The one single, unconvincing reason for retaining the status quo is that if there is not a charge at the point of delivery, no-one is dissuaded from having an eye examination because of a financial disincentive.
The author does not dispute this, but unequivocally disagrees that it should be the overriding consideration. The whole health service is unrecognisable from 1948 and optometry is not an exception, so we need to investigate an alternative funding option.
Six reasons for advocating change to direct payment
? A state-funded eye examination free at the point of delivery has never covered the cost of delivering the service. If there ever had been the slightest chance of an examination fee sufficient to cover the cost, it would have been put in place by now. We always have to ask for more with nothing to offer in return. That is not a criticism, but it is not negotiation. An annual telephone call would have achieved the same result and saved a lot of unnecessary work.
Practitioners have to make up the shortfall by supplying spectacles or by selling accessories. This may have been acceptable in 1948 as an interim measure, but nearly six decades later, are we still expected to accept that this is the right way to practise optometry?
? A state-funded eye examination free at the point of delivery favours a bad standard over a good standard. The practitioner who skimps on processes puts in a greater number of examinations into a unit time and earns more than the practitioner who allows more time. This is a powerful argument against a flat fee, irrespective of whether it is high or low. Direct payment by the patient engenders a sense of seeking value for money. Practitioners are automatically more accountable, and clinical standards must be seen to be at a high level.
? A state-funded eye examination free at the point of delivery favours practitioners who prescribe unnecessarily. The practitioner who overprescribes is able to subsidise losses made on inadequate examination fees. The less the payment for clinical eye examinations, the more this is the case. The practitioner who prescribes fairly cannot recoup funds in this way. With an unswerving support for flat state paid examination fees, the AOP is favouring practitioners whose selfishness does the profession the most damage.
? A state-funded eye examination free at the point of delivery cannot be made equitable for practitioners. The fee paid is the same wherever it is carried out and does not take geographical variations into account.
? Direct payment from patients generates flexibility. A practitioner can choose to meet practice costs from provision of clinical services or from revenue generated from dispensing, or can strike up an appropriate balance. If an individual practitioner believes there should be no financial disincentive to accessing examinations, the choice can be to charge no fee at all, in which case all the costs would have to be put onto spectacles, contact lenses, or accessories.
? Free NHS spectacles have already been replaced by vouchers towards the cost and has been an unqualified success. Vouchers introduced flexibility and choice. Practitioners can offer a functional range completely covered by the voucher, or a wider choice.
State assistance - how should it be implemented?
If we promoted alternatives to a flat fee paid by the state, especially in a way to show that they are in the public interest, it is possible that the Ministry of Health would consider them. If our negotiators denigrate them, or project them in such a way that suggest they are unsatisfactory, there is not the slightest chance the government will take them up. So, what are the alternatives that can be put forward?
In theory, payment by item of service would favour the conscientious practitioner. However, in practice, it would be dependent on the practitioner truthfully ticking boxes. There would be claims for procedures carried out inadequately, for example, a 10-second confrontation test passed off for a comprehensive field assessment, or claims for procedures not carried out at all. This is a complete non-starter.
If a voucher was available towards the cost of an eye examination, the profession, the public and the government could share in a system with genuine versatility and with the prospect of addressing many of the problems listed above.
A voucher towards a privately charged fee considerably reduces the element of favouring a bad standard over a good standard. A high standard would still be expected, but the practitioner's fee can make up the shortfall in costs and can be justified in giving value for money.
The regional variations are less of a problem because practitioners with higher overheads because of geographical location can justifiably charge a higher fee.
It would be a less important issue that the examination fee does not cover the cost since it is a part-payment only. The practitioner would be able to meet the shortfall with fair and honest charges for clinical services provided. If we promoted such a method we would be seen to acting responsibly by suggesting a scheme which maximises resources. This is the only realistic way to proceed if we are to continue to request assistance towards the cost of examinations.
Which groups would qualify for a voucher? This is a complex issue, and a matter for a separate debate, but until the AOP shows some essential support, not a very productive one. However, one presumes there is a limited budget, so if the voucher were to be universal, the amount allocated per person must be less.
The AOP must have a major rethink on the subject of funding for eye examinations. We need to promote the benefits of shifting to an essentially private system with a form of a voucher towards the cost.