London Health Commission Call for Evidence
The UK Vision Strategy welcomes the opportunity to comment on the London Health Commission Call for Evidence; reflecting the views of the eye health and sight loss sector.
The UK Vision Strategy is a cross-sector initiative, uniting all those in the UK who want to take action on issues relating to vision and sight loss. It is a framework which supports the development of excellent services to build a society in which avoidable sight loss is eliminated and where people with sight loss can fully participate. UK Vision Strategy is a VISION 2020 UK* initiative led by the Royal National Institute of Blind People.
The UK Vision Strategy was launched in 2008 following extensive consultation with over 650 individuals and organisations. It was developed in response to the World Health Assembly’s resolution of 2003 to tackle visual impairment. Through VISION 2020 UK, the Strategy is part of the global VISION 2020 initiative led by the World Health Organisation and the International Association for the Prevention of Blindness.
Collaboration is the cornerstone of the UK Vision Strategy and the comments below are supported by the following UKVS partners.
· Action for Blind People
· Association of Directors of Adult Social Services
· British and Irish Orthoptic Society
· College of Optometrists
· Guide Dogs
· NHS Alliance
· Optical Confederation
· Royal College of Ophthalmologists
· Royal College of General Practitioners
· Royal College of Nursing Ophthalmic Forum
· Royal National Institute of the Blind
· Thomas Pocklington Trust
· VISION 2020 (UK) Ltd
· Visionary
* VISION 2020 (UK) Ltd is a registered charity and supporting member of the WHO “Vision 2020 right to sight”, global initiative for the elimination of avoidable blindness. The characteristic feature of this initiative is collaborative, cross sectoral working aimed at preventing sight loss.
General comments:
This response will focus on the importance of addressing eye health and sight loss issues across London, making links to other health issues as appropriate. We would recommend that eye health is considered as a priority issue and that an eye health expert is appointed as a Member of the Commission.
The reasons behind our recommendation have been summarised below and have been reflected in the answers to a selection of questions posed as part of this consultation.
1. Rising Demand: There are 1.86 million people in the UK living with sight loss. By 2020 this number is predicted to increase by 22 per cent and will double to almost four million people by the year 2050 (1). The increase can be attributed chiefly to an ageing population; over 80 per cent of sight loss occurs in people aged over 60 years (1).
Within London, RNIB estimates that there are 175,430 people living with sight loss with this number expected to rise to 210,090 people by 2020 (2). It is essential that we prepare now to meet this increasing demand.
2. The economic costs of certifiable sight loss are estimated to be £2 billion associated with direct health care costs, and £4 billion to indirect costs. These costs are only set to increase with the introduction of new interventions for previously untreatable conditions, the changing demographic profile of the population, and rising demand and expectations from patients and the public (1, 4).
The associated costs and demands on NHS outpatient services are high with ophthalmology having the third highest attendances in 2011-2012 (3). In 2010/11, Primary Care Trusts across London spent a total of £338 million on problems of vision (5). This does not take into account expenditure by local authorities, the voluntary sector and other providers. Additionally, this does not take account of associated costs of sight loss linked to issues such as falls.
3. Improve outcomes for people with or at risk of sight loss – people with sight loss are significantly more likely to suffer from depression (6) and have an increased risk of sight loss-related conditions, such as falls (7). Effective eye care pathways can help reduce unnecessary sight loss among at-risk communities and, for conditions that cannot be treated, effective social care support can help individuals successfully adapt to a life with sight loss.
4. Improving eye health can improve other health outcomes – improved detection and treatment of eye health conditions can have a positive effect on other health outcomes, including reducing social isolation and falls (7) and improving stroke rehabilitation through earlier discharge (8).
Section A - Improving the quality and integration of care
1) What has been successful in improving the quality of London’s healthcare?
We have outlined examples below of successful interventions that show improved quality of London’s healthcare. These are schemes that could be replicated throughout London.
a) Primary Eyecare Assessment and Referral Service
Bromley operates a Primary Eyecare Assessment and Referral Service (PEARS) scheme in conjunction with Bexley and Greenwich, enabling a quicker assessment and treatment of patients presenting themselves with an eye condition. Examinations are undertaken by accredited optometrists within suitably equipped premises, allowing assessment and some treatments to be carried out in the primary care setting, rather than an individual going to hospital. This saves NHS costs of treating individuals in secondary care settings and the patient time and anxiety while they wait for further tests.
The aim of the PEARS pathway is to:
· reduce unnecessary referrals to the hospital eye services
· reduce patient anxiety and increase capacity within the overburdened hospital eye health services
· provide a more cost effective service with a greater number of patients being managed within the primary care setting
b) Bexley Care Trust Repeat Measurement Scheme
The Bexley glaucoma repeat measurement scheme was introduced in 2005 and used the West Kent protocol as its basis. It provides a service where community optometrists can improve the quality of referrals by repeating IOP measurements using Goldmann or Perkins applanation tonometry and/or by repeating suspect visual fields. The protocol was updated following NICE guidance to allow applanation tonometry immediately after a sight test and again on another occasion if necessary.
The Bexley repeat measurement scheme resulted in 76% of patients not being referred (audit data 2007/08). In 44.5% of patients, where raised IOP was found by non-contact tonometry, repeated measurement by Goldmann / Perkins applanation tonometry resulted in referral being avoided.
Comparison has been made between the repeat measurement service and referral refinement by another practitioner in the Bexley community eyecare team. Financial review demonstrated that repeating measurements achieved 62% savings when compared with secondary care tariff while refinement resulted in a saving of only 3.5% (9).
2) What are the main challenges to improving the quality of London’s healthcare?
The prevention of sight loss is crucial as over 50 per cent of sight loss can be avoided (1). Increased public health campaigns to raise the importance of regular sight tests would be welcomed. In particular, the following groups should be prioritised.
a) Ageing population
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 (1).
b) Ethnicity
The risk of developing glaucoma is higher in African and African-Caribbean populations (4). People from South-East Asia and China are at higher risk of angle-closure glaucoma (10).
Evidence shows that people from the Asian population are at a higher risk of developing cataracts. African, African-Caribbean and Asian populations are at a higher risk of developing diabetic eye disease (1).
Evidence indicates that targeting preventative sight loss amongst people from black and ethnic minority (BME) communities can form part of a cost effective prevention programme (4).
c) Diabetics
Diabetic retinopathy is the leading cause of sight loss in working age people (11).
Across London, the number of people with diabetes receiving diabetic retinopathy screening varies between 86.3% in Sutton and Merton (amber status) to 45.5% in Islington (red status) according to the National Diabetes Audit 2010/11. (12)
The Royal College of Ophthalmologists recommends that “good communication between diabetic retinopathy screening programmes and the hospital diabetic retinopathy services to which they refer is essential. This is frequently the weakest link in the services for patients with diabetic retinopathy. Screening programmes need to be notified regularly of the status of patients attending hospital diabetic retinopathy clinics so that the fail-safe database can be kept up to date. Hospital diabetic retinopathy clinics should have access to retinal screening images in order to determine the optimal frequency of follow-up.”
d) Learning disabilities
There is a high prevalence rate of sight loss amongst adults with learning disabilities. An estimated 96,500 adults with learning disabilities in the UK, including 42,000 known to the statutory services, are blind or partially sighted. This means that nearly one in ten adults with learning disabilities is blind or partially sighted. Adults with learning disabilities are 10 times more likely to be blind or partially sighted than the general population (13).
e) Dementia
At least 123,000 people in the UK have both dementia and serious sight loss (1). Most are aged over 65 and, among everyone of that age, normal ageing of the eye will reduce their vision to some extent. As the population ages an increasing number of people will experience both dementia and sight loss (14).
3) What are London’s most important future health and care needs?
Eye health and associated issues need to be addressed as a matter of urgency. If eye health issues are not addressed, there is a significant risk of people continuing to lose their sight unnecessarily, falling into social isolation and depression.
4) How can we accelerate existing approaches that support high quality and more integrated care?
The Royal College of Ophthalmologists and the College of Optometrists have developed guidance (released 25 November 2013) to improve the quality and efficiency of eye health services.
David Geddes, Head of Primary Care Commissioning for NHS England has publically endorsed this guidance.
The guidance recommends how to improve services in three key areas:
· urgent eye care,
· age-related macular degeneration,
· low vision.
The guidance shows how commissioning community services delivering urgent eye care can reduce the number of people attending hospital casualty services at a time when they are struggling to meet demand.
Age-related macular degeneration is the biggest cause of sight loss in the UK. The guidance highlights how eye health teams can change the way they work to improve their services and reduce avoidable sight loss.
Low vision services help people who have lost their sight maintain their independence and quality of life. Many parts of the country do not provide low vision services and the guidance recommends how low vision support can best be extended to all those who need it.
The guidance was written by leading eye care clinicians with support from clinical commissioners at the National Association of Primary Care, Royal College of General Practitioners and the Department of Health’s Right Care Team. Patient groups contributed through the UK Vision Strategy with the Macular Society providing further support on the age-related macular degeneration and low vision guidance.
5) What new approaches to high quality and integrated care do we need to consider?
Work conducted by Thomas Pocklington Trust to develop local VisionStrategies across all London boroughs suggests two issues across London with regards eye health:
1. Eye health and sensory services are not given the appropriate level of priority they need. This is backed up by a recent report from RNIB which states that ‘over half of council local needs assessments in London do not include any information on people with or at risk of sight loss’. (15)
2. In the main, there is a lack of effective integration of services which is putting the eye health of individuals, and associated health issues, at risk. Local consultations have highlighted people waiting between six months to two years to be seen by local sensory teams following referral from their local eye clinic.
Services should be commissioned from, and coordinated across all relevant agencies encompassing the whole eye health and care pathway, with direct input and discussion with people with eye health problems, sight impairment and sight loss. An integrated approach to provision of services is fundamental to the delivery of high quality care to people with sight impairing conditions, for all levels of prevention (primary, secondary and tertiary) of sight loss.
Some examples of approaches to address these can be seen in the following:
In April 2012, LOCSU launched the Community Eye Care Pathway for Adults and Young People with Learning Disabilities which was supported by leading charities SeeAbility and Mencap. LOCSU and SeeAbility are piloting the pathway in three London boroughs - Kensington and Chelsea, Hammersmith and Fulham, and Westminster.
Implementing the pathway requires strong links between the Local Optical Committee(s) and health and social care professionals who are supporting people with learning disabilities.
The main features of the pathway are:
• optometrists receive additional training in providing eye tests for people with learning disabilities;
• reasonable adjustments such as the provision of a longer appointment will increase access to eye care;
• optometrists receive a higher fee to recognise the longer appointment;
• SeeAbility's "Telling the optometrist about me" and "Feedback from the optometrist" forms are used to ensure that good quality information is shared.
There are serious concerns arising that similar schemes in other London boroughs are at risk.
The Adult UK sight loss pathway (16) offers commissioners and practitioners a unique tool to enable people with sight loss to get the right support at the right time and from the right person. It clarifies the pathway across health and social care and so enables better partnership working and a smooth transition for the person with sight loss.
The Adult UK sight loss pathway is a process map for the ‘Seeing it my way’ (17) outcomes framework. It describes how the principles of best-practice can be put into place for an adult with a sight loss so that they can enjoy: