Cumbria JSNA Refresh Process 2012

Cumbria JSNA refresh process 2012

Joint response of voluntary sector visual impairment groups

1. Introduction

Cumbria Societies for the Blind, RNIB and Action for Blind People are working together in Cumbria to support visually impaired people across the county. The driver behind this partnership is the UK Vision Strategy that has three key aims:

Improve the eye health of the people of the UK (or Cumbria)
Eliminating avoidable sight loss and delivering excellent support for people for people with sight loss
Inclusion, participation and independence for people with sight loss

In particular we wish to ensure that eye health and sight loss is embedded in health and social care planning including within the Joint Strategic Needs Assessment (JSNA).

This document outlines some of the key areas that we would like to see included and offers support to those completing the refresh process.

This includes:

The costs of sight loss
Prevalence and incidence of sight loss and key common eye conditions
Demography and sight loss – The impact of an ageing population
Sight loss and other considerations – learning disability; socio economic factors; smoking; obesity; stroke; falls; depression and dementia
Sight loss and current service provision and planning – local strategy and planning; voluntary and statutory provision
Recommendations for improving services and preventing sight loss.

2.Costs of sight loss

RNIB research calculates the cost of sight loss at £6.5bn in 2008 rising to £7.5bn by 2013. This figure includes the direct and indirect costs of sight loss.

If factors like loss of health and premature death are taken into account - using World Health Organisation and government figures – RNIB estimates that it cost a further £15.5bn in 2008[1].

A significant increase in spending on "problems of vision" was noted in a recent Department of Health report, which confirms the validity of these predictions.[2] Commissioners will spend an average of £3.72 million on eye care per 100,000 head of population[3].

3. Prevalence and incidence of sight loss

3.1Eye conditions

This section allows for the number of the population with a particular eye condition to be indentified. This will allow for targeted services to be developed and will allow for identification of areas where support may need to be focused. The most common conditions leading to sight loss can be set out with the estimated number of people currently affected and how these figures may grow in the next 10 -15 years.

Estimates for Cumbria PCT area 2006

Condition / Current Prevalence / Potential Prevalence
2015 / Potential Prevalence 2020
Age related macular degeneration (AMD) / 4486
Glaucoma / 4762
Cataracts / 17,324 (high)
4,815 (low)
Low Vision / 6,322

This information is collected by the National Eye Health Epidemiological Model (NEHEM) which provides estimated data on the main eye conditions for each local authority and primary care trust using 2001 census data. Future predictions can be based on this data.[4]

The common conditions listed above pose different demands on health planners. AMD is the most common condition but there are two forms (wet and dry). The wet type requires early intervention if treatment is to be effective. Similarly, glaucoma requires early detection if treatment is to stabilise and control the eye condition. Patients often have to take drops for the rest of their lives to prevent further deterioration.

JSNA planners may also wish to include information on the prevalence and incidence of Diabetic Retinopathy. This is an increasingly common eye condition and the numbers of new cases may be prevented via screening and early diagnosis. Information is available via the NHS information Centre[5]

3.2Understanding Registration Data

The number of people living with sight loss is increasing[6]. Almost 2 millionpeople in UK live with sight loss; by 2020 this number is predicted to increase 22 per cent and double to 4 million by 2050.

The Certificate of Visual Impairment (CVI) and the CVI register are both vital steps in ensuring that people with diagnosed with sight loss have an opportunity to access support to assist with rehabilitation, benefits and eventual independence. The CVI process involves both Clinicians and Social Services, who together need to ensure timely processing of the CVI and inclusion of individuals on the local CVI register.

In Cumbria there are 1400 people registered as blind (severe sight impaired) and 1700 registered as partially sighted (sight impaired)[7]. This number is thought to be under representative of the actual number of people living with sight loss. Estimates, based on RNIB research, interpolated from census figures provide a figure nearer to 15,000for Cumbria[8]. This gives an apparent discrepancy that is near to five times what is known and planned for in budgets and forecasting (consistent across the UK).Cumbria’s 2009 JSNA already predicted this at some 9000 people. Again well above the actual known figures.

3.3Age and sight loss

The prevalence of sight loss increases with age, and the UK population is ageing. One in five people aged 75 and over, and one in two people aged 90 and over are living with sight loss in the UK.

For older people with sight loss there is a correlated loss of independence and an increased risk of poverty, with three out of four people blind or partially sighted people living in poverty or on its margins.

Older people with sight loss in Cumbria[9]

2012 / 2015 / 2020 / 2025
People aged 65-74 predicted to have a moderate or severe visual impairment
People aged 75 and over predicted to have a moderate or severe visual impairment
People aged 75 and over predicted to have registerable eye conditions
Total

This table can be populated using the Projecting Older People Population Information (POPPI) data source. JSNA planners can extrapolate future estimates based on population growth estimates for Cumbria.

3.4 Learning disabilities and sight loss

There is a high prevalence rate of sight loss amongst adults with learning disabilities. They are ten times more likely to be sight impaired or severely sight impaired than the general population. In addition six in ten people with a learning disability needing glasses will also require support to get used to them.[10]

UK wide figures show estimated 40,600 people with learning disabilities aged 20 - 49 (including 25,390 known to statutory services) are blind or partially sighted.

However, the official figures for Cumbria indicate that of 3,100 people on the register only five[11]are recorded as having a learning disability. This figure may need more investigation and may reinforce the notion that people with learning disabilities may require targeted interventions to assess the extent of sight loss more robustly.

We can also see that only 95[12] people registered as blind or partially sighted in Cumbria are shown as having an ‘additional disability’. This contrasts sharply with Lancashire and elsewhere that suggest a figure closer to a third of the population have sight loss and additional disabilities.

The need for robust figures has recently been given further impetus with the Department of Health having recently published their Public Health Outcomes framework for England, which includes an indicator for eye health and sight loss[13]. Statutory bodies are now subject to collecting robust data to comply with this framework.

3.5Health determinants and sight loss

The impact of sight loss (both refractive error and eye conditions) and other health determinants can dramatically increase risk and demand on health and social care services. The links between sight loss and other health determinants include:

Smoking

The link between smoking and age-related macular degeneration (AMD), the UK's leading cause of sight loss, is as strong as the link between smoking and lung cancer. Smokers not only double their risk of developing AMD, they also tend to develop it earlier than non-smokers do. Furthermore, smoking can make diabetes-related sight problems worse, and has been linked to the development of cataracts[14]

Research has shown that cessation programmes which link sight loss and smoking provide a strong motivation for people to reduce or give up smoking.

Obesity

Amongst different eye diseases, obesity has been linked to several eye conditions including Cataracts and Age Related Macular Degeneration. Obesity also has a strong link to Diabetes and an exacerbation of sight deterioration in Diabetic Retinopathy[15]

Stroke prevention

Damage of a stroke can impact on the visual pathway of the eyes which can result in visual field loss, blurry vision, double vision and moving images.

Around 60% of stroke survivors have some sort of visual dysfunction following a stroke. The most common condition is 'homonymous hemianopia' (loss of half a person's visual field) which occurs in 30% of all stroke survivors[16]

Blood Pressure /Hypertension

In addition to the different types of Glaucoma, uncontrolled high blood pressure can cause retinal damage by constriction of the retinal blood vessels (hypertensive retinopathy).

In England, about 480,000 people have chronic open-angle glaucoma. Among white Europeans, about 1 in 50 people above 40 years old and 1 in 10 people above 75 years old has chronic open-angle glaucoma. Glaucoma tends to be more common among people of black-African or black-Caribbean origins.[17]

Dementia

As well as the effect of ageing, many diagnosed with Dementia may have eye conditions such as Cataracts or Macular Degeneration; others will have a type of Dementia that impairs their vision by affecting perception of depth, colour and detail. It is estimated that around 2.5% of people over the age of 75 will have Dementia and significant sight loss[18]

Falls

A review of 31 studies on the risks and type of injuries associated with sight loss suggest that those with sight loss are 1.7 times more likely to have a fall and 1.9 times more likely to have multiple falls.

The estimated medical costs of falls nationally cost on average £269 million. Of the total cost of treating all accidental falls in the UK, 21% was spent on the population with visual impairment.[19]

Depression

The link between visual impairment and reduced psychological well-being is now well-established, particularly for older people. Older people with sight loss are also almost three times more likely to experience depression than people with good vision.[20]

It was noted that the stress that living with visual impairment places on relationships, as people become less able to live independently and are compelled to rely on family and friends to meet their support needs was a contributing factor.

JSNA planners in Cumbria may wish to consider how sight loss can be included more effectively into the related strategies relating to falls prevention strategy; older people’s strategy and health and well being (or smoking cessation) strategies.

3.6 Children’s sight loss

JSNA planning in Cumbria should also gather information on the eye health of children. Official figures suggest that no children aged 0-4 are on the register (either blind or partially sighted). This may need further analysis to establish blockages and gaps in the system.

Cumbria’s efforts to screen children for potential eye conditions should also be assessed. Screening procedures are set out in the National Screening Committee Child Health Sub-Group Report on Vision Screening[21].

This advises that all newborn and 6-8 week old babies should be examined as part of the routine review to exclude retinoblastoma, glaucoma and cataract since they are treatable and, respectively, life and sight threatening; and a specialist neonatal ophthalmic examination is recommended for babies at a known higher risk of visual disorders, such as very low birth weight and pre-term babies or babies with a known hearing impairment or with other major disabilities.

4. Current Activities, service provision and assets

JSNA planners should be aware of local and national strategies and local provision and assets. Some are listed below.

4.1Cumbria Strategy for Sensory Impairment 2010 - 2014

NHS Cumbria, the County Council and 3rd sector (voluntary) organisations have worked together to produce the Cumbria Strategy for Sensory Impairment 2010 - 2014. A copy of this report can be sent to you on request. This strategy which has adopted the key aims of the UK Vision Strategy is the starting point for JSNA planners to reference in terms of local planning and strategic focus.

4.2The UK Vision Strategy

The UK wide initiative, based on the World Health Organisation report that has widespread support across the political spectrum and the key statutory bodies and professional groups.

4.3 Public Health Outcomes Framework

The Public Health Outcomes Framework now includes an eye health indicator. This indicator will track the rates of three major causes of sight loss including glaucoma, age related macular degeneration (AMD) and diabetic retinopathy. In many cases sight loss from these eye conditions can be prevented if detected and treated earlier.

The eye health indicator will measure the rate of sight loss through chronic glaucoma, age related macular degeneration (AMD) and diabetic retinopathy per 100,000 of the population. The data used will be based on CVI (certificate of visual impairment) registrations and will be measured annually.

The indicator should enable the eye health and sight loss sector to work with the new NHS and Public Health England to improve eye health and counter issues of inequality across England.

Inclusion of this indicator will ensure that avoidable sight loss is recognised as a critical and modifiable public health issue. Research by the Royal National Institute for Blind People (RNIB) suggests that 50% of cases of blindness and serious sight loss could be prevented if detected and treated in time.

Prevention of sight loss will help people maintain independent lives as far as possible and reduce needs for social care support, which would be necessary if sight was lost permanently.

4.4Local Services

Primary care services are provided by opticians, optometrists and GPs.
Low Vision clinics are funded by NHS Cumbria and include services provided by opticians/orthoptists, rehabilitation officers from the County Council and staff from local blind societies/sight support organisations (Cumbria Societies for the Blind).
Secondary eye care services are provided by hospitals in Cumbria, with some specialisms being provided outside of the County. There are no Eye Care Liaison Officer (ECLO) posts in Cumbria (which elsewhere in the country ensure that emotional support, advice and information are provided at the point of diagnosis in hospital) but local blind societies/sight support organisations (Cumbria Societies for the Blind) support some clinics.
The registration process is run by the County Council on receipt of Certificates of Visual Impairment from the NHS. All those registered are contacted by the County Council and offered registration and/ or assessment for services.
The rehabilitation service is run through a specialist ROVI (rehabilitation officers for the visually impaired) service. This offers a specialist assessment and offers assistance with daily living, communication and orientation and mobility. The service also accepts referrals in and makes referrals out to the re-ablement service run by the County Council and signposts to relevant services in both statutory and voluntary sectors.
Support Services – advice and information, benefits advice, emotional support, social groups, resource centres, home visits, IT support and training, employment support are provided by Cumbria Societies for the Blind and Action for Blind People/RNIB.

5. Further Considerations and Recommendations

Eye health has a major impact on health inequalities. Existing local initiatives and proposed actions that will be included to take forward areas highlighted within the JSNA should be considered, these may include:

Inclusion in the Cumbria Health and Wellbeing Strategy.
Review of local Eye Care pathway to ensure the efficient and effective use of existing assets.
Include any commissioning activities for follow up arrangements for Diabetic Retinopathy, Cataracts, AMD, Glaucoma and Low Vision.
Establish services which provide support at time of sight loss and how to adapt to sight loss, including rehabilitation support, counselling services or Eye Care Liaison Officers at every point of diagnosis.
Incorporating eye health messages into other public health campaigns around obesity and smoking cessation.
Establish a Public Health campaign to raise awareness of the importance of regular sight tests (stressing their role as ‘eye health checks’). This is a particular concern for ‘at risk’groups such as older people, BME communities and smokers.
A joined up approach been adopted as required to identify the numbers of registerable people to inform the public health outcomes indicator.
Prevention activities are required across different ethnic groups to address preventable sight loss as a result of AMD, Glaucoma, Diabetic Retinopathy or Cataracts.
What provision is in place to deal with the increase in sight loss due to the ageing population profile will impact on service planning?
A joined up approach to conditions and lifestyle choices that impact on vision needs to be considered (e.g.) Diabetes, heart disease, blood pressure, strokes, smoking, obesity, depression, falls will support prevention of avoidable sight loss and more cost effective treatment.
A joined up approach to learning disability will support cost effective service provision.

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Sheelagh O'BrienDevelopment Officer, Cumbria Societies for Blind

Lindsay ArmstrongRegional Campaigns Officer, RNIB

Tom ReckRegional Development Manager, Action for Blind People

March 2012

[1] RNIB 2009- Cost oversight? The cost of eye disease and sight loss in the UK today and in the future.