My noble friend the Chief Whip has understandably pulled out all the stops. I am happy to say that he has in no way attempted to twist my arm. So many noble Lords are here today who will not have heard or read our debates so I shall very briefly outline—and I mean briefly—the reasons why I disagree with the Government. I believe that there will be many people who will be deterred from having their eyes examined if they have to pay for it with the consequence that many diseases, not only of the eye, will not he picked up until it is too late. I will not go into the detail of all those diseases because we have heard about them so often on previous occasions.

Whatever Ministers may say, I believe that many people, particularly the elderly, will find it difficult to raise £10 or so for a sight test and will be tempted not to do so. The Government hold the view that payment will not be a deterrent. I find that surprising for a Government that believe so much in market forces. Surely, cost is a vital ingredient in any market. I mentioned earlier that the Government have made concessions only at the margin. I have no desire to be a party to some constitutional difficulty between the two Houses nor to impede the passage of the Bill which I warmly welcome, apart from the dental and optical clauses which do not seem to belong in this Bill at all.

As many of your Lordships know, I am not by nature a particularly rebellious character. So I ask my noble friend the Leader of the House to offer a compromise. The Government have wide-ranging, rule-making powers to add to the categories who will continue to be entitled to free eye examination. There will be no need to touch the Bill at all. If my noble friend can give a positive assurance to make worthwhile additions to the exempt categories by regulations I should personally not wish to divide the House. If he cannot find his way to do that I shall have no alternative and this my noble friend understands. So we are in my noble friend's hands.

One very obvious category for exemption would be the elderly who are most at risk as regards the many diseases that can be detected in an eye examination. I am told that this would cost something like £22 million. However, since the Bill was first debated, as a result of an EC directive VAT has been imposed on spectacles. Therefore, the Government will have a windfall of about £25 million a year. I do not think that we are asking for very much there.

The other category that I should dearly like to be exempted is people who are referred to opticians by their GPs for medical reasons. It would be a small but a very important category.

In conclusion, I have the greatest admiration for this Government's remarkable achievements, but I believe that it is right and proper for all of us to speak up if we are convinced that the Government are making a mistake.

Moved, That this House do insist on their amendment numbered 3 to which the Commons have disagreed and do disagree with the amendments numbered 4 to 6 proposed by the Commons to the words so restored to the Bill and to the Commons consequential amendments numbered 7 and 8 to the Bill.—(Lord Cullen of Ashbourne.)

Lord Belstead

My Lords, it may assist your Lordships if I say just a few words early on in this discussion. It occurs to me that the issues in relation to this group of amendments are very similar to those we have just debated. Another place has voted for the second time in favour of charging for eye tests which would enable about £85 million a year to be spent on improvements elsewhere in the health service. In that way it is the same issue as the one we have just debated and decided.

In this case, however, the Commons made various other amendments to the Bill which are to be seen subsequently on the Marshalled List. Members of another place did so in order to fulfil an undertaking to give extra financial assistance to people who just fail to qualify for income support. Apparently it is not the custom in another place to give a reason for disagreement when any other amendments are made to a Bill. So the issue of Commons financial privilege does not arise on the Marshalled List out of the Commons message with which we are now dealing. But, clearly, questions of' financial privilege are involved here.

In introducing the Lords amendments a week ago today, Mr. Speaker reminded the House of Commons that privilege is involved in these amendments. This is clearly on the Hansard record for Tuesday of last week. Having said that, perhaps I may follow my noble friend by saying a brief word about the merits of the case.

Next year the National Health Service is to receive its biggest ever increase in funding. However, as your Lordships know all too well, the demands on the modern health service are ever increasing. So we are planning to increase the level of spending on the primary health care services—family practitioners, dentistry and the eye service—by £600 million over the next two years to take spending on the primary health care services to a new plateau. We are proposing to make a significant contribution towards this very large sum by asking those who can afford it to pay a contribution towards the cost of their teeth and eye examinations, so releasing £135 million. In a world where decisions have to be taken sometimes- and they are not always easy—surely it must be right to put such a sum to good use for better services, provided of course that those who cannot or should not pay are exempt.

I should like therefore to remind the House about the help that people will receive. The exemptions go a good deal wider than the exemptions on the previous amendment. Those who are on income support or family credit will continue as now to receive a free National Health Service sight test. And as a result of the announcement by my right honourable friend the Secretary of State for Social Security two weeks ago, a further 90,000 people in this category will also become eligible for free tests. Additionally, for those whose incomes are a little above the qualifying level for income support, we intend to introduce a voucher arrangement, similar to the very successful voucher scheme to help buy spectacles, which will give relief in that respect. There will also be free tests for people suffering from glaucoma or diabetes. Because of the hereditary element in glaucoma, people of 40 or over who are the children or brothers or sisters of glaucoma patients will also be exempt. There will also be exemption for children under 16, students under 19 and the registered blind and partially sighted. These exemptions will cover very nearly 37 per cent. of the population.

I have listened to my noble friend. He suggested that our proposals will deter people from having their sight tested. This was certainly not the case when the Government brought forward legislation four years ago to deregulate the dispensing of spectacles. At that time there was doom and gloom from noble Lords opposite who suggested that this would lead to an increase in undetected eye disease and sight problems and fewer visits to the optician. What has happened? Nothing of the kind has happened. As the years have gone by greater use has been made of the optical services available; and this has been good news for us all.

My noble friend, who has been absolutely consistent in his attitude to these matters over the years, has put two specific points to the Government. He suggests that the Government should undertake to exempt the elderly—meaning, presumably, everyone of pensionable age—from the charges for sight tests provided for in the Bill. I should remind the House that 25 per cent. of all pensioners are on income support and they will automatically qualify for free testing under the Bill as is stands. For example, anyone who relied solely on the basic state pension would undoubtedly be covered by this as would those of pensionable age who suffer from diabetes or glaucoma or who are closely related to those who suffer from glaucoma. In the light of all these exemptions, and indeed of the voucher scheme for those who are a little above the income support level, it is difficult to see the force of the argument as to why better off pensioners should be exempted in preference to other sections of the population who may be on the same income.

My noble friend made a second and very important point. He asked the Government to consider exempting from charges any person who has been referred to an optician by his or her general practitioner. The difficulty with this proposal is that it would not focus on those in need. It would invite people almost always to visit their doctor before going to an optician and so arguably would overburden those very services of primary care which we are all seeking to improve.

However, my noble friend's case, a case on which he has been absolutely consistent and about which he knows a great deal, requires an undertaking. The assurance 1 gladly give him today is that clearly we must keep a very close eye on the consequences of charging. Statistics will continue to be kept of the National Health Service eye tests—the 20 million people who are exempt and the voucher holders—and I promise that by sampling we will find out whether the number of eye tests in the rest of the community is going up as it has continued to do. Then of course we would reconsider any aspects of these arrangements should the evidence require it. I hope my noble friend will accept that my assurance is given in good faith and will be carried out by the Government.

The Government are planning to spend a great deal more on primary health care. In setting out our priorities—because, heaven only knows, that is what we have to do in such an enormous area as the health service—it is only reasonable to seek a contribution from people in receipt of teeth and sight testing. It involves a large sum of money—some £135 million£of which the greater part is involved in this amendment. I should remind the House that Mr. Speaker has made clear that privilege was involved in these amendments but that the House of Commons gave no reason for their disagreement in respect of this amendment because it is not the custom to do so when consequential amendments are made to a Bill. For that reason there can be no question that this is an issue which involves Commons financial privilege. I must strongly recommend that the House should not now insist in the face of Commons disagreement.

Lord Cullen of Ashbourne

My Lords, before my noble friend sits down, perhaps I may ask him about the monitoring suggestion. For how long would that go on, and at what point would the Government decide whether any alterations should be made to the categories?

Lord Belstead

My Lords, my noble friend, who keeps a close eye on the matter, knows more about the speed with which monitoring statistics are received. I stand absolutely by the assurance I gave to my noble friend. We would monitor and sample as well. As the statistics came in, should the evidence require it, we would reconsider any aspects of the arrangements. It is an assurance given in good faith and it would be carried out by the Government.

Lord Hunter of Newington

My Lords, as the Leader of the House has said, in November of last year the Government published their White Paper entitled Promoting Better Health. This was their programme for improving primary health care services with a sub-title, "Putting Patients First". Raising the standards of dental care was one of the declared objectives and the Government referred to the increased and widened remit for pharmacists but, in relation to opticians, they said: Increased competition for ophthalmic services while providing adequate safeguards for consumers". One was disappointed to see that there was no mention whatever of an increased use of opticians in the provision of ophthalmic diagnostic services. That would have had the effect of sparing the hospital eye departments for their increasing role in therapeutics.

It is an exciting world now with lens implants, increased use of lasers and other treatments. All of this makes the necessity of early treatment in eye conditions imperative. The new hope of prevention or cure by modern methods seems to have passed unnoticed; but it has not passed unnoticed by the general public who see new hope if their eye complaints are diagnosed early and treated properly. The demand on the eye departments of hospitals means that every conceivable step must be taken to prevent patients going there simply for routine eye tests. There is no doubt that the properly trained and properly equipped optician can do that job well, including the detection of abnormalities.

Reading the Government's proposals for primary care one wondered if their strategy was to deal substantially with hospital services and specialised services through the Prime Minister's review of the NHS with a consequence that both in the primary care field and in the hospital and specialist field it would be possible within the next year or two to evolve a strategy for the NHS so that resources are spent reasonably and in the best possible way. Such a revolution—and it would be a revolution—would involve disciplining by the medical profession, and other professions, which they have not yet imposed upon themselves; but they are certainly willing to discuss such matters.

Then we received the Health and Medicines Bill. As has been said, it is a Money Bill and certainly in relation to dentistry this has been clearly stated by the Speaker in another place. But the distress on reading this, in the light of those happenings, leads one to the view that we are far from obtaining a policy for the National Health Service, that financial considerations rule supreme and that decisions are made about financial matters which totally neglect the medical aspects of the proposals.

Compounding that distress is the argument in the Bill that by stopping free dental and eye tests it will be possible for the Government to devote those moneys to extend and develop primary health care systems. Both those measures are preventive measures which have lasted since the beginning of the National Health Service. Some of the primary care proposals recommended by the Government, to which the Leader of the House has referred, are by no means so certain in their consequences and will require substantial retraining and reorganisation in general practice.

Moreover, the proposals for funding the White Paper seem to be totally inadequate. The proposal to raise funds in this manner has undermined confidence in the Government's concern. Another concern which does not promote confidence is the proud allocation in the Autumn Statement of additional funds for the National Health Service over the next two years. Those sums are almost exactly the amounts of money which the Government have repeatedly been told were needed by responsible agencies, including the health authorities association, during the past two years to maintain the present level of care. The money seems to have been allocated before the consequences of the proposals, emerging from the review of the National Health Service, have been considered—although one has to admit that the Government may have considered the matter carefully in a series of confidential meetings with the medical profession.

The concern which is being expressed by many is the necessity to concentrate constructively on that report about the National Health Service and also to debate in your Lordships' House—I am glad to see my noble friend Lord Nelson, is here—the proposals by the Select Committee on Science and Technology to make medical research and research and development part of the sinews of that service. Without some measure of that kind, savings will not be made in a responsible manner and certainly everyone wants to see the closing of beds by administrators minimised as soon as possible.

Such is the concern in the country about the National Health Service that the Government must be seen to be concerned with its constructive development into the 1990s and beyond. Most have agreed that what seems to have happened on this occasion—namely, the throwing of money at the NHS—is not enough. Forward planning of quality is required. I believe that given the reasons and cogent arguments the medical profession and the people of this country will respond. But funding improvements in primary care by cutting out two long-established and effective measures causes grave concern and a profound lack of confidence in the Government's intentions.

If this opinion is confirmed by the House, can we have an assurance that the effect will be monitored by the review body or by the Government?

Lord Ennals

My Lords, I warmly welcome the responsible statement which has been made by the noble Lord. Lord Hunter, who like the noble Lord, Lord Cullen, speaks with great authority on these issues. I was, however, disappointed in the assurance given by the noble Lord the Leader of the House and I should not imagine that what he had to say could satisfy the concerns of those who are facing a difficult issue this evening.

In another place the Minister said that there would be no concessions. That quite clearly is the situation as reflected by the noble Lord, Lord Belstead. As regards financial privilege, it is quite clear that Mr. Speaker has not ruled against the consideration of this particular Motion and thus no constitutional issues arise.

We are not debating the broad issue of the funding of the National Health Service, although I hope that we shall soon do so. We are debating a proposal to breach a 40-year agreement, an all-party agreement, across both sides of the House, which has been in support of preventive medicine. The Government's decision that they would introduce charges has, as the noble Lord, Lord Hunter, said, caused a tremendous amount of concern not just among the people of this country—that is, the patients and the potential patients—but also among those who really know. I believe that the country is waiting for a decision this evening by your Lordships' House.

I believe that the decision of principle which we took when we last debated the issue was one which was warmly welcomed. I also believe that it was warmly welcomed by the majority of Members in another place. 1 further believe that not only would we be letting down the country; but we would also be letting down those who elsewhere have given their support in principle to the position taken by your Lordships in this House.

What must be accepted is that this is an exceptional issue and one on which I believe Ministers really should think again. It is quite clear that all those who know—that is, the professional organisations, be they in dentistry or in ophthalmics—have said that they profoundly disagree with the position which the Government have taken. They have stated that fact absolutely clearly. No doubt within the last few days we have all received the briefing from the British Medical Association. I should like to quote but one paragraph: In the White Paper the Government clearly states that it 'attaches great importance to the promotion of good health and the prevention of ill health'. The BMA believes that the introduction of these charges would be a serious deterrent to preventive medicine and contrary to the declared aims of the Government in the promotion of better health". I could quote similar statements from all the professional organisations. I do not believe that Ministers can bring forward any evidence to support the proposal they are trying to push through the House as they pushed it through another place.

It is especially interesting that not only has there been unanimity among the professional organisations, but unanimity also among those in this House and in another place who understand the subject. The position of the noble Lords, Lord Cullen, Lord Mottistone and Lord Colwyn, the noble Baroness, Lady Gardner of Parkes, and those general practitioners on both sides of the House who have spoken in our debates, is clear. It is difficult to see on what evidence, other than a requirement to make financial savings, the Government's position is being taken.

Two former Conservative Ministers for Health in another place, Sir Gerard Vaughan and Sir Barney Hayhoe, both of whom voted against the Government last week, have made their position absolutely clear.

We are not dealing with an issue upon which the Government fought a general election. There was no suggestion in their manifesto that this proposal would be brought forward. It was not even referred to when the White Paper was published. It can only be an after-thought pushed through by the Chancellor of the Exchequer to make financial savings. It is not for the good health of the people. Sir Gerard Vaughan gave a firm assurance to Parliament in 1981 when he said that it was not the intention to proceed with charges for sight tests. That was a clear statement of government policy. One should compare that commitment with the statement made by Mr. Kenneth Clarke on 1st November in another place. He said: I have no intention of introducing charges on any other things". Presumably the "things" were other types of testing. He went on to say, "for the time being". He explained that he said, "for the time being" because he could never say "never". Such a situation causes deep concern to all of us who oppose what the Government are trying to do. Once one starts on the slippery slope with no control over, where one is going, who knows what the consequences will be? How many hundreds of thousands of people may suffer as a consequence? Your Lordships would be right to take a profoundly principled view of the matter.

In the same speech, Mr. Clarke referred to, a misplaced sense of priorities which suddenly seized their Lordships when they first considered the matter".—[Official Report, Commons, I I I 88; col. 869.] I have to say to the Secretary of State for Health that the House has been totally consistent throughout. The House has never in 40 years voted in favour of introducing charges for sight tests and dental examinations. That has been the position across both sides of the House.

We took the decision firmly. We reached our conclusion by a majority of 26 which was a substantial vote for your Lordships' House. I see no reason, and no evidence has yet been brought before us, to lead us to change the view that we then took.

It would be wrong to break the all-party consensus which has survived well for 40 years. There are not many things upon which we manage to be in agreement. But this matter until now has been one of them. Let us not lose it. There is no doubt that if there had been a free vote in another place and if there were to be a free vote here, the Government's proposals would be thrown out by a large majority. On the other side, there is only the influence of the Whips who are required to do a duty we all respect and which sometimes hurts us.

Some may have read the description given by Mr. Nicholas Winterton in the Mail on Sunday of the arm twisting that he suffered. It did not make pleasant reading. I heard a great deal of laughter over Mr. Nicholas Winterton. I served with him for several years on the Social Services Select Committee of another place. He was a diligent member of that committee. He is an independent-minded man. That may sometimes offend people. I respect those who show their independence of spirit, especially when they happen to agree with me.

What about attitudes in your Lordships' House? As I have said, there is no reason why anyone should now take a position different to that they took when we had a majority of 26. A leader in The Independent last week said that the Government's decision earlier this year to dragoon hundreds of hereditary Peers to vote through the poll tax demeaned the reputation of the Upper Chamber. I agree with that view. I believe that everyone here will agree with it. Such a situation does no good to the reputation of the House nor to the Peers who, it is suggested, are prepared to be used as Lobby fodder. That is surely an insult to the integrity of Members of your Lordships' House.

I hope that there is no Peer voting tonight who has not carefully considered the issues and whose vote is not based on that careful consideration. I have to say to those who have not taken part in our debates that we have had a high standard of discussion in the earlier stages of the Bill. What would enhance the reputation of your Lordships' House, if it needs it, is for those Peers who have been persuaded to come today—and of course they are welcome—fto use their own judgment on the basis of the arguments that are presented and to vote according to their consciences.

What if we were to succeed tonight? It is suggested by Mr. Kenneth Clarke that the Bill would be lost. That is nonsense. It need not be the case, unless that is what the Government decide. It is possible for the Government to bend to the will of Parliament and of the public. That is what we hope they will do. It would not only preserve the high respect in which your Lordships are held throughout the country; it would do immeasurable good for the principles of preventative medicine for which we have been battling over the years. That point was made by the noble Lord, Lord Colwyn.

If we do not succeed this evening, that will be a blow. I agree that there will be many people, especially those on small incomes, who will be deterred from having their sight tests. All the evidence proves it; so I hope that when we vote tonight in support of the National Health Service we shall also vote in support of our own principles.

Lord Thorneycroft

My Lords, I rise to express the hope that we will leave this Bill alone. I feel that if we reflect quietly about it, the House may come to the conclusion, in more quarters than one, that that is the right course. I recognise to the full the sincerity of those who have argued the case regarding the charges for dentistry, or, as we are now discussing eye tests. Of course they are sincere. Of course there are merits in the arguments that they have put forward.

My noble friends, Lady Gardner and Lord Cullen, and others, do not argue cases which have no merit: They have put forward strong arguments. There is a case for tests and checks. Even under the Bill as it now stands, some 20 million people will have free checks. I am among them. I am not a rich man, but a Bill that is prepared to ask the taxpayer to subsidise my eye test is not lacking in generosity. I am a diabetic and that is why I have free tests.

The noble Lord the Leader of the House indicated that the Government would look to see whether further exemptions should be made. So it is not a question of arguing that no testing is ever any good or any use. I agree with the noble Lord, Lord Ennals: he is absolutely right that there are merits in these tests.

That is not the issue. The issue here is the question of priorities. It used to be said that socialism was the language of priorities. To tell the truth, priorities ought be to be the language of any government, they are the business of government. To my mind, the priority here is to preserve the central core of the National Health Service and to preserve the principle that when men are struck by these emergencies of life and suffer disease and illness, they should not be deterred by their financial position from seeking the greatest skills available which are willingly given by the great medical services of this country.

However, to keep that central core and to hold on to that principle means that one has to go for the central problems: the payment of nurses; the introduction and establishment of new hospitals; the enormous programmes of training; grappling with the new diseases which we see; new methods of tackling old diseases with changed techniques; the growing number of elderly and the introduction of new equipment. The problems of financing those are very great indeed.

The noble Lord, Lord Glenamara, talked the other day at Question Time of money oozing up through the floorboards. It came as a shock to him, he had not seen it oozing up under the floorboards in previous administrations. There is some money—enough to enable this Government to make available £2 billion in extra money for the health service. That seems to me to have been an enormously important event. But it did not just happen. It happened because we have had a Government who have refused to spend £10 million here, £25 million there, £50 million somewhere else, £135 million now. Constantly, amid uproar sometimes and derision, they have stood their ground and kept a very close control over what is spent. As a result, they have been able to spend more on the health service and in some other fields. They have reduced taxes, paid debts and seen the revenue moving upwards.

It seems to me that that policy is right. It would be amazing if any members of the Conservative Party were to challenge the Government on that policy today. For we boast of it, we are proud of it. It is what has made the financing of the National Health Service possible. We ought to stick with it. It is not right to say that £120 million is chicken-feed. I once resigned high office for half that figure. The difference today is that we have a Prime Minister and a Chancellor of the Exchequer who are agreed upon these matters. The difference today is that we have a Government who really think it matters to control government expenditure; who really watch the proportion of government expenditure in relation to the gross national product.

It is those hard, economic decisions and that honest money that have made it possible for this country to keep the social services and to manage to advance the National Health Service and matters of that kind. I believe that we ought to support the Government at this moment.

Finally, I ask this question: how would these sums of money which are now asked for by some of my noble friends be financed? There are only two ways. We could ask the Commons to reopen the statement on public expenditure. We could ask them to do that. We could challenge their financial arrangements and tell them that they have to vote more money. We could do that. But, if that is not going against the principle of privilege, what is? It surely must be. There is an alternative: we could take it out of the National Health Service. It represents two district hospitals a year. We could say, "Let's sacrifice two district hospitals a year in order to pay opticians £10 for a test", knowing that many of them might charge much less and quite a lot of them would charge nothing at all. It seems to me that that is the most extraordinary approach to the running of a health service. I therefore beg the House to leave the Bill alone.

4.15 p.m.

Lord Winstanley

My Lords, it would not be in the interests of the side of the argument that I support for me merely to repeat arguments which have already been put forward by noble Lords in every single part of the House. I feel sure that those arguments have already convinced every noble Lord in your Lordships' House, even those who voted against the suggestion. The argument was won.

I rise merely to make it quite clear that I and my noble friends on these Benches will support the noble Lord, Lord Cullen of Ashbourne, in this Motion on a matter of principle. It is a very important principle indeed. We have accepted charges for the National Health Service. The Labour Government introduced them twice, the Conservative Government introduced them later and increased them and increased them, over and over again. But here we are in danger of creating an alarming precedent. Never at any time have we levied a charge for an examination.

There is no charge for testing a patient's urine to see whether he has diabetes. There is no charge for a blood test to see whether somebody has AIDS. There is no charge levied on a woman for a cervical smear to see whether she has cervical cancer. We have never accepted the principle of charges for examinations. I am opposed to charges, but we have never had charges for examinations. We are here establishing a very dangerous precedent and that is why my noble friends on these Benches will support the noble Lord, Lord Cullen.

I have listened most carefully to the Leader of the House telling us about exemptions from the charges. However, if something is wrong in principle, then it does not become right because certain people are exempted from the provisions. It is still wrong in principle. It is the principle to which we are opposed. The noble Lord the Leader of the House said that he was convinced that despite this charge many people would still go for sight tests. He says they will, but will they? It might have been different had this argument been about the dental examinations because I believe many people will go for other reasons. But the sight test is not an eye examination, although it should be. We should like it to be an eye examination, but it is merely a sight test. The noble Lord will know that the Secretary of State has taken power in this Bill to change that, so that by order he can insist that when an ophthalmic optician tests eyes: it shall be his duty— (a) to perform such examinations of the eye for the purpose of detecting injury, disease or abnormality in the eye or elsewhere as the regulations may require". I say that because this test does not require those provisions at the moment; it should require them and it will later, if and when the Secretary of State introduces that regulation. Therefore there is a very real danger that if a charge is imposed people will not go for sight tests at all. Here we have a new principle established—a charge for an examination. There have never been charges under the National Health Service purely for examinations. I ask your Lordships' House to do everything possible to resist what I think would be a very dangerous and a very damaging precedent.

Lord Wyatt of Weeford

My Lords—

Noble Lords

Baroness Young.

Baroness Young

My Lords, I thank the noble Lord, Lord Wyatt, for giving way on this occasion. Feelings are running high, and that is not surprising. This is a matter about which everybody cares a very great deal. Like my noble friend Lord Thorneycroft, I respect very much the sincerity and integrity of my noble friend Lord Cullen of Ashbourne. We worked together as close colleagues in government:. We stood side by side on various matters during the days of opposition. We have often argued on the same side.

I hope that at the end of the debate, when my noble friend Lord Cullen of Ashbourne has listened to all that has been said, he will feel that it is not right to press his amendment on this occasion. My noble friend Lord Thorneycroft stated very clearly the arguments about the health service, the money aspect and the success of the Government. I would only add that since I left the Government I have been involved in trying to raise a very considerable sum of money for medical research. That has brought me into close contact with the Oxford hospitals, and indeed other hospitals. I am very conscious of the extremely difficult decisions that confront the health service, particularly with an ageing population. I am quite certain that my right honourable and honourable friends in another place only took this decision about charges after very careful thought and after consideration of the right place for the money to be used.

We are talking about £120 million. That money will continue to be used in the health service, but for something else. The poorest will be helped; 20 million people are to be helped. I do not think there is any question that this is a perfectly fair argument in a world where the living standards of pensioners have risen very considerably, thank goodness. Those living standards will continue to rise and the poorest will be protected, quite properly.

But there is an issue of constitutional principle here for the House to consider. It is on that point that I wish to add a few words in support of the very carefully chosen words of my noble friend the Leader of the House. He has done a very great service to your Lordships' House in very difficult circumstances. As a former Leader of the House I know the kind of problems that can arise. As he explained to us, my noble friend Lord Cullen quite properly moved his amendment, but he was fortunate, if that is the right word, in being able to move it. That position only arose because one of the amendments that the Government were intending to put down in this House was not called and there was a further amendment in another place.

Technically the privilege applies just as much to this measure as it does to the question of dental charges. It would be a great mistake for the House to pretend that the position is otherwise. No one could be more devoted than I to the House of Lords for the work that it does and for the many amendments that it has moved which have, quite properly, improved Bills. Nevertheless I say to the noble Lord, Lord Ennals, that it is a very dangerous argument to try to persuade the House that it would somehow do itself some good by moving and agreeing to this amendment this afternoon. I fear that it would not. It would go against the constitutional principle, as my noble friend Lord Belstead said. It would be damaging to your Lordships' House. As my noble friend said, another place accepted 50 out of 54 amendments to this Bill and, to my certain knowledge, very many other important amendments to other Bills.

The views of this House have been listened to in another place when those in another place quite properly should have listened. But in this case we would be damaging the relationship between the two Houses to persist with this amendment. That damage would be felt not just today but on future occasions. For those reasons I hope very much that the House will listen to the words of my noble friend the Leader of the House and give him the support which he so justly deserves on this occasion.

Noble Lords


Lord Wyatt of Weeford

My Lords, I have given way once. I think it is the turn of the Cross-Benches now.

Lord Belstead

. My Lords, may I suggest that we listen to the contribution of the noble Lord, Lord Wyatt, who was about to get in when my noble friend spoke. Then I suggest we listen to the noble Lord, Lord Kilmarnock, then possibly my noble friend Lord Boyd-Carpenter and then see how we go from there.

4.30 p.m.

Lord Wyatt of Weeford

My Lords, I am very grateful to the noble Lord the Leader of the House. This debate must remind some of us of merry old times. The subject of teeth and spectacles always raises more emotion than anything else to do with the National Health Service.

In 1951 Nye Bevan split the Labour Party by resigning in protest against Hugh Gaitskell's Budget proposals for charges on teeth and spectacles. Labour lost the general election later that year. Now it is the turn of the Conservatives to try splitting their party over teeth and spectacles. They should be warned by the fate which befell the pioneers in this strangely passionate cause.

I was surprised when Nye Bevan resigned over charges imposed in the health service. In October 1949 he commended to the Parliamentary Labour Party a Bill which he thought was urgent and which he wanted to bring in. That Bill was to impose prescription charges of a shilling a time. I shall never forget his words, which went as follows: Something has to be done about the cascades of medicine pouring down British throats, and they're not even bringing the bottles back". Nye Bevan's Bill did not become law for administrative reasons. But it was obvious that the architect of the National Health Service realised very early on that the NHS could never be entirely free. He realised there would have to be charges. If the NHS were to be really free, the ceaseless new developments devouring ever-increasing sums would crush the nation, NHS patients and all, into total poverty. That is why a Labour Government correctly began the introduction of charges in 1951. That is why all governments will have to go on finding ways of supplementing taxation to fund the National Health Service. Even the colossal extra £2 billion or so of recently announced government spending on the National Health Service is not enough.

I thought it very intelligent of Mr. Kenneth Clarke, the Secretary of State for Health, to propose harmless little charges for teeth and eye checks. They will only be paid by 60 per cent. of the population, but they will raise £134 million for the National Health Service which it would not otherwise have. That is not a small amount. The noble Lord, Lord Thorneycroft, reminded us of the numbers of hospitals, operations and so on that it can fund. An enormous improvement could be made with that money.

We are asked today to deprive National Health Service patients of these benefits, not because of hardship caused by the new charges because there cannot be any hardship. No one on family credit or income support will pay them. The list of exemptions is enormous. Only the two-thirds best off in the country will be asked to pay the charges. Many of the same people who attacked the tax reductions for this section of the nation now complain that the better off will have to pay minute charges when they have teeth or eye checks, but surely the tax reductions of which they complain for two-thirds of the population make it all the more reasonable that they should be asked to make a small contribution.

In the past three years gambling on football pools has risen by 26.2 per cent., gambling in bingo halls has risen by 23.5 per cent. and betting on horses and dogs has risen by 29 per cent. Bets of all kinds total more than £8,000 million a year. Is this a hard-up nation that cannot afford to pay £ 3.15 for an occasional dental check or up to £10 for an occasional eye test? The idea is farcical.

We are told that some people with plenty of money in their pockets may be put off vital tests by these tiny costs. If this is true, what are we to do with people who put a few cigarettes or drinks or the hire of a few videos in front of taking care of their teeth or eyes? People who are such fools should take the consequences. It is not for the state to employ town criers or social workers to go up and down the streets asking whether the citizens have had their occasional teeth and eye checks.

There must be some responsibility left on the individual to look after his own health; or is it proposed that there should be a law requiring people to take regular eye tests and teeth checks and to fine them if they do not? Charges in the health service are a long-established and necessary principle. It is suggested that these new charges may lead to more charges in the NHS for those who can afford them. 1 hope that they do. It used to be a socialist principle that state help should be directed at the poor, not at the better off. Now the cry is that if something is available from the state everyone, however rich, should have it free. The right way to get more money to give more help to the poorest is to make the better off pay something, not to get it free.

I support the Government in their forward-looking approach and in their obvious determination to see that the expanding National Health Service really is safe in their hands. I supported the unpopular charges in 1951 when I sat on the Labour Benches in the other place, and I support these charges now.

Lord Kikmarnock

My Lords, it may take some temerity to venture to disagree with the noble Lord the Leader of the House in his advice on the amendment. In his earlier intervention—I noted his words—he said that it was appropriate in certain cases for this House to disagree again and again, which means twice; and this seems to be one such occasion. If the Bill went back once again to the other place, there is no reason whatever why it should not meet for an additional day or morning and reassert its view or change its mind, as the case may be. Either way, that would be the end of the matter.

I have only one point to make. In this case I believe that there is a reason that has not so far been mentioned for returning the Bill to the other place a second time. Some have adduced the narrowness of the majority in the House of Commons as a sufficient reason for so doing, but a majority is a majority and I do not believe that to be the real point.

What strikes me as extremely important is that the Chancellor's Autumn Statement was deliberately made on the very day that these charges were to be debated in another place. The timing was obviously intended to influence the outcome by creating the impression of' a cornucopia of National Health Service spending, in which case it would be churlish and unmannerly of the rebels to persist in their revolt.

As we all know, NHS statistics are open to many different interpretations. In making his Statement the Chancellor mentioned large cash sums—this has been referred to also by the noble Lords, Lord Thorneycroft and Lord Wyatt of Weeford—that he claimed would amount to an increase in real cash terms of 4.5 per cent., but detailed analysis tells another story. The Financial Times in a leading article on 3rd November could find a rise of only 1.5 per cent. in real terms for next year, with even smaller increases in the two succeeding financial years. One reaches this conclusion principally because much of the £861 million cash increase for hospital and community services will he wiped out by inflation, which is now running at 6 per cent., not:5 per cent. as calculated by the Government.

There are other technical factors that reduce the cornucopia further that I will not go into. Noble Lords who are interested will find them all set out in an article in the next issue of the British Medical Journal, which comes out with a real increase of only 1.4 per cent., very close to the figure reached by the Financial Times and considerably less than the 2 per cent. in real terms that the Government themselves admit is necessary to stand still.

The point I make is that these are intricate calculations. I very much doubt whether all Members of another place had either the time or information available to make them on their cuffs or on the back of an envelope last Tuesday. If they had, some who were overwhelmed by the Government's apparent generosity might have changed their minds when it came to vote on optical and dental charges. Now that they have had time to digest the evidence, it seems to me entirely appropriate on those grounds that in this specific instance this House should give the other House a chance to think again.

Lord Boyd-Carpenter

My Lords, for those like the noble Lord, Lord Wyatt of Weeford, and myself who have been in one House or another for a good many years, this debate and its subject have a rather nostalgic effect. As the noble Lord, Lord Wyatt of Weeford , partly reminded us, as long ago as 1951 not only the late Mr. Bevan but also the noble Lord, Lord Wilson of Rievaulx, resigned from the Labour Government on the grounds that the Government were introducing charges in respect of teeth and eyes. It is a curious indication of the continuity of controversies in our system and in our society that here we are again in 1988 having largely and fully attended strongly felt debate on those very subjects.

Before I pass to my main point, I wish to say how amused I was by the noble Lord, Lord Ennals. Not only did he indicate that he thought that this House was strengthening its reputation by accepting the amendment but he added a statement referring to the high regard in which this House is now held. That coming from a Front Bench spokesman of a party that has recently committed itself to the abolition of this House, seems to carry a paradox rather far. To the noble Lord who said, "Wrong again" I can only suggest, if it does not bore him too much, that he has not talked to his friend Mr. Hattersley, who said exactly this.

Noble Lords


Lord Boyd-Carpenter

My Lords, there are two issues before your Lordships this afternoon. One is the constitutional; the other is the merits. I think that the constitutional has been very clearly and definitely thrashed out, particularly by my noble friend Lady Young. It is quite clear that we should be acting contrary to the spirit of the constitution if we were to reject the Commons amendment.

Moreover, from a practical point of view we should undoubtedly be hardening and making more difficult our relations with another place if we were to push to this extent what some of your Lordships seem to think are our powers and to reverse its decision on a matter of this kind. Therefore the final legal assessment of the situation, from a practical point of view I think that we should be doing a great deal of harm to the working not only of this House but of Parliament as a whole if we were to throw this legislation once again back at the Commons.

Lord Cledwyn of Penrhos

My Lords, perhaps the noble Lord will give way. Is he not aware that when in opposition the party opposite did precisely that on at least three occasions in the 1970s. In 1974 during the passage of the Trade Union and Labour Relations Bill, on an occasion comparable with this one, the noble Lord, Lord Carrington, as Leader of the Opposition, urged his colleagues who were then on the Opposition Benches to follow him into the Division Lobby, and they did so. Among those who went into the Division Lobby on that occasion—a comparable case with this one—were the noble Lord, Lord Belstead, the noble Earl, Lord Ferrers, and the noble Lord, the Government Chief Whip.

Lord Boyd-Carpenter

My Lords, the noble Lord, Lord Cledwyn, has been sitting there all afternoon longing to get that off his chest. I do not know whether he refers to it as an example of what should be done or uses it merely as a form of reproach. I rather understood his tone to be one of reproach, with the suggestion that my noble friends to whom he referred had erred. If that is so, it is no argument that the offence should be repeated by the present Opposition. On the other hand, if the noble Lord is holding it out as an example of correct behaviour, I am sure my noble friends will be greatly embarrassed to have such a tribute from such a source.

The substance of the matter is the reality of social policy. As one who for six-and-a-half years held appointment as Minister of Pensions and National Insurance, I want to put to your Lordships the point about conflicting philosophies because they are highly relevant to this issue. There are two philosophies. There is the philosophy that practically everything should be provided by the state and that everyone, however well off or comfortably funded, should share in it but pay very heavily in taxation for the privilege. The other philosophy—and it is one which I support— is that social welfare and social payments should be concentrated on the least well off and that those who are better off should again and again be encouraged to provide for themselves. After all that is the prevailing philosophy in the United States which has produced the highest standard of living of any major country in the world. That is highly relevant to this discussion.

As your Lordships know, roughly one-third of the population—the poorest one-third—will be exempt from these charges. My noble friend has made clear that if at the margin there are any hard cases which are not covered by that exemption, he and the Government will look into the matter. However, the great majority of the population will not suffer any hardship through charges of this sort because, fortunately, for the reasons given by one or two of my noble friends, under this Government the general standard of living of the population has risen so substantially over the years that charges of this kind are not a deterrent to going for tests; they are not a deterrent to using the services.

Your Lordships therefore have to judge between the two different philosophies. There is the philosophy which, I must confess, I tried to follow as Minister; namely, that of concentrating more and more of the aid—except of course in respect of contributory benefits—that is to say, the non-contributory aid, on the poorest section of the population. That is exactly what this Bill and these clauses do. While exempting the poorest one-third from the charges the money saved—and it is a substantial sum—is then put into the health service as a whole to help those in need of it.

Noble Lords opposite often rightly complain about the underfunding of certain parts of the health service. Yet, when the proposal is made, without inflicting hardship on anyone who is poor enough to suffer, to transfer funds (which is what this operation amounts to) toward the general benefit of the service and its improvement, noble Lords opposite seem to object to it. According to their philosophy, which I tried to outline a moment ago, that is a perfectly consistent attitude. I believe that the prevailing philosophy in this country increasingly tends to favour the concentration of public aid on the least well off. And the matter of these charges is a small but significant contribution to that shift.

Finally, I ask your Lordships to look at the matter in this way: if these charges were in effect now, would anybody think that their abolition should take priority over any other expenditure or improvement in the health service? I have no doubt what the answer would be.

4.45 p.m.

Lord Mishcon

My Lords, before the noble Lord sits down feeling any contentment with his reply to the very valid point made by my noble friend the Leader of the Opposition, perhaps I might be allowed to quote something said by the noble Lord, Lord Carrington, when he was Leader of the Opposition. The noble Lord said: In our system we have hitherto taken the view that the will of the elected House must in the end prevail, but there should be a second House which has the opportunity—in rare cases, perhaps—to enforce a delay in which there can be a reassessment by Government, by Parties and by the people of this country of the rights or wrongs of an issue. If now we decide to use that very limited power, we are not thwarting the will of the people for, in so far as it is represented by the House of Commons, it will and must prevail in a comparatively short time. We shall be using those powers for the purpose for which they were given to us—that is, as an opportunity for further consultation, for second thoughts before this legislation inevitably reaches the Statute Book and because we did not want the Second Chamber to be associated with what the Government are doing".—[Official Report, 11/11/75; col. 1742.)

Viscount Whitelaw

My Lords, I have been provoked. I did not intend to take part in the debate but surprisingly for me I want to rise in answer to the noble Lord the Leader of the Opposition. I say "surprisingly for me" because I owe so much to him from the time when I was Leader of your Lordships' House. I think that his point and that made by the noble Lord, Lord Mishcon, are completely misplaced.

I come back to what my noble friend Lady Young said. There is all the difference in the world between the case put by the noble Lords and the case which I and my noble friend Lady Young believe in. The difference is that the case they put does not relate in any circumstance to financial privilege. It is no good the noble Lord, Lord Ennals, trying to pretend that there is no constitutional principle involved in the case we are looking at today. One of the amendments is financially privileged. That is admitted. The other amendment is not so privileged, because of a minor technicality resulting from a concession made in another place to views put forward in this House. Theirs is a most extraordinary argument.

The noble Lord, Lord Cledwyn, refers to my noble friends Lord Carrington, the Leader of the House and the Chief Whip and says that this situation goes back in time. On this occasion however there is all the difference in the world. This is a question of financial privilege in one case and, but for a technicality, financial privilege in the other. If we are going to go back on that, we shall do grave damage to your Lordships' House.

Lord Molloy

My Lords, the noble Lord, Lord Wyatt, referred to the fact that the quarrel within the Labour Party over the introduction of prescription charges, which Nye Bevan opposed and others wished to introduce, resulted in the Labour Party losing the subsequent election. He forgot to mention that it lost the election in spite of having half a million votes more than the Tory Party. That is a very significant fact because it means that the majority of people who voted in that general election wanted Labour Government.

The noble Lords, Lord Thorneycroft and Lord Boyd-Carpenter, have brought in taxation. They have argued that people who might be in danger of going blind or having some terrible disease of the eyes should make a contribution to some other aspect of the National Health Service if they can afford it. While they argue that point, like the Leader of this House, they also agree that tax relief should be given to people on £100,000, £250,000 or £300,000 a year. Such tax relief would have paid for all the matters that have been argued about this afternoon. The noble Lord the Leader of the House quite rightly, and I believe generously, paid his sincere respects to his two colleagues who are experts in this matter—and they are. But after recognising them as experts, he refused to take their advice.

However, the argument goes much further than that. If there is some severe economic or other problem in the country we have what are called think-tanks to argue it out and to find the solution. We have think-tanks for the National Health Service. They have given their advice, but the Government are totally rejecting it. Every Member who votes tonight has to take this into consideration. The British Medical Association is opposed to the Government's proposals. The Health Visitors Association, which deals specifically with preventive measures, is opposed to the Government's proposition. The Confederation of Health Service Employees, which covers a vast area of our National Health Service, is opposed to the Government's proposition. The ophthalmic practitioners are opposed to the Government's proposition. The opticians are opposed to the Government's proposition.

I am suggesting that a remarkable number of specialised people who work in this area every day of their professional lives feel that our Government are making a serious mistake; but they are going to be totally ignored. I hope that the arguments advanced by the ophthalmic practitioners and the opticians will not be considered a laughing matter by Members opposite. These professions argue that sometimes, because people have not taken advantage of the possibility of having free eye tests, they have become blind. I hope that the House will take that into consideration. Even those who have not become blind may have had some other fearful eye disease. The Society of Ophthalmic Practitioners says—these are its words, not mine—that in the main all these instances of people who have gone blind or who have serious eye diseases could have been prevented if they had been sensible enough to have their eyes tested. Is it a good thing that extremely rich people have massive tax reductions and that ordinary folk who believe that they should have their eyes tested but who may not be able to afford it are to have a means test to find out who shall go blind and who shall not? I consider that a deplorable attitude.

I sincerely ask the House to consider these points. They may not be the points of view expressed by great practitioners in the City of London but they are the views of every single British professional organisation involved in Britain's National Health Service. I believe that we should show ourselves to be an arrogant House if we totally disregarded the advice that they have given us.

Lord Campbell of Alloway

My Lords, I shall be very brief at this stage of the debate. I wish to make one point. The noble Lord, Lord Ennals, has said specifically and quite clearly that no constitutional issue arises. He is of course entitled to his view. However, I am bound to point out to your Lordships' House that it is not the view of Mr. Speaker. Mr. Speaker said: I remind the House"— that is the other place — that privilege is involved in these amendments". Mr. Speaker carried it further: Lords amendments Nos. 20 and 22 involve Commons privileges. The House gave a reason for disagreeing with the Lords on amendment No. 20. It did not do so in respect of amendment No. 22 as it is not the custom to give a reason when consequential amendments arc made to a Bill".—[Official Report, Commons. 1/11/88; cols. 923 and 1197.] Therefore my noble friend the Leader of the House and my noble friend Lord Whitelaw are totally correct when they maintain to your Lordships that there is a constitutional issue involved. It is for that reason that the hope must be that your Lordships will not insist on this amendment. If we do so we surely put comity between the two Houses in the ordering of their affairs to the hazard, and for all one knows invite possible confrontation—one cannot look too far into the future—or perhaps impose reform.

When the noble Lord, Lord Ennals, said on the first amendment that the principles are the same for teeth and eyes, that the two go together, he was in essence right, because it is to be inferred from what Mr. Speaker said—and I have quoted it—that but for the concessionary amendments on the eye test charges he would have certified by reasoned agreement on the eye test charges.

Surely the position quite shortly is this. Privilege has not been waived on either dental charges or on eye test charges. Privilege was claimed on dental charges by reasoned disagreement, but privilege could not be claimed on eye test charges by reasoned disagreement, by reason of the concessionary amendment. As I understand it from reading Erskine May and Hansard only—and I speak with deference to noble Lords who have served in another place—unless another place waives its privilege as regards the allocation of public funds, which on no showing is the case here if one reads the Commons Hansard, the convention is that your Lordships' House does not insist upon the amendment. In these circumstances it would surely be wrong to trespass upon the spirit of these privileges.

There is a grey area. Mr. Speaker has certified. I agree that Mr. Speaker is the guardian of the privileges of another place, but so in a sense are we, quite apart from our own privileges, because both Houses have an interest in the maintenance of the bicameral system. To trespass upon privilege against the spirit of a convention would be unwise and would at this stage of this Session, of all times, appear to create a situation where we are seeking to force the Government to introduce alternative proposals acceptable to your Lordships' House.

Your Lordships may think this a reasonable suggestion. It is in that that perhaps lie the possible seeds of confrontation to which I have referred. Does not the maintenance of the spirit of our conventions and the conventions of the other place transcend the merits of this single amendment? The Clerks at the Table, quite rightly, have declined to advise on the constitutional implications for your Lordships' House.

Noble Lords

Not so; not right.

5 p.m.

Lord Campbell of Alloway

My Lords, noble Lords say "Not right", but I have a copy of the document. In the last paragraph of the document dated 7th November 1988, signed by J. M. Davies, the Clerks at the Table declined to advise on the constitutional implications of insisting on this amendment; and rightly so, because that is not the responsibility of the Table. It is the responsibility of your Lordships' House.

Noble Lords

Quite misleading.

Lord Cledwyn of Penrhos

My Lords, with great respect, the noble Lord has quoted from a submission from the Clerks at the Table, but he did not read all the submission. That is a great weakness. If I may I shall read the appropriate paragraph, if I am in order in doing so. The noble Lord has opened this door. The document states: The Commons have disagreed to the Lords amendment but because they have amended it, in response to Government undertakings given last summer, they have not given a Reason for their disagreement. It is therefore proper for the House of Lords to seek to insist on their amendment and return it to the House of Commons for further consideration".

Lord Campbell of Alloway

No, my Lords. There is no suggestion that there is any procedural impropriety in the amendment that has been put forward. I have made none. All that I sought to maintain was that, in the circumstances which exist, to trespass on the spirit of a convention would not be wise.

The Earl of Halsbury

My Lords, the Cross-Benches, I think.

Lord Diamond

My Lords, from the words used by the mover of the amendment—

The Earl of Halsbury

My Lords, we know—

Noble Lords


Lord Diamond

My Lords, I shall be very short, my Lords.

Noble Lords

No; Cross-Benches.

The Earl of Halsbury

My Lords, I am greatly obliged to the noble Lord for giving way. I have always tried to discriminate between right and its wise exercise. Undoubtedly the noble Lord, Lord Cullen of Ashbourne, has a right to put forward the amendment. Your Lordships have a right to support it, but whether it would be wise to do so is another matter. I probably have a common law right to climb some tree or other, provided that it is not governed by the law of trespass on the one hand or by the by-laws of some public park on the other, but it would not necessarily be a wise exercise of my right at my age.

At this point in the parliamentary year it might be unwise to embark upon a game of ping-pong, with only four working days left to go on a Bill of this character. I know that it is part of the fun of the game that the Government always mix cunning with bluff at this stage and manage to get their Bills through with the threat that they may get lost if we insist on out right to do this, that and the other.

However, I feel that this is not a case of bluff. I believe that we might lose the Bill if we play pingpong and say "Ping" this afternoon and then at the beginning of next week the Commons say "Pong" and back it comes again with some procedural nicety which enables the Commons to claim privilege. It is too late in the parliamentary year to play that kind of game. Therefore I shall not support the noble Lord, Lord Cullen, but I shall support the noble Lord, the Leader of the House.

Lord Ferrier

My Lords, as an aboriginal Life Peer back in the days when a Back-Bencher could get a word in edgeways. I started to speak continually about the necessity for preventive medicine. I have done so for 30 years. I am sorry that I was unwell and unable to take part in the debates on the Bill until this came. Now I have a new point to raise which I want to make. I came here to support my noble friend Lord Cullen, but if he is going to hedge bets and suggest a compromise, I shall be against him and I shall agree with the noble Lord, Lord Ennals, that this is a straightforward constitutional problem and we have the right to say no.

The importance of this matter is that well-to-do people, government people, Members of the House of Commons, say that £10 can easily be afforded. People cannot afford it, as people like myself who are constantly in touch with others, know. I agree with what the noble Lord said about the BMA, the opticians and the like who are against these charges. Of course they are. They are more than that. The district nurses, people who live alone and one-parent families are amazed when they are told £10 and that they can easily afford it. They cannot. Whatever one may think about privilege and the like, this House is entitled to choose. When they know what we have been doing here, they say "Well done, the House of Lords!"

Noble Lords

Hear, hear!

Lord Ferrier

They are speaking from their hearts. I speak from my heart. The point I want to make is that it is no use saying that we lose the money if these charges are not accepted, but there are other ways of saving money that the department could well undertake. What about accepting manipulative therapy as a contribution? There would be enormous savings there if only it could be accepted. Is there any penalty for people who do not take up beds when they have been allotted a bed and are advised that it is vacant? If they do not turn up the bed is lost and the operation time and the doctors' time are wasted. I am strongly of the opinion that we have every right to oppose this matter, even if it means losing the Bill by opposing any application of charges of this nature.

Lord Rea

My Lords, I hope the House will think that it is appropriate that the voice of a practising general practitioner, as well as that of a practising dentist, should be heard in the debate, particularly as it is about eyes and not teeth. Some of my remarks will follow the arguments which convinced your Lordships to vote for the original amendment at Committee stage.

Many noble Lords were not present during the earlier stages of the Bill. Most reasonable people—and on 2nd November that included Mrs. Edwina Currie—concede that the £10 charge will deter a proportion of the 7.2 million people who will have to pay for seeking eye tests.

In 1986 a similar exercise took place in Alberta, Canada, when free eye tests were abolished. In the following year there was a fall of 30 per cent. in the number of eye tests undertaken on members of the population between the ages of 16 and 64; that is the economically active population. If, in the United Kingdom, that proportion was applied to those who would have to pay, it would result in 2.2 million fewer eye tests per annum. It is important to examine the implications. On the current rates 150,000 of the 2-2 million people would have been referred by their GP for a specialist's opinion because of the finding by an ophthalmic optician of a potentially serious condition. Early glaucoma makes up the largest proportion of those referrals—approximately 20 per cent. of the recent series reported in this week's British Medical Journal, for example.

If there is a delay in diagnosing glaucoma—and it has been pointed out many times that people do not seek help until their vision begins to deteriorate—there is a greater chance of eventual blindness. The costs of out-patient and in-patient treatment for such people will be far higher than it would have been had it been detected at an earlier stage. One conservative estimate suggests between £11 million and £22 million extra hospital costs per annum, plus £10.5 million extra per annum to support the resulting 3,000 additional blind people. Therefore, £30 million must be deducted from the savings which the Government hope to make, quite apart from considering the social and human costs of additional blindness and impaired vision.

Further costs are involved. It is likely that at least one in ten of the 2.2 million people deterred from having eye tests will go to their GP requesting referral to a hospital eye department which is free. At £25 to £50 per out-patient visit, that may total a further £5 million. General practitioners are not so expert as ophthalmic opticians in detecting and describing early eye conditions, and they fully admit that. They do not have the training, equipment or time. That is clearly shown in the report from Burton-on-Trent published in the British Medical Journal.

General practitioners have no wish to be cast into the role of screeners for eye disease and they are not particularly well-qualified for it. However, approximately 900 general practitioners are specially qualified medical practitioners who carry out excellent work. Approximately one in ten of referrals to hospitals are theirs. Their livelihood would be in jeopardy if free eye tests were abolished and an excellent service would be lost.

I have concentrated on glaucoma because that is the most common cause of preventable blindness detected by eye tests. However, there are numerous other conditions which it is useful, even essential, to detect at an early stage in order to achieve good results. For example, diabetic retinopathy which, according to the BMJ series I mentioned, was discovered in a few cases even before the patient knew he had diabetes. Other general medical conditions are high blood-pressure and thyroid disease which are often first discovered at an eye examination when the patient is unaware of it.

I consider that it would be a proper step for your Lordships to uphold the original amendment. The stated intention of the Bill, which is to improve the health of the population, may look more credible. I reiterate the fact that the clause allowing the sale of over-the-counter reading glasses may act as a further deterrent to eye tests for those who have presbyopia, which is difficulty in reading in early middle age. By temporarily improving their sight a more serious underlying condition, such as glaucoma, may be masked. The two clauses sit ill together, and that is a further reason for insisting on our original amendment.

Lord Belstead

My Lords, at the end of a long debate, during which there has been a good deal of disagreement, there is one issue upon which all noble Lords are agreed. It is that, unquestionably, the National Health Service as we know it today—we are all interested in it for different reasons and although meeting together on one issue today we shall all make use of it at one time or another—

Lord Mottistone

My Lords—

Noble Lords


Lord Mottistone

My Lords, as a supporter of the amendment I should like to say a few words. However, my noble friend the Leader of the House rose, and I should not like to speak after him. Many of my noble friends, particularly those whom I respect a great deal, have made the point that the issue is constitutional and that we should not go through with it. It may help your Lordships if I read an extract from a letter from my right honourable friend the Secretary of State for Health with whom I have been in correspondence during the past two days. I said that I was sorry I could not see him last Thursday because of other commitments and that I believed that one of the difficulties was the constitutional issue. He replied as follows: I do not want to rely particularly on the so-called constitutional argument. Their Lordships did exercise their undoubted right to make the Commons think twice about this issue. However, the Commons has now given the Government a majority for the second time and I think the House of Lords should think very seriously before forcing a crisis over £140 million of expenditure on the National Health Service". I have read the whole of the quotation.

I have thought very seriously, and I believe that your Lordships have thought very seriously. Before I supported my noble friend's amendment we took advice from the Clerks. We were thoroughly reassured that there was no consitutional issue and it is clear that my right honourable friend the Secretary of State does not wish to make a great issue of that aspect.

Secondly, there is absolutely no doubt, as everyone who has spoken agrees (including Mrs. Edwina Currie) that if charges for eye tests are imposed, some people—it is anyone's guess how many; some will say more and some will say less—will forgo a test that they would otherwise have had and will suffer from doing so.

I quote from a letter I received from a university lecturer. He says: In June, 1987, I went for an eye test more to accompany my elderly mother who was due for one rather than for any great need myself. The oculist on examining my eyes advised me to have a blood-pressure test. The doctor found that my blood pressure was very high and said that I might well have had a stroke. He put me on a course of tablets which has brought my blood pressure back to normal. I would have known none of this if I had not had the eye test and would certainly not have had it if there had been a charge". That is the kind of situation that we seek to avoid. The writer goes on to say that had he had a stroke the cost of treating him would have been a great deal. That is one of the reasons why we believe that the amount which the Government will save will be offset by many unforeseeable charges.

I believe that on balance we must challenge the issue and accept my noble friend's amendment.

Noble Lords

Hear, hear.

Lord Belstead

My Lords, I am sorry if I seemed to be trying to cut out my noble friend and I am glad that we have had an opportunity to hear him. The first point I should like to make at the end of this long debate is that although clearly my noble friend Lord Mottistone and the Government do not agree on this issue I believe that there is one matter with which all your Lordships would agree; that is, that the health service as we know it today constantly needs more and more resources.

I was interested that my noble friend Lord Thorneycroft made the point very clearly that priorities must be the language of any government and particularly in the health service. It is in that context that the Government believe on this issue that they are right to ask those who can afford to do so to make a contribution towards the cost of a sight test so as to release greatly increased resources for the development of primary health care services. That means in simple terms better services for patient care with, however, wide exemptions for people who either cannot or should not pay.

We have heard the argument put today—it has been put by the noble Lord, Lord Rea, and the noble Lord, Lord Winstanley, in particular—that there would be deterrents in this policy. However, I say to both noble Lords that the evidence simply does not support that contention.When we took the dispensing service for spectacles out of the National Health Service and started the voucher scheme some years ago, noble Lords, as I said earlier, predicted doom and gloom. And yet, people going for sight tests know perfectly well that in most cases the tests will lead to their spending money on the purchase of spectacles. Those people have done what? People have made steadily increasing use of optical services in this country.

The noble Lord, Lord Rea, and my noble friend Lord Mottistone sought to suggest that my honourable friend the Parliamentary Under Secretary of the department had suggested in some way that there would be deterrence. My understanding of what my honourable friend said was that she was clearly making the point that it would be commercial suicide for opticians to charge a fee for sight tests at a level which would drive customers away from having spectacles. Three out of four tests result in a prescription for glasses and therefore I believe that what my honourable friend said was perfectly sensible.

At the beginning of this debate I gave an assurance to my noble friend Lord Cullen which I shall not repeat except to say that it was made in good faith and I do not detract one word from what I said twice in my opening speech.

I should like to end this debate by making a brief reference to the position between the two Houses. We have heard a good deal about matters of principle in the past hour and a half. My noble friends Lady Young and Lord Boyd-Carpenter made it clear that they believed that insistence in this case would be damaging to relations between the two Houses. The noble Lord the Leader of the Opposition, Lord Cledwyn, asked why that should be so in this case and not, for example, in the case of aircraft and shipbuilding. It was because the sticking point on the question of aircraft and shipbuilding was hybridity and ship repair and was not money. On another famous Bill of the 1970s concerning trade unions and labour relations, the sticking point was freedom of the press and the closed shop and it was not money. Therefore when my noble friend Lord Whitelaw intervened, he was right—and oddly enough he very often is.

Despite the fact that he did not go any further, there is one other issue which I believe I need to lay before your Lordships. Under the conventions which regulate the passage of Bills between the two Houses, if this House were to insist on this amendment and if another place again insisted on its disagreement, which incidentally would be the third time that the issue was before another place, the Bill would be lost for this session. It would only be open to the Commons either not to insist on their disagreement or to offer an amendment in lieu. It would not be possible for them to insist again. That option would be closed to them.

Nonetheless, noble Lords opposite, and particularly the noble Lord, Lord Ennals, and the noble Lord, Lord Kilmarnock, from the SDP Benches, said that they believe we should ask another place to think again. The fact is that if we insisted on the amendment we should not so much be asking another place to think again as to prefer the judgment of your Lordships' House in a matter involving the major financial arrangements on which another place has twice taken the same decision. I feel sure that that is not what your Lordships would wish to do and I ask the House not to insist on this amendment.

Lord Cullen of Ashbourne

My Lords, there are one or two points I should like to pick up from the debate. First, I did not make clear originally that I have another interest to declare; namely, that my mother had extremely bad glaucoma for many years, not having had a proper sight test. My wife took my mother to the ophthalmologist about 50 times. She had operations on both eyes. I shall therefore be eligible for free sight tests as a result of this Bill as the son of somebody who has had glaucoma. Therefore that is another interest to declare.

One remark made by my noble friend Lord Thorneycroft needs correcting. He suggested that instead of the sight test fee being £10, it might be £5 or less, or even nothing. Your Lordships will remember that in Clause 14 of the Bill it is laid down that opticians, having given the sight test, have to give the prescription to the person who has had the test. That person can take that prescription away and shop around; that was really the whole point of it. I do not know what your Lordships!:kink about opticians, but they are not so silly as to give a free sight test and then have the person walk straight out of their shop and go elsewhere. There is no doubt that the cost of the sight test will not come down in general terms, and in some cases it will probably go up. I know some opticians have said that they definitely cannot make a profit on the £10 charge.

We seem to have been talking more about constitutional matters than health matters this afternoon. I said originally that my noble friend the Chief Whip had not twisted my arm in any way, and that was so. As regards this debate, I feel that I have been twisted a great many ways. Both my arms feel dislocated and mentally I feel absolutely whacked because of all the constitutional problems that seem to have arisen. However, I go back to the advice I have received from the Clerks at theTable and I have no reason to think that they would have given me advice that was not entirely right. I suspect that some Members of the Government may have given me advice which was a little biased, but perhaps I should not say that. I commend my Motion to your Lordships, and I wish to test the opinion of the House.

5.30 p.m.

On Question, Whether the Motion shall be agreed to?

Their Lordships divided: Contents, 207; Not-Contents, 257.

Addington, L. Gloucester, Bp.
Airedale, L. Graham of Edmonton, L.
Alport, L. Gray, L.
Amherst, E. Greenway, L.
Ardwick, L. Gregson, L.
Auckland, L. Grey, E.
Aylestone, L. Grimond, L.
Banks, L. Hampton, L.
Barnett, L. Hanworth, V.
Basnett, L. Harris of Greenwich, L.
Beaumont of Whitley, L. Hart of South Lanark, B.
Birk, B. Hatch of Lusby, L.
Blackstone, B. Hayter, L.
Blease, L. Henniker, L.
Bonham-Carter, L. Hertford, M.
Boston of Faversham, L. Hirshfield, L.
Bottomley, L. Hooson, L.
Bramall, L. Howie of Troon, L.
Briginshaw, L. Hughes, L.
Brimelow, L. Hunt, L.
Broadbridge, L. Hutchinson of Lullington, L.
Brooks of Tremorfa, L. Hylton, L.
Bruce of Donington, L. Ilchester, E.
Buckmaster, V. Ingleby, V.
Burton of Coventry, B. Irvine of Lairg, L.
Callaghan of Cardiff, L. Irving of Dartford, L.
Campbell of Eskan, L. Jacques, L.
Carmichael of Kelvingrove, L. Jay, L.
Carter, L. Jeger, B.
Chandos, V. Jenkins of Hillhead, L.
Chelmsford, Bp. Jenkins of Putney, L.
Chelwood, L. John-Mackie, L.
Chesham, L. Kearton, L.
Chichester, Bp. Kennet, L.
Chitnis, L. Kilbracken, L.
Cledwyn of Penrhos, L. Kilmarnock, L.
Cocks, of Hartcliffe, L. Kinloss, Ly.
Colwyn, L. Kirkhill, L.
Combermere, V. Kirkwood, L.
Craigavon, V. Kissin, L.
Cudlipp, L. Lawrence, L.
Cullen of Ashbourne, L. Leatherland, L.
[Teller.] Leathers, V.
Darcy (de Knayth), B. Listowel, E.
David, B. Liverpool, Bp.
Davies, L. Llewelyn-Davies of Hastoe, B.
Davies of Penrhys, L. Lloyd of Hampstead, L.
Dean of Beswick, L. Lloyd of Kilgerran, L.
Denington, B. Lockwood, B.
Diamond, L. Longford, E.
Donaldson of Kingsbridge, L. Lovell-Davis, L.
Donoughmore, E. Lucas of Chilworth, L.
Dormand of Easington, L. Lytton, E.
Ennals, L. McCarthy, L.
Ewart-Biggs, B. McGregor of Durris, L.
Ezra, L. McIntosh of Haringey, L.
Falkender, B. Mackie of Benshie, L.
Falkland, V. McNair, L.
Ferrier, L. Mais, L.
Fisher of Rednal, B. Manchester, Bp.
Fitt, L. Masham of Ilton, B.
Flowers, L. Mason of Barnsley, L.
Foot, L. Mayhew, L.
Gallacher, L. Meston, L.
Galpern, L. Milner of Leeds, L.
Gardner of Parkes, B. Mishcon, L.
Gifford, L. Molloy, L.
Gladwyn, L. Monkswell, L.
Glenamara, L. Monson. L.
Mottistone, L. [Teller.] Southwark, Bp.
Mountevans, L. Stallard, L.
Mulley, L. Stanley of Alderley, L.
Murray of Epping Forest, L. Stedman, B.
Nelson, E. Stewart of Fulham, L.
Nicol, B. Stoddart of Swindon, L.
Northfield, L. Strabolgi, L.
Ogmore, L. Swann, L.
O'Neill of the Maine, L. Tanlaw, L.
Oram, L. Taylor of Blackburn, L.
Paget of Northampton, L. Taylor of Gryfe, L.
Parry, L. Taylor of Mansfield, L.
Perry of Walton, L. Tedder, L.
Peston, L. Teviot, L.
Phillips, B. Tordoff, L.
Pitt of Hampstead, L. Turner of Camden, B.
Ponsonby of Shulbrede, L. Underhill, L.
Prys-Davies, L. Vernon, L.
Raglan, L. Wallace of Coslany, L.
Rathcreedan, L. Walston, L.
Rea, L. Wedderburn of Charlton, L.
Ritchie of Dundee, L. Whaddon, L.
Robertson of Oakridge, L. White, B.
Robson of Kiddington, B. Williams of Elvel, L.
Rochester, L. Willis, L.
Ross of Newport, L. Wilson of Langside, L.
Russell, E. Wilson of Rievaulx, L.
Ryder of Warsaw, B. Winchilsea and Nottingham,
Sainsbury, L. E.
Scanlon, L. Winstanley, L.
Seear, B. Winterbottom, L.
Sefton of Garston, L. Wise, L.
Serota, B. York, Abp.
Shepherd, L. Young of Dartington, L.
Sidmouth, V. Zuckerman, L.
Simon, V.
Abinger, L. Campbell of Croy, L.
Airey of Abingdon, B. Carnegy of Lour, B.
Aldington, L. Carnock, L.
Alexander of Weedon, L. Carrick, E.
Allenby of Megiddo, V. Cathcart, E.
Allerton, L. Cayzer, L.
Annaly, L. Chalfont, L.
Arran, E. Chelmer, L.
Ashbourne, L. Chilston, V.
Astor of Hever, L. Coleraine, L.
Aylesford, E. Colnbrook, L.
Barber, L. Colville of Culross, V.
Bathurst, E. Constantine of Stanmore, L.
Bauer, L. Cornwallis, L.
Bearsted, V. Cottesloe, L.
Beaverbrook, L. Cowdray, V.
Bellwin, L. Craigmyle, L.
Beloff, L. Craigton, L.
Belstead, L. Crathorne, L.
Bessborough, E. Crickhowell, L.
Bethell, L. Croft, L.
Birdwood, L. Dacre of Glanton, L.
Blanch, L. Daventry, V.
Blatch, B. Davidson, V. [Teller.]
Blyth, L. De La Warr, E.
Boardman, L. Denham, L. [Teller.]
Bolton, L. Denman, L.
Borthwick, L. Derwent, L.
Boyd-Carpenter, L. Digby, L.
Brabazon of Tara, L. Dilhorne, V.
Braye, B. Dulverton, L.
Bridgeman, V. Dundee, E.
Brookeborough, V. Dunrossil, V.
Brougham and Vaux, L. Eccles, V.
Broxbourne, L. Eden of Winton, L.
Bruce-Gardyne, L. Elibank, L.
Butterworth, L. Ellenborough, L.
Caccia, L. Elles, B.
Caithness, E. Elliot of Harwood, B.
Camden, M. Elliott of Morpeth, L.
Cameron of Lochbroom, L. Elphinstone, L.
Campbell of Alloway, L. Elton, L.
Erne, E. Moyne, L.
Erroll of Hale, L. Munster, E.
Falmouth, V. Murton of Lindisfarne, L.
Fanshawe of Richmond, L. Nathan, L.
Ferrers, E. Nelson of Stafford, L.
Foley, L. Newall, L.
Forbes, L. Norfolk, D.
Forester, L. Norrie, L.
Forte, L. Nugent of Guildford, L.
Gainford, L. Onslow, E.
Geddes, L. Orkney, E.
Gibson-Watt, L. Orr-Ewing, L.
Gisborough, L. Oxfuird, V.
Glenarthur, L. Peel, E.
Goold, L. Pender, L.
Gorell, L. Pennock, L.
Goschen, V, Perth, E.
Gowrie, E. Peyton of Yeovil, L.
Grafton, D. Piatt of Writtle, B.
Grantchcster, L. Plummer of St. Marylebone, L.
Gray of Contin, L.
Gridley, L. Portland, D.
Grimston of Westbury, L. Portman, V,
Halsbury, E. Pym, L.
Hardinge of Penshurst, L. Quinton, L.
Harmar-Nicholls, L. Reay, L.
Harris of High Cross, L. Rees, L.
Harvington, L. Rees-Mogg, L.
Havers, L. Reigate, L.
Henley, L. Reilly, L.
Hesketh, L. Renton, L.
Hives, L. Renwick, L.
Holderness, L. Rippon of Hexham, L.
Home of the Hirsel, L. Rochdale, V.
Hood, V. Rockley, L.
Hooper, B. Rodney, L.
Inchcape, E. Romney, E.
Ingrow, L. Rotherwick, L.
Ironside, L. Rugby, L.
Jenkin of Roding, L. Sackville, L.
Johnston of Rockport, L. St. Aldwyn, E.
Joseph, L. St. Germans, E.
Kaberry of Adel, L. Sanderson of Bowden, L.
Kemsley, V. Sandys, L.
Kenilworth, L. Savile, L.
Kimball, L. Selborne, E.
Kimberley, E. Selkirk, E.
Kinnaird, L. Sharpies, B.
Kitchener, E. Sherfield, L.
Knutsford, V. Simon of Glaisdale, L.
Lauderdale, E. Skelmersdale, L.
Lindsay, E. Southborough, L.
Lindsey and Abingdon, E. Stevens of Ludgate, L.
Liverpool, E. Stockton, E.
Loch, L. Stodart of Leaston, L.
Long, V. Strange, B.
Luke, L. Strathcarron, L.
Lurgan, L. Strathclyde, L.
Lyell, L. Strathcona and Mount Royal, L.
McAlpine of West Green, L.
McFadzean, L. Strathspey, L.
McFadzean of Kelvinside, L. Suffield, L.
Mackay of Clashfern, L. Swinfen, L.
Macleod of Borve, B, Swinton, E.
Malmesbury, E. Terrington, L.
Mancroft, L. Thomas of Gwydir, L.
Margadale, L. Thomas of Swynnerton, L.
Marley, L. Thorneycroft, L.
Marsh, L. Thurlow, L.
Marshall of Leeds, L. Tollemache, L.
Massereene and Ferrard, V. Torphichen, L.
Maude of Stratford-upon-Avon, L. Torrington, V.
Townshend, M.
Merrivale, L. Trafford, L.
Mersey, V. Trefgarne, L.
Middleton, L. Tryon, L.
Montagu of Beaulieu, L. Ullswater, V.
Montgomery of Alamein, V. Vaux of Harrowden, L.
Moran, L. Vestey, L.
Mountgarret, V. Waldegrave, E.
Mowbray and Stourton, L. Wedgwood, L.
Weinstock, L. Windlesham, L.
Weir, V. Wolfson, L.
Wellington, D. Wyatt of Weeford, L.
Westbury, L. Wynford, L.
Whitelaw, V. Yarborough, E.
Wigram, L. Young, B.
Willoughby de Broke, L. Young of Graffham, L.

Resolved in the negative, and Motion disagreed to accordingly.

5.43 p.m.

10 Lord Belstead rose to move. That the House do not insist on their amendment numbered 3 to which the Commons have disagreed and do agree with the Commons in their amendments numbered 4 to 6 to the words so restored to the Bill and to the Commons consequential amendments to the Bill numbered 7 and 8.

The noble Lord said: My Lords, I beg to move.

Moved, That the House do not insist on their amendment numbered 3 to which the Commons have disagreed and do agree with the Commons in their amendments number 4 to 6 to the words so restored to the Bill and to the Commons consequential amendments to the Bill numbered 7 and 8.—(Lord Belstead.)

11 Lord Ennals rose to move, as an amendment to the above Motion, at end to insert ("with the following amendments to Commons consequential amendment 7—

Line 16, leave out ("and)

Line 19, at end insert ("; and (d) make provision for those in receipt of state retirement pensions to be exempted from such charges us are levied under this subsection.")

The noble Lord said: My Lords, I beg to move the Motion standing in my name which would amend the Motion that has been moved by the noble Lord the Leader of the House.

Naturally I had hoped that it would not be necessary for me to move this amendment because it is very much a fallback position. I find it sad that so many of those noble Lords who have come and voted today do not come more frequently and take part in the debates in your Lordships' House. It is sad that, having taken a major decision after a substantial debate in which this House recorded its views with a majority of 26, we now find that it is reversed and we have to ask why that is so. I am not going to produce the answer now because I believe that this should be a short debate because many people have already considered the issues that are at stake.

If by some mischance on our original vote with our 26 majority we had not succeeded, instantly there was an amendment that would have done the same as I am seeking to do today. I have no doubt that it would have been carried by an overwhelming majority. I know too that that would have been the case in another place. It had been expected by many of us who have taken an active part in this debate that at some stage the Government would have made a concession and would have said, "Right, we will make the concession of excluding retirement pensioners from this new charge that we are introducing".

The Government were determined to make the minimum concessions possible. I hope that this time the Government will not look upon this matter as a concession but as something that should properly be done because we know that it is not the case that there is only a small minority of pensioners who are poor. The King's Fund Centre report published in The Times yesterday revealed that 25 per cent. of the 65 to 70 age range and 40 per cent. of the over 75s have an income lower than half the national average. It is no fun being a pensioner on a very modest income. It is those people more than any others who are likely to suffer from complaints that can be detected by an eye test at the right time. Moreover, it is those people who are most likely, because of their modest income, to be deterred by the charge. This is something that has been said by experts throughout this debate. Somehow or other the Government always seem to think that they know best.

A number of noble Lords have referred to personal cases. I received this morning a letter from an elderly relative of mine written with a very shaky hand. She said: Two years ago I went to an optician for a sight test. He sent me to the optical surgeon at Plymouth Eye Hospital. He said he would like me to see the neurologist, who arranged for me to have tests at Freedom Fields Hospital, where they discovered a cyst on my brain. I was operated on and was in intensive care for five weeks. I think without this eye test I would not be writing this to you now". I believe that to be absolutely the case for very many people. I believe that it would be utterly wrong for this Parliament and this House at this moment to decide to take some positive action which would make it more difficult for pensioners to obtain what up to now has been an absolute right, namely an eye test without payment. I believe that there will be no saving to the Government at all. Not only do I believe that people will suffer, but the actual cost to the health service will be substantially greater if my amendment is not carried through or if the Government offer to do it in some other form—but I do not suppose they will.

I believe that this is an issue which many of us have thought about. If anyone has uncertainty or doubts about the way to cast their vote and be loyal to the Government today, they should feel that this is some kind of a gesture that they can make to people who are most likely to need it. I hope that that sympathy and concern will be thought of carefully by noble Lords when they come to reach their decision and the vote is taken.

Moved, as an amendment to the above Motion, at end to insert ("with the following amendments to Commons consequential amendment 7—

Line 16, leave out ("and)

Line 19, at end insert ("; and (d) make provisions for those in receipt of state retirement pensions to be exempted from such charges as are levied under this subsection."—(Lord Ennals.)

Lord Belstead

My Lords, we have spent the whole afternoon debating whether money should be contributed to the improvements of primary health care services by asking people who can afford it to contribute towards the cost of dental and eye examinations, and this is in addition to an enormous injection of funds into the health service next year. The House of Commons has now voted twice on each of the matters—dental examinations and eye examinations—and both issues undoubtedly involve Commons financial privilege. The noble Lord, Lord Ennals, tabled his amendments yesterday. They give the Secretary of State powers to exempt pensioners from sight test charges. The issue has been fully debated, as the noble Lord himself said in his brief remarks, and I shall follow him by saying only a brief few words.

Perhaps I may remind the House that pensioners' total incomes have increased by more than 23 per cent. in real terms since 1979. That should be compared with a 3 per cent. increase when the noble Lord and his right honourable friends and noble Lords were in office in the 1970s—

Noble Lords


Lord Belstead

Although noble Lords opposite do not like that, therein lies a difference. It is that the blanket exemption which the noble Lord seeks this afternoon is not appropriate. What is appropriate—and here I agree with him—is that help must be available to those who are in need. Twenty-five per cent. of all pensioners are on income support, which incidentally was uprated only 10 days ago, and accordingly, they will automatically qualify for free sight tests under the Bill as it stands. Anyone who relies solely on the basic state pension will be covered by this, as will those who are of pensionable age who are diabetics or glaucoma sufferers or have a near relative who suffers in that way. The amendments made in another place will enable us to start a scheme to help people who are a little above the income support level.

In the light of these exemptions, there are two views about what the noble Lord has said. I take the view that it is not unreasonable to ask those who can afford to do so to make a contribution to the cost of sight tests. I am comforted by the experience of my noble friend Lord Thorneycroft who said quite clearly that, leaving politics aside, priorities ought to be the language of us all. I should like to assure your Lordships that the proposals before the House today have only been brought forward after trying to think carefully about priorities. In the context of primary health care services, these priorities have been fully debated and then confirmed by another place last week. So both Houses have been round and round this course.

One thing is crystal clear. We are talking about trying to use a large sum of money to good effect in developing primary health care services. In allocating that money, Commons financial privilege clearly is involved. Yet the noble Lord comes along at the last minute demanding that a certain sum of money—he did not favour the House by saying how much it would be—must be peeled off in order to exempt every single person of pensionable age. We are talking probably of upwards of £30 million. If we agree to what the noble Lord wants, we shall get into exactly the trouble which the House has voted twice this afternoon not to get into.

Noble Lords


Lord Belstead

My Lords, on merits, and in terms of relations between the two Houses, I do not think that the noble Lord is being reasonable in this amendment. I ask your Lordships not to agree to it.

Lord Ennals

My Lords, as it seems that no other Lord wants to take part I shall briefly reply. The noble Lord said that this issue had been debated several times before. Yes, I said that, but it has never been voted on before. That is because, in your wisdom, your Lordships have always sought to protect the whole population from these new charges.

There is a debate about the standard of living of pensioners. In making my case 1 sought to leave politics aside. When the noble Lord plunged into some comparison between the position of pensioners 10 years and more ago with those of today he did so quite deliberately, involving politics in the issue. I urge noble Lords not to involve themselves in party politics on this issue.

Noble Lords


Lord Ennals

Yes, I certainly do. I do not think that pensioners would respect us much if they thought that, even in your Lordships' House, we were playing politics with their interests.

The noble Lord referred to people who are in need. He said that the Government would ask people to make a contribution. Will they have a church plate so that they can put in their pennies if they want to? No, it is a charge that will be imposed on all those who are not excluded. I am seeking to ensure that more are excluded. Who is in need? How do we tell who is in need? The only way is to have a means test. Do Members of the House recognise the extent of the pride of many pensioners who are simply not prepared to involve themselves in a means test? This has always been the case and it is the case no less today than it was 30 years ago.

This presents a great problem because, as the noble Lord knows, means tested benefits very often have a low take-up. Here we are depriving people of what has been an absolute right ever since the National Health Service was set up. The Government are not targeting but are saying that all pensioners will have to pay except for the limited number who have been exlcuded. I believe that we should leave the pensioners out.

The noble Lord asked me about the cost. I prefer to use the word "saving". It would cost £22 million to make this exclusion. I ask your Lordships to recognise the actual cost of treating people who go blind and of treating people during their illness or disease. I ask them then to consider the cost of the operations that have to be carried out and of the help the state must give not only to those in hospitals but to those in care homes and nursing homes. I believe that government will save not £22 million but much more for the NHS by ensuring that people have this opportunity. The arguments are overwhelming and I hope that this will be recognised by noble Lords when they go into the Division Lobby.

5.58 p.m.

On Question, Whether the amendment to the Motion shall be agreed to?

Their Lordships divided: Contents, 196; Not-Contents, 237.

Addington, L. Greenway, L.
Airedale, L. Gregson, L.
Alport, L. Grey, E.
Amherst, E. Grimond, L.
Ardwick, L. Hampton, L.
Auckland, L. Hanworth, V.
Aylestone, L. Harris of Greenwich, L.
Banks, L. Hart of South Lanark, B.
Barnett, L. Hatch of Lusby, L.
Basnett, L. Hayter, L.
Beaumont of Whitley, L. Henderson of Brompton, L.
Birk, B. Henniker, L.
Blackstone, B. Hertford, M.
Blease, L. Hooson, L.
Bonham-Carter, L. Houghton of Sowerby, L.
Boston of Faversham, L. Howie of Troon, L.
Bottomley, L. Hughes, L.
Briginshaw, L. Hunt, L.
Brimelow, L. Hutchinson of Lullington, L.
Broadbridge, L. Hylton, L.
Brooks of Tremorfa, L. Ingleby, V.
Bruce of Donington, L. Irvine of Lairg, L.
Buchan, E. Irving of Dartford, L.
Buckmaster, V. Jacques, L.
Burton of Coventry, B. Jay, L.
Callaghan of Cardiff, L. Jeger, B.
Campbell of Eskan, L. Jenkins of Hillhead, L.
Carlisle, Bp. John-Mackie, L.
Carmichael of Kelvingrove, L. Kagan, L.
Carter, L. Kennet, L.
Chandos, V. Kilbracken, L.
Chelmsford, Bp. Kilmarnock, L.
Chesham, L. Kirkhill, L.
Chichester, Bp. Kirkwood, L.
Chilston, V. Kitchener, E.
Chitnis, L. Lawrence, L.
Cledwyn of Penrhos, L. Leatherland, L.
Cocks of Hartcliffe, L. Leathers, V.
Craigavon, V. Listowel, E.
Cudlipp, L. Liverpool, Bp.
Cullen of Ashbourne, L. Llewelyn-Davies of Hastoe, B.
Darcy (de Knayth), B. Lloyd of Kilgerran, L.
David, B. Lockwood, B.
Davies, L. Longford, E.
Davies of Penrhys, L. Lovell-Davis, L.
Dean of Beswick, L. Lucas of Chilworth, L.
Denington, B. Lytton, E.
Diamond, L. McCarthy, L.
Donaldson of Kingsbridge, L. McGregor of Durris, L.
Donoughmore, E. McIntosh of Haringey, L.
Dormand of Easington, L. Mackie of Benshie, L.
Ennals, L. McNair, L.
Ewart-Biggs, B. Mais, L.
Ezra, L. Manchester, Bp.
Falkender, B. Masham of Ilton. B.
Falkland, V. Mason of Barnsley, L.
Fisher of Rednal, L. Mayhew, L.
Fitt, L. Merrivale, L.
Flowers, L. Meston, L.
Foot, L. Milner of Leeds, L.
Gallacher, L. Mishcon, L.
Galpern, L. Molloy, L.
Gardner of Parkes, B. Monkswell, L.
GifTord, L. Monson, L.
Gladwyn, L. Mottistone, L.
Glenamara, L. Mountcvans, L.
Gloucester, Bp. Mulley, L.
Graham of Edmonton, L. Murray of Epping Forest, L.
Gray, L. Nicol, B. [Teller.]
Northfield, L. Southwark, Bp.
Ogmore, L. Stallard, L.
O'Neill of the Maine, L. Stanley of Alderley, L.
Oram, L. Stedman, B.
Paget of Northampton, L. Stewart of Fulham, L.
Parry, L. Stoddart of Swindon, L.
Perry of Walton, L. Strabolgi, L.
Peston, L. Taylor of Blackburn, L.
Phillips, B. Taylor of Gryfe, L.
Pitt of Hampstead, L. Taylor of Mansfield, L.
Ponsonby of Shulbrede, L. [Teller.] Tedder, L.
Tordoff, L.
Prys-Davies, L. Turner of Camden, B.
Raglan, L. Underhill, L.
Rathcreedan, L. Vernon, L.
Rea, L. Wallace of Coslany, L.
Ritchie of Dundee, L. Walston, L.
Robertson of Oakridge, L. Wedderburn of Charlton, L.
Robson of Kiddington, B. White, B.
Rochester, L. Willis, L.
Ross of Newport, L. Willoughby de Broke, L.
Russell, E. Wilson of Langside, L.
Ryder of Warsaw, B. Wilson of Rievaulx, L.
Sainsbury, L. Winchilsea and Nottingham, E.
Scanlon, L.
Seear, B. Winstanley, L.
Serota, B. Winterbottom, L.
Shepherd, L. Wise, L.
Sidmouth, V. York, Abp.
Simon, V. Young of Dartington, L.
Abinger, L. Colville of Culross, V.
Airey of Abingdon, B. Constantine of Stanmore, L.
Aldington, L. Cork and Orrery, E.
Alexander of Weedon, L. Cornwallis, L.
Allenby of Megiddo, V. Cottesloe, L.
Allerton, L. Craigmyle, L.
Annaly, L. Craigton, L.
Arran, E. Crathorne, L.
Ashbourne, L. Crickhowell, L.
Astor of Hever, L. Croft, L.
Barber, L. Dacre of Glanton, L.
Bathurst, E. Daventry, V.
Bauer, L. Davidson, V. [Teller.]
Beaverbrook, L. De La Warr, E.
Bellwin, L. Denham, L. [Teller.]
Beloff, L. Denman, L.
Belstead, L. Derwent, L.
Bessborough, E. Digby, L.
Bethell, L. Dilhorne, V.
Birdwood, L. Dulverton, L.
Blanch, L. Dundee, E.
Blatch, B. Eden of Winton, L.
Blyth, L. Elibank, L.
Boardman, L. Ellenborough, L.
Bolton, L. Elles, B.
Borthwick, L. Elliot of Harwood, B.
Boyd-Carpenter, L. Elliott of Morpeth, L.
Brabazon of Tara, L. Elphinstone, L.
Braye, B. Elton, L.
Bridgeman, V. Erne, E.
Brookeborough, V. Erroll of Hale, L.
Brougham and Vaux, L. Falmouth, V.
Broxbourne, L. Fanshawe of Richmond, L.
Bruce-Gardyne, L. Ferrers, E.
Butterworth, L. Foley, L.
Caccia, L. Forbes, L.
Caithness, E. Forester, L.
Camden, M. Forte, L.
Cameron of Lochbroom, L. Geddes, L.
Campbell of Alloway, L. Gibson-Watt, L.
Campbell of Croy, L. Gisborough, L.
Carnegy of Lour, B. Glenarthur, L.
Carnock, L. Goold, L.
Cathcart, E. Goschen, V.
Chalfont, L. Gowrie, E.
Chelmer, L. Grafton, D.
Coleraine, L. Grantchester, L.
Colnbrook, L. Gray of Contin, L.
Gridley, L. Piatt of Writtle, B.
Grimston of Westbury, L. Plummer of St. Marylebone, L.
Halsbury, E.
Harmar-Nicholls, L. Portland, D.
Harris of High Cross, L. Portman, V.
Harvington, L. Pym, L.
Havers, L. Quinton, L.
Hemphill, L. Reay, L.
Henley, L. Rees, L.
Hesketh, L. Reigate, L.
Hives, L. Renton, L.
Holderness, L. Renwick, L.
Home of the Hirsel, L. Rochdale, V.
Hood, V. Rockley, L.
Hooper, B. Rodney, L.
Inchcape, E. Romney, E.
Ingrow, L. Rugby, L.
Ironside, L. Russell of Liverpool, L.
Jenkin of Roding, L. Sackville, L.
Johnston of Rockport, L. St. Aldwyn, E.
Joseph, L. St. Germans, E.
Kaberry of Adel, L. Saltoun of Abernethy, 1
Kemsley, V. Sanderson of Bowden,
Kimball, L. Sandys, L.
Kimberley, E. Savile, L.
Kinnaird, L. Selborne, E.
Knutsford, V. Selkirk, E.
Lauderdale, E. Shannon, E.
Lindsay, E. Sharpies, B.
Lindsey and Abingdon, E. Sherfield, L.
Liverpool, E. Simon of Glaisdale, L.
Loch, L. Skelmersdale, L.
Long, V. Slim, V.
Luke, L. Southborough, L.
Lyell, L. Stevens of Ludgate, L.
McAlpine of West Green, L. Stockton, E.
McFadzean, L. Stodart of Leaston, L.
McFadzean of Kelvinside, L. Strathcarron, L.
Mackay of Clashfern, L. Strathclyde, L.
Macleod of Borve, B. Strathcona and Mount Royal, L
Malmesbury, E.
Mancroft, L. Strathspey, L.
Margadale, L. Suffield, L.
Marley, L. Swinfen, L.
Marsh, L. Swinton, E.
Marshall of Leeds, L. Thomas of Gwydir, L.
Massereene and Ferrard, V. Thorneycroft, L.
Maude of Stratford-upon-Avon, L. Thurlow, L.
Tollemache, L.
Mersey, V. Torphichen, L.
Middleton, L. Torrington, V.
Montgomery of Alamein, V. Townshend, M.
Mountgarret, V. Trafford, L.
Mowbray and Stourton, L. Trefgarne, L.
Moyne, L. Tryon, L.
Munster, E. Ullswater, V.
Murton of Lindisfarne, L. Vaux of Harrowden, L.
Nathan, L. Vestey, L.
Nelson of Stafford, L. Waldegrave, E.
Newall, L. Wedgwood, L.
Norfolk, D. Weinstock, L.
Norrie, L. Weir, V.
Nugent of Guildford, L. Westbury, L.
Onslow, E. Whitelaw, V.
Orkney, E. Wigram, L.
Orr-Ewing, L. Windlesham, L.
Oxfuird, V. Wolfson, L.
Peel, L. Wyatt of Weeford, L.
Pender, L. Wynford, L.
Pennock, L. Yarborough, E.
Perth, E. Young, B.
Peyton of Yeovil, L. Young of GrafFham, L.

Resolved in the negative, and amendment to the Motion disagreed to accordingly.

6.9 p.m.

The Lord Chancellor

My Lords, the Question is that the House do not insist on their amendment numbered 3 to which the Commons have disagreed and do agree with the Commons in their amendments numbered 4 to 6 to the words so restored to the Bill and to the Commons consequential amendments to the Bill numbered 7 and 8.

On Question, Motion agreed to.