Health and Care Bill

Lord Low of Dalston Excerpts

Committee stage
Thursday 20th January 2022 Lords Chamber

Moved by

[Lord Low of Dalston]

56A: Schedule 3, page 151, line 16, at end insert—
“116C Primary ophthalmic services for people with learning disabilitiesNHS England must make arrangements for the assessment of the need for primary ophthalmic services by people with learning disabilities, including access to sight tests, and ensure primary ophthalmic services are commissioned to meet those needs.”Member’s explanatory statement
Under Schedule 3 of the Bill, NHS England retains its powers to make arrangements for the provision of primary ophthalmic services itself or direct Integrated Care Boards for such provision. This seeks to improve eye care for people with learning disabilities.

[Lord Low of Dalston (CB)]

Right on cue, my Lords, I am rising to move Amendment 56A, which seeks to improve eye care for people with learning difficulties, as they are much more likely to have a sight problem but much less likely to access primary ophthalmic services, including access to NHS sight tests. The Bill offers an opportunity to seek improvements to an often-overlooked area of primary care: namely, primary eye care or ophthalmic care. Schedule 3 to the Bill contains amendments to the National Health Service Act 2006, regarding primary ophthalmic services: that is to say, commissioning of NHS sight tests and more.

Primary eye care is vital for the health of the nation. We know that half of sight loss could be prevented but is not because people do not go for sight tests as frequently and regularly as they need to. Many people are living with sights problems that could be picked up and treated quickly if people were going for regular sight tests. We also know that our hospital eye clinics are overwhelmed and are one of the busiest outpatient specialities. There were delays to treatment prior to the pandemic, but now these have been greatly exacerbated as a result of the pandemic. Work is under way to look at how primary eye care can add capacity to the system through an NHS England eye care transformation programme. Just like their colleagues in general practice, dentistry and pharmacy, there are optometrists and dispensing opticians working in primary care who have the clinical training to provide early and ongoing support to patients but do not have the chance.

Supporting primary eyecare makes sense in very many ways. However, we know that, as with other areas of healthcare, there are inequalities in primary eyecare. Some parts of the population are not accessing regular sight tests, even if they might be eligible to have them free under the NHS. In 2018, the All Party Parliamentary Group on Eye Health and Visual Impairment explored this issue, particularly for people with learning disabilities and people who are homeless. This work was supported by the APPG on learning disabilities. I know that the noble Baroness, Lady Hollins, supports this amendment, but she has not been able to stay to join in the debate.

The APPGs on eye health and visual impairment and on learning disabilities took evidence from the charity SeeAbility. People with learning disabilities are much more likely to have a sight problem but much less likely to access NHS sight tests. Vision problems in people with severe learning disabilities are so high that researchers have said that this population should be considered visually impaired unless proven otherwise. SeeAbility’s work in special schools found that more than four in 10 children had never had a sight test. In other studies, it was found that half of adults with learning disabilities had not had a sight test in all the recommended period. SeeAbility found that many children were attending hospital eye clinics for routine eye tests.

A recommendation that the APPGs made in 2018 that there should be a sight-testing and glasses-dispensing service in all special schools is now being taken forward by NHS England, which is excellent news. It will reach around 130,000 children and help address and prevent avoidable sight loss, as well as reducing the need to use hospital eye clinics. Once the proof of concept phase is completed in 2023, it is understood that a new special schools scheme will need to be legislated for to provide for an additional service to be added to the National Health Service ophthalmic services contract through an amendment to regulations. It is hoped that at the appropriate time the Secretary of State for Health and Social Care will ensure that the special schools eyecare service has the legislative authority that it needs. The commitment by NHS England to this service is commendable, and it must continue with that commitment as these children deserve an equal right to sight. This is something we will all want to follow closely.

However, the APPGs went further in 2018 and also recommended that there is a continuing need to improve eyecare outside special schools for people with learning disabilities. There are an estimated 1 million people with learning disabilities in England. The APPGs noted that the tariff for primary eyecare acts as a disincentive to carry out sight tests within optical practices when seeing adults or children with more severe or profound learning disabilities, despite this group being at most risk of having a sight problem. This compares poorly with other areas of primary care, such as the GP annual health check for people with learning disabilities, or special needs dentistry. The local optical committee support unit’s learning disability eyecare pathway, which is endorsed by SeeAbility and Mencap, can be commissioned by clinical commissioning groups to provide more targeted, longer and adjusted optical appointments for people with moderate to severe learning disabilities. However, it has been commissioned in only a few areas in England and it really needs to be countrywide.

Eligibility for NHS sight tests under secondary legislation has also missed out people with learning disabilities from the exclusive list of eligible groups—that is, children, older adults, people in receipt of certain means-tested benefits and high-risk groups such as those with a family history of glaucoma or diabetes. This places the burden on the person with a learning disability to work out whether they are eligible in other ways. For that reason, no data is collected on how many people with learning disabilities access NHS sight tests in the community. For the purposes of this debate, this is a straightforward amendment that bolsters NHS England’s existing commitment to the special school eye care service across England’s special schools. It reminds us that all people with learning disabilities are in need of particular attention when it comes to eye care.

Schedule 3 to the Bill amends the section on primary ophthalmic services in the National Health Service Act 2006 by introducing general powers to make arrangements, in Section 116A, and to publish general information, in Section 116B. The amendment would supplement that with a new Section 116C, which would simply oblige NHS England to make an assessment of the needs of those with learning disabilities for primary ophthalmic services, including access to NHS sight tests, and ensure that services were commissioned to meet those needs.

The amendment’s national focus is needed because the local discretionary approach to introducing the aforementioned LOCSU learning disability eye care pathway by clinical commissioning groups has not worked. It exists in only six areas of the country when it really needs to be available across the country as a whole. The amendment would allow for the possibility of extending eligibility for NHS sight tests to all people with learning disabilities once the evidence was reviewed.

The Bill clearly envisages that the Secretary of State and NHS England can work together and both can exercise powers to improve primary ophthalmic services, with NHS England having a clear national oversight role. The amendment is supported by three existing NHS England objectives into the bargain: first, the programme of work to address the health inequalities of people with learning disabilities; secondly, the programme of work to improve community eye care and reduce the unnecessary use of hospital eye clinics; and, thirdly, the commendable work in primary optometry of the special school eye care service.

There may be those who would say that no population needs to be explicitly prescribed for in primary legislation and that matters can be left to the discretion of secondary legislation and directives. However, the health inequalities experienced by people with learning disabilities justify putting them in the Bill. People are dying of avoidable health issues at least two decades before their peers. We cannot have a situation where people are living without good sight and even going avoidably blind because NHS services overlook their needs. I beg to move.

--- Later in debate ---

[Lord Kamall (Con)]

I thank my noble friend; I was not aware of that. But at the end of the day, the result has to be the care that the patient receives. There will always be debates on how you can configure who should be involved at what level, but at the end of the day, it has to be the quality of the care the patient receives. To a wider point, we must also focus on prevention. We are seeing a lot of innovation in the primary sector; we are seeing GP services sometimes merge into primary care centres, taking on medical procedures that were previously considered the domain of hospitals. We have seen more blurring of the lines, and patients welcome that innovation in many cases.

What matters at the end of the day is the experience of the patient and making sure they have a decent service all the way through their life. It is one of the reasons we are talking about integration. In this country, care is literally from the cradle all the way to the grave, as we integrate social care more. That is why some of these discussions we have been having on social care and palliative care have been important. We are aware of that.

There are a couple more points I would like to make before I allow people to get in before the 5.30 pm deadline for getting a teacake. We support the idea that all areas should have an adequate number of GPs. That is why we launched the targeted enhanced recruitment scheme to attract doctors to train in locations that either have a history of under-recruitment or are currently finding it difficult recruiting. The scheme reflects the fact that trainees who are attracted to these areas usually stay on after training. Hundreds of doctors have trained in hard-to-recruit places since the scheme’s introduction, with 500 places available in 2021 and, we hope, 800 in 2022.

We also recognise that each community has different health needs, which emphasises the point noble Lords have made—that it is so important to hear the voice of primary care more loudly. We are taking steps to diversify the general practice workforce, such as by recruiting 26,000 more primary care staff. Making sure we have the correct mix of skills available in general practice is critical to delivering appropriate patient care across England.

One of the issues that we have to appreciate, though, is that as most GP practices are private partnerships and GPs are free to choose where they practise, a general medical practitioners equitable distribution board would have limited influence over the distribution of GPs across England, which is why we have to look at other ways to target those areas that are underserved. That is why it remains critical to continue encouraging trainees to train in hard-to-recruit areas and diversify the primary care workforce to support general practice in meeting the needs of its local community across England.

I have heard, once again, the mood of the Committee. That has become a familiar theme. I hope noble Lords will accept that I am open to further conversations in this area, particularly on how we hear the voices of all those in primary care, not just those of GPs but all of them, including those in ophthalmology, dental care and others. I hope that, in that spirit, noble Lords will feel it appropriate to withdraw or not move their amendments at this stage.

[Lord Low of Dalston (CB)]

My Lords, I thank the Minister very much for his response and all other noble Lords who have participated in the debate. I moved a rather modest little amendment but I am encouraged that it has stimulated such a rich discussion with so many knowledgeable contributions. If nothing else, my amendment has stimulated a discussion that has emphasised the importance of primary care. If we can take that message away, we will not have been wasting our time. I shall leave it there. I thank everyone for their contributions and the Minister for his response. I am sure he will have been enriched by the way the discussion has focused on the importance of primary care. It has been beneficial all round. I beg leave to withdraw the amendment.

Amendment 56A withdrawn.