Section two of this submission highlights action needed in relation to current provision of eye care services and the importance of clear communication to the public. It also outlines the need for increased capacity in the provision of NHS eye care services in the recovery phase after lockdown, including consistent provision of low vision services. Section three addresses rehabilitation services which are vital to enabling people with sight loss to maintain independence. Section four highlights the importance of sigh loss registers held by local authorities. Section five focuses on child vision screening and the need for adherence to Public Health England guidance, the final section six relates to the provision of eye health services for children in special schools.
2. Eye Care
NHS eyecare services have rapidly transformed to respond to the coronavirus pandemic. Currently hospitals have put in place measures which enable social distancing and minimise the risk of infection to ensure people can receive time sensitive sight saving treatment for conditions like wet Age Related Macular Degeneration (wAMD).
NHS England and NHS Improvement (NHSE&I), working with ophthalmic professional bodies rapidly developed the COVID Urgent Eyecare Services (CUES) framework, in response to the crisis. It is essential this is implemented throughout England and communicated to the public, so patients clearly know where to go if they experience injury or rapid change in vision.
As in other health care areas, there is increasing evidence that many patients are not attending eyecare appointments or going for emergency care because of their concern about contracting the virus and burdening the NHS. The NHS Open for Business communications campaign is very welcome in highlighting the importance of people going to their appointments. It is essential that information about eye care services is included in NHS communications. CUES is designed to alleviate pressure on GP services and ophthalmology A&E and make best use of the eyecare workforce. Going forward this collaborative approach between hospital eyecare services and high street optometrists needs to continue.
Ophthalmology is the largest outpatient speciality. Prior to the coronavirus pandemic, hundreds of thousands of people received excellent sight saving NHS treatment. However robust evidence from the Ophthalmology Get It Right First Time (GIRFT) programme and the ‘Lack of timely monitoring of patients with glaucoma’ Healthcare Safety Investigation Branch (HSIB) inquiry found that thousands of patients experienced delays which resulted in hundreds of people losing sight that could have been prevented if they had been seen on time. The need to increase capacity within ophthalmology was recognised by NHSE&I prioritising eyecare within the NHS Outpatient Transformation Programme.
The suspension of routine eyecare and cataract surgery due to the pandemic will create an unprecedented backlog that current eye care services will be unable to meet without significant changes. The majority of eye care patients are over sixty with a high proportion over 70 and therefore particularly vulnerable to COVID 19. The reopening of ophthalmology services will need to balance the risk of coronavirus infection against the risk of avoidable sight loss. Amongst older people sight loss has a profound impact on health, wellbeing and ability to maintain independence. People with sight loss are more at risk of injury due to falls, requiring hospital treatment and often leading to loss of independence. Older people with sight loss are also more at risk of isolation and poor mental health.
NHS care beyond the pandemic requires transformation of eye care services to ensure that the best use is made of the whole eyecare workforce, including high street optometrists, orthoptists, ophthalmic nurses and technicians alongside ophthalmologists. It is vital that professional competencies are used appropriately to increase capacity within eyecare.
This requires effective IT connectivity between high street opticians and hospital eye care services. The current situation has promoted healthcare economies throughout England introducing new ways of working, particularly between optometrists and ophthalmologists using a variety of IT systems. In effect, a variety of IT systems are being trialled. Learning from these pilots must be collated to enable the most efficient and effective IT systems to be widely adopted. New ways of using technology such as video consultations, virtual clinics and teleophthalmology are being used. There is tremendous potential for these new ways of working to significantly increase capacity in eye care.
All routine primary eye care appointments at high street opticians have been suspended in response to the lock down. New ways of managing patients to retain social distancing will need to be developed. Attendance for routine sight tests is on the basis of self-referral. There is likely to be a backlog once businesses reopen. However, there may also be a fall in demand if people feel unable to or ration the purchase of spectacles because of economic concerns. It is possible that there may be a significant number of optometric practices that go out of business because of a loss of income during the lockdown.
Provision of low vision services varies enormously throughout England, including through hospital eye services, high street optometrists and charities. Essentially low vision services seek to enable people to make the best use of the sight available to them. Practitioners conduct an assessment, provide or sell low vision aids, such as magnifiers, lighting and eye shields to help people with everyday tasks like reading and going outside in bright light. A service will provide training about how to use the vision aids. Most low vision service users are older people. Some services have closed completely during the lockdown while others are providing some level of services remotely. Over time services will need to adapt the way they work to reduce infection control.
Recommendations for change (short term)
- Procedures need to put in place to enable people with sight loss to access hospital and other NHS services. This includes enabling people with sight loss people to be accompanied by guides and the provision of PPE equipment for guides where appropriate.
- Ensure implementation of CUES in Integrated Care Sytems (ICSs) and Sustainable Transformation Partnerships (STPs) throughout England so that members of the public are clear how to access urgent and emergency eyecare services and professionals are clear how to appropriately direct people.
- Include messaging about access to urgent and emergency eye care services as part of the NHS Open for Business communication campaign.
- Develop a plan for the supply of Personal Protective Equipment to the whole of the eyecare workforce to enable not only hospital eye services to reopen but also optometric practices and low vision services.
Recommendations for change (longer term)
- Enable effective use of the whole eyecare workforce to increase capacity in eyecare services.
- Develop appropriate IT connectivity between community optometrists and hospital eye care services informed by learning from the different approaches used throughout England during the pandemic. This is critical to enable appropriate use of the whole eyecare workforce.
- Ensure ophthalmology remains a priority for the NHSE&I Outpatient Transformation Programme.
- Implementation of recommendations from Ophthalmology GIRFT and the glaucoma HSIB inquiry.
- Support the development of innovative ways of monitoring patients using teleophthalmology, video conferencing, virtual clinics etc.
- Ensure that NHS Digital continues to work with the UK Ophthalmology Alliance (UKOA) to implement and monitor delays to clinically recommended follow up appointments.
- Support more consistent provision of low vision service to enable people with sight loss to make the best use of the vision they have.
3. Vision rehabilitation
People who develop sight loss rely on local authority provided vision rehabilitation services, which form part of the Care Act Section 2 preventative duties. These services carry out a rehabilitation assessment, preferably in-person at the individual’s home, so that their interaction with the home environment can be assessed for, for example, lighting and trip hazards, and the impact of their sight loss on daily living skills and mobilisation can be evaluated. Adaptations, equipment, aids and training can then be provided to maximise independence.
There is already a substantial existing backlog of people in England waiting for vision rehabilitation assessment, and services, upwards of 12 months in some areas. The reasons for this are complex, but include:
- prevention services being unique amongst wider social care services in not being monitored by CQC;
- vision rehabilitation not generally being treated as a high priority by local authorities (particularly within known financial constraints);
- there being a shortage of specialist Rehabilitation Officers for people with Vision Impairments (ROVIs);
- inefficient referral pathways from some NHS Consultants;
- variation in the depth of support between local authorities;
- individuals are largely unaware of their rights, and the nature of support that should be available.
The Coronavirus Act Statutory Guidance to local authorities makes clear that preventative services, which includes vision rehabilitation, are not affected by Care Act easements, and they continue to be a duty of local authorities.
However, we are aware that some local authorities have suspended waiting lists, and that Rehabilitation Officers of Visually Impaired people (ROVIs) have been redeployed away from rehabilitation duties in response to front-line pressures, in response to front-line pressures and the use of Care Act easement.
During the restrictions, ROVIs that are not redeployed are adapting to circumstances and conducting work by phone or online where possible. Health and allied professionals such as Occupational Therapists have been provided with PPE. ROVIs work is vital to enable people with sight loss to maintain independence, it is essential they have access to PPE equipment to effectively continue their face to face work.
Longer-term, further delays as a result of the use of easement powers will have significant implications for people who will be unable to access services and be left isolated, more dependent and at greater risk of unnecessary harm from falls and accidents, and of neglect.
The existing backlog is likely to be made worse following the end of COVID-19 restrictions, as local authorities are likely to prioritise the completion of care needs and financial assessments before specialist rehabilitation assessments, unless directions are received to prioritise assessment and delivery of services in parallel. We are also concerned to hear reports of local authorities that are considering a “Year 0” approach post COVID-19, deleting previous waiting lists and starting again.
- CQC should have its mandate extended to include Care Act Section 2 preventative services, during and after the COVID-19 restrictions.
- CQC should monitor the provision of preventative services and Government should reiterate, if necessary, that they continue as a duty to provide.
- ROVIs should have priority access to PPE, alongside other care staff who work with clients face-to-face.
Post COVID-19 recommendations
- The Government should make clear that preventative services, including vision rehabilitation, must be prioritised in parallel with needs assessed services, rather than consecutively, once COVID-19 restrictions end, and that deleting existing waiting lists is an unacceptable practice.
- Once restrictions end, NICE should be commissioned to produce vision rehabilitation guidance and quality statements.
- Once restrictions end, these NICE quality statement measures should be included in the DHSC Adult Social Care Outcomes Framework for reporting and monitoring.
4. Sight Loss registers
Section 77 of the Care Act 2014, which requires councils to maintain a Sight Loss Register, does not appear to be covered by the Coronavirus Act.
As it is an important duty for RNIB’s clients, in requiring the council to identify and make contact with those who have lost sight, it should be clarified in the guidance that this duty remains. This could be contained in the Guidance section on “Protections and safeguards”.
The COVID-19 response has highlighted a problem that contact details on the Sight Loss Register are not actively maintained, and may be years out of date. This should be considered as part of emergency response preparedness in future, to ensure those who have alternative format preferences for communication are not disadvantaged in a crisis.
- The Government should include clarification in Guidance that the duty to continue to maintain a Sight Loss Register by local authorities is unaffected by the Coronavirus Act.
Post COVID-19 recommendations
- The Government should amend the Care Act, and Guidance, to ensure that local authorities actively maintain the contact details on Sight Loss Registers.
- The Government should develop the use of the register, with the sight loss sector and blind and partially sighted people, so that in a future crisis, it can be used to proactively contact blind and partially sighted people with information that is most useful to them and in preferred accessible formats.
5. Child Vision Screening
Child vision screening, when first attending school at the age of four or five, is undertaken as part of prevention and early intervention services, is important to identify and treat eye problems during the critical development period, while the brain is still developing neural connections to the eyes, therefore preventing avoidable sight loss such as amblyopia (lazy eye).
Over 20% of 6-7 year old children in the UK have imperfect vision; mainly refractive errors such as hypermetropia (far-sightedness), myopia (short-sightedness), anisometropia (eyes having different refractive power) and astigmatism, but also vision deficits such as strabismus (where the eyes are not straight) and amblyopia. Amblyopia is the most common vision deficit in children in the UK, occurring in 2-5% of children, which can lead to a failure to develop binocular vision, interfere with social and psychological development, and ultimately lead to loss of sight in the weaker eye, and an increased risk of blindness, if untreated.
Child Vision Screening, for which the UK National Screening committee has produced guidance, forms part of the “Healthy Child Programme: Pregnancy and the first 5 years of life” document from the former Department of Health. Delivery of the programme is a legal duty for local authorities under “The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) and Local Authority (Public Health, Health and Wellbeing Boards and Health Scrutiny) (Amendment) Regulations 2015”, which transferred specific NHS Act 2006 health functions from the Secretary of State.
However, screening services are only mentioned in general terms 2015 amended regulation 5A(5)(b), and Child Vision Screening is not specifically included in the mandated universal elements of the 0-5 Healthy Child Programme, or the Mandation factsheets, produced as part of the transfer of functions.
All of this makes it unclear as to whether or not Child Vision Screening is a mandatory element of the screening services delivered by English local authority Public Health departments.
RNIB is concerned that an already inconsistent approach to screening in England, by contrast with the universal coverage in the other devolved nations, could be exacerbated post COVID-19 if local authorities feel able to opt-out of provision. This will lead to a greater risk of vision deficits being missed, in time to be treated.
- The Government should amend regulations and guidance to specifically include Child Vision Screening, which follows UK NSC guidance, in the 0-5 Healthy Child Programme.
Post COVID-19 recommendations
- All local authorities should use the UK NSC service specification, screening competencies, diagnostic and screening pathways, and supporting materials to commission child vision screening in school for 4 to 5-year-olds, to create a universal and consistent service across England.
6. Eye health services to special schools
Children with learning disabilities are at a much higher risk of sight problems and eye health disorders, and there is evidence of barriers to their accessing eye care and high unmet need.
They also face extra barriers to accessing wider healthcare, which can put them at increased risk of missing out on the care they need, and avoidable death. In addition, due to the increased risk of adverse outcomes from respiratory conditions for many disabled people, they may be more likely to need to access healthcare services.
At this time, it is vital that health and social care workers can still make the reasonable adjustments required by law that these patients need.
In the longer term, SeeAbility, a sight-loss charity that specialises in working with people with autism and learning disabilities, reports that 85% of children attending special school would either be unable to participate in or fail the UK NSC child vision screening tests, which makes these tests unsuitable for this customer group. There is also, currently, no wider planning for their community eye health needs.
- Public Health England should publish coronavirus guidance for health and social care professionals based on “Advice for care staff on supporting health equality during the coronavirus pandemic” developed by the sight-loss sector.
Post COVID-19 recommendations
- NHS England/Improvement should:
- adopt the “Framework for provision of eye care in special schools in England” developed by SeeAbility;
- ensure commissioning of local Special Schools Ophthalmic Teams that deliver as much eye care as possible in the school environment; and
- reform community eye care to provide equitable access for children with learning disabilities and/or autism.