Preventing Avoidable Sight Loss

David Mowat Excerpts

Tuesday 28th March 2017 Westminster Hall

[The Parliamentary Under-Secretary of State for Health (David Mowat)]

It is a pleasure to serve under your chairmanship, Mrs Gillan. I congratulate my hon. Friend the Member for Wealden (Nusrat Ghani) not only on leading the charge today but on her work on the APPG more generally. A number of Members have made the point this morning that we have not debated eyes and sight in this place very much over the past few years. It is good that we have the time to put that right today, so I congratulate her on doing so.

I start by acknowledging what a number of Members have said—that 50% of sight loss is preventable. I think my hon. Friend said that 85% of people regard sight as the most precious of all our senses. Frankly, I am surprised that the figure was not higher than that. This is clearly massively important. We can debate numbers—the hon. Member for Burnley (Julie Cooper) just talked about £28 billion—but the key figure is the statistic that my hon. Friend the Member for Twickenham (Dr Mathias) started with. Some 20 people a month are losing their sight, whether due to lack of prevention or lack of early treatment, in ways that are preventable. That is not acceptable, and we need to work collectively to address it—I will try to set out the Government response to it now.

I will talk first about prevention and the need for early detection and improved treatment. We heard about waiting lists in Great Grimsby, which I will come to. I will also talk about the social exclusion that can occur, and the mental health issues that can come from that. As I go through, I will try to address the points raised during the debate by Members on both sides of the House. If I do not, I am sure Members will remind me that I have not; in any event, we will write on any points that are not directly addressed.

The UK vision strategy was produced jointly with the RNIB, which does a lot of extremely good work in this space, for which the Government are grateful. Both the Department of Health and NHS England fully support that strategy, and need to continue to drive it forward. We also support global issues; Members have talked about the WHO global plan, which intends to eliminate preventable sight loss by 2020, and my hon. Friend the Member for Wealden talked about some of the work we do globally. She talked about patient choice and the referral process—whether it is via GPs or direct—which is an interesting point that I will come to. She talked about STPs, as did the hon. Member for Burnley, cancelled appointments and the need for a national strategy in England. I will come back on those points, if I do not get to them during my remarks.

To frame the issue, 2 million people in the UK have sight loss—because sight loss is so related to age, 4 million people will almost certainly be affected by 2050—and 80% of those are over 60 years old. Several Members cited statistics illustrating the demographic changes, including the hon. Member for Strangford (Jim Shannon), who spoke about Northern Ireland. As we debate these things across health and social care, we have to recognise the incredibly significant changes to our demography.

When the national health service was set up in 1948, one person in four lived to be over 65. We have totally fixed that, in the sense of increasing longevity. In the last 10 years, our population has increased by 10% and our population of over-85s has increased by nearly 28%. That trend will continue and accelerate, which gives us all challenges, including resourcing and all that that means. I heard a very apposite phrase recently: “We have done a good job of increasing quantity of life, but we haven’t yet increased quality of life to the same extent.” That is true of sight loss. As we heard, 148,000 people are certified blind in this country, with all that that means in terms of benefits and tax changes. That figure has been fairly stable—indeed, it has gone down slightly in the past three years—but nevertheless, it presents us with a big challenge.

In responding to those changes, we have to look at prevention and understand the risk factors. I have just covered the first risk factor, which is age. We cannot do a great deal about that, other than note that we are all getting older. Like the hon. Member for Strangford, I am over 50—considerably so—and the fact is that the sight loss numbers are driven by age. Smoking and obesity also play a big part in eye health, as they do in other aspects of health. Our tobacco control strategy will be produced imminently. We have done a good job in this country of reducing smoking, but we need to go further and faster, and I hope that the strategy will be a big part of that. There will be specific targets by age group for what we need to achieve. Obesity is equally and possibly more important; it is a risk factor for all sorts of things. I perhaps did not fully understand that obesity affects people’s chances of getting cancer, dementia and suffering from sight loss as much as it does. We need to drive home the potential benefits of the obesity strategy that we published, which aims for a 20% sugar reduction by 2020.

Hon. Members, including the hon. Member for East Kilbride, Strathaven and Lesmahagow (Dr Cameron), mentioned cataracts. Obesity doubles the probability of getting a cataract. That is an extraordinary statistic given that it is not intuitive that those are linked, even though they clearly are. I do not want this debate to be about money—what we are talking about is more important than money—but the cost to the country of obesity and diabetes put together means that we now spend more in the NHS on treating them than we do on the police service, the judiciary and the Prison Service combined. That puts into perspective the magnitude of the cost and what we need to achieve.

On prevention, we have not talked about the screening programme that we have introduced for diabetic eye disease, which was the principal cause of blindness in working-age people until recently. As a result of the programme, which involved offering a digital photograph to all people with diabetes over the age of 12, something like 2 million people were screened last year. For a screening programme, there was a very high uptake—over 80%—and some evidence shows that it has resulted in significant progress in preventing that type of blindness. This is the first year for which we have those figures, and diabetic eye disease is no longer the principal cause of blindness in working-age adults. That has largely been achieved through that very effective screening programme.

Let me talk briefly about the four most common causes of blindness, which are cataracts, age-related macular degeneration, glaucoma—that is the most prevalent, as we have heard—and diabetic eye disease. All of those can be treated most effectively through early diagnosis—frankly, that applies in most areas of health, but it is particularly true of eye health—and the first part of that is timely sight tests. Sight tests are free for children at school, although parents have to arrange them. They are also free for the over-60s, for anybody who is in a high-risk group, including those with diabetes or glaucoma, and for people on various income-supported benefits. There were 13 million eye tests last year, which was an increase of 2%. There is always a case for doing more, and I say to anyone who is listening to this debate, even if they are not of such an advanced age as me or the hon. Member for Strangford, that these things are worthwhile.

Treatment is CCG-led in this country. The principal reason relates to some of the issues that we heard about from the hon. Member for Great Grimsby (Melanie Onn), who spoke well about the large numbers of people on the waiting list of the Northern Lincolnshire and Goole NHS Foundation Trust and the extra clinics that had to be put on. That is a CCG responsibility. With national strategies, there is a choice about whether something should be locally focused, with local commissioners having the resources and money—although resources are a different issue—or whether there should be an overarching national plan.

I was struck by what the hon. Lady said about the actions that were taken. Those were local actions, which were completely appropriate. In England, we produce a public health outcomes framework—I do not think that is the case in Scotland, notwithstanding the excellent speeches by the Scottish National party Members about what is done in Scotland. The framework sets out for every local authority area in the country the extent to which there is glaucoma, diabetic eye disease and age-related macular degeneration, and the total number of people who are certified blind. Those data are tracked over the years and ought to inform local commissioners, and indeed, local health and wellbeing boards in the priority areas. There are striking differences and clusters of different types of blindness and different issues in different areas.

To cite a few of those differences, Barnsley has three times the national average of age-related macular degeneration and twice the national average of people who are certified blind. To me, that suggests that the commissioners in Barnsley should, in particular, be putting effort and resources into treating AMD. London has something like 20% more diabetic eye disease than other parts of the country. That may be to do with the large south Asian population in parts of London and the diabetes that that implies. Those sensible decisions should be taken by local commissioning groups in the knowledge of the facts. I commend the public health outcomes framework to hon. Members, who may not have looked at it for their own constituencies and patches. That should be considered and understood, because for this and other issues, it tells us where the priorities ought to be.

[Melanie Onn]

If CCGs are to focus on providing more support for a particular service, it prompts the question, “What will support be taken away from?” The trust in my constituency has now gone into financial special measures. There is only so much give in the system. What does the Minister think is the solution?

[David Mowat]

I did say, when I was making the point, that I was not talking about priorities in terms of total resource there. We must make choices. I will come to the point about the £20 million budget.

The hon. Member for East Kilbride, Strathaven and Lesmahagow mentioned concerns that cataract operations were being rationed. In response, the Secretary of State requested that NICE issue guidelines this year rather than next year, and we will pursue that. However, I make the point that 17% more cataract operations are being done in England now than five years ago. That does not imply rationing to me, but we need to be careful. Operations should not be rationed, and we want NICE guidelines in place to ensure that they are not.

I will address some of the points made by hon. Members. My hon. Friend the hon. Member for Wealden mentioned referral pathways. She is right to say that different CCGs do things differently. Some CCGs will require an optician to refer a patient to a GP, who then refers onward to the hospital or ophthalmologist; around 11% of CCGs do not do so, which is quite odd. I will ask officials to investigate why. The principle is that CCGs are responsible for setting their own pathways. It is not for the Government to tell them what to do, but it is possible—indeed, likely—that some might not have wholly addressed the issue.

There is a general drive right across the health service to do more things in the community and fewer things in hospitals. Part of that involves using opticians in the best way possible, and not just on this issue. Although it has not been mentioned in this debate, I would like to see opticians used much more for glaucoma monitoring and other such things that, at the moment, tend to happen in hospitals, because as we have heard, there is a great deal of strain on a number of hospitals. We will try to make progress on that issue. I am happy to sit down with my hon. Friend and the Royal National Institute of Blind People, as she asked, to talk about it in more detail.

My hon. Friend mentioned shared delivery plans. She said that only 50% of STPs include a coherent eye strategy, and the hon. Member for Burnley said that some of those looked like tick-box exercises. I accept that, and I have two points to make. One is that an STP is not an organisation but a planning document, which must be put in place to begin to establish planning areas across the country where we can marry up prevention, primary care and secondary care. Not all STPs have yet addressed all the issues that they should; they are a process, not an event. I say to the people concerned about that that they should keep lobbying their local STP leadership, who are responsible for addressing it. Frankly, many STPs have a long way to go to become coherent plans, and eye health is just one area on which we need to make more progress.

We heard about the issue of cancelled appointments. They are a particular problem with eye appointments, which can be time-critical; the figure of 20 avoidable sight losses a month was quoted. The principles governing missed appointments across the NHS apply in exactly the same way to eyes as they do to all other things. The NHS constitution sets out an 18-week limit. I have heard speakers in this debate mention clinics where 50% of appointments are not attended. Such numbers are completely unacceptable. What is hard to understand in that context is that in the last five years we have increased the number of consultant ophthalmologists across the patch by around 27%. That does not imply that the problem is staffing, but I will take the issue away and consider it. I reiterate that the same provisions that apply to all aspects of our NHS apply to eyes and to national waiting lists. People who fail to get appointments for which they are clinically ready should be on a national waiting list. We should performance manage it in that way.

My hon. Friend the Member for Wealden mentioned choice, rightly saying that people are entitled to choice in their secondary care. The same principle applies to eye care as to all other types of care, but there is more that we can and must do to build awareness.

I will touch briefly on the issue of an eye strategy. I have asked why NHS England feels that it is better for it to be owned and controlled locally; I made the point previously about the degree of local variation. We heard some instances from Northern Ireland, where there is an eye strategy, that show that it is not a panacea. As a Minister, I have a general view. There are a lot of strategies, but many fewer clear action plans with deliverables and accountabilities. It is rather like what we heard about in Great Grimsby. My preference is to work with NHS England and with Health Education England, if it is a question of getting more people into roles and all that goes with that. Having said that, I am happy, as I said, to talk to my hon. Friend the Member for Wealden and the RNIB more generally, but overall, across the health system, I do not see a lack of strategies. I sometimes see a lack of action plans with accountabilities and clear deliverables. My bias is towards the latter, not the former.

On the point about rationing, the NICE process is an attempt to create, across the whole health system, coherent guidelines and structured ways to evaluate different medicines. Broadly speaking, a cost of £20,000 per quality-adjusted life year is used by NICE to decide whether a drug should be offered or not. However, the point about the £20 million cap is slightly different. The cap is being introduced, potentially, for new drugs; it would not apply to any existing treatment. We are accelerating new drugs coming into the system. The cap would act as a trigger point: after £20 million has been spent, a renegotiation with the manufacturer would take place. On that point, I will sit down and allow my hon. Friend to sum up.