Work done in the course of the review
The changing role of the community optometrist
With the introduction of free NHS eye examinations from 1 April 2006, the role of the high street optometrist has expanded from the testing of sight to the provision of a more extensive eye health examination. Given that optometrists are the largest professional group in the field of eyecare, this has enhanced their capability to manage eye disease in the community setting. All of the optometrists and optometric medical practitioners ( OMPs) listed with Health Boards since 1 April 2006 to provide general ophthalmic services have had to demonstrate their competency in the use of optometric equipment and to ensure that they have the appropriate range of equipment available for use with their patients. By doing so they have achieved level one competence, as set out in the interim report of the review of community eyecare services. This was an important step towards the integration of community eyecare services.
The changes will have a range of benefits for patients and they will make more efficient use of health resources. The removal of the charge will encourage wider use of optometry services and the majority of patients will benefit from regular sight testing. The extended eye examination will enable optometrists to detect early signs of sight problems and to deal with these in partnership with the hospital ophthalmology service. The updated arrangements enable GP's and other members of the local eyecare network to refer patients to optometrists for the management of common eye conditions. Some conditions can now be treated and reviewed by optometrists while more complex cases can be worked up to a higher clinical level before they are referred to the hospital.
The extended role of the optometrist also offers the opportunity for greater involvement in the local eyecare network. The interim report of the review described the changes in optometry in some detail, including examples of joint work, like the GIES scheme in Glasgow. In addition, two of the three locality studies undertaken as part of the wider review examined the contribution of community optometry networks. In both instances, optometrists played a key role in identifying problems associated with failing sight, supplying low vision equipment and referring patients on for other local services. Details are given in the section of the report on locality-based interagency work which can be found at annex F.
Centre for Change and Innovation ( CCI) patient pathways
Alongside the initial review of eyecare services in Scotland the CCI Outpatients Programme established several projects to help improve the interface between primary and secondary care. Seven pathways of care (Strabismus, Glaucoma, Flashes and Floaters, External Eye Disease, Diplopia, Cataract and Age Related Macular Degeneration) were developed and published on the CCI website www.cci.scot.nhs.uk. The pathways are being piloted and the results will be evaluated.
Certification and registration
The formal link between health and social care services for visually impaired people is the certification and registration system. When a serious sight problem is identified, the individual is referred to a consultant ophthalmologist. If the condition cannot be cured, the consultant will certify the individual as blind or partially sighted. With the patient's consent, the consultant will send the certification form to the local authority (or its agent) for inclusion in the local register of blind and partially sighted people. The principle benefits of registration are: it is a passport to a range of financial benefits; it is used by some organisations as a means of allocating their services; and it is the main source of data on the extent of visual impairment.
The current system of certification and registration in Scotland is widely considered to be out of date. The definition of blindness, based on the 1948 National Assistance Act, was originally devised to identify adults who were unable to work because of sight problems. The definition is irrelevant to the majority of the visually impaired population. A working group looked in detail at the shortcomings of the current system and made a range of recommendations which can be found in annex H.
In summary, certification and registration in Scotland should be modernised and some aspects of the recently revised English system should be adopted. There should still be two levels of certification, but the terms "blind" and "partially sighted" should be replaced by "seriously sight impaired" and "sight impaired". The English reforms also introduced two stages of notification, prior to certification. Notification is a mechanism for putting patients in touch with helping agencies while they await certification. It is also recommended that the clinical criteria for certification be extended to reflect the changes in clinical practice since 1948.
In defining sight impairment in adults and in children, care should be taken to ensure that those who have additional impairments are included in the planning and delivery of services. For example, there is evidence that many adults who have learning disabilities have undetected sight problems. Particular attention should be paid to the needs of visually impaired children, as is illustrated by the following description of work undertaken by an eyecare review working group on children's services.
Services for visually-impaired children
There are significant differences between the nature of visual impairment in children and in adults. The causes of visual impairment can be divided into three categories: problems of the eye, the optic nerve or the brain. In contrast to sight loss in adults, which is predominantly a consequence of problems of the eye, the majority of children suffer visual impairment because of damage to the optic nerve or the brain. Almost all sight problems occur before or at birth, or in the first twenty-eight days of life. It is estimated that 70% of visually impaired children have an additional disability. (Visual Impairment Scotland 2003)
The distinctive nature of childhood visual impairment requires a specialist response. Vision is required to access information, to interact socially and to move around safely. Impaired vision in childhood can limit development in each of these areas and can lead to long term education and social disadvantage unless appropriate provision is made at an early age. The needs of visually impaired children are primarily met by education services, with additional input from hospital, optometric, orthoptic and social services when required.
The working group looked in detail at the needs of visually impaired children. There was some overlap with the work of the certification and registration working group. The detailed recommendations of the working group can be found in annex E.
In summary, the working group emphasised the need to recognise the particular needs of visually impaired children, rather than treating them as small adults. Access to specialist support and equipment is essential to minimising the impact of visual impairment in the child's development. Above all there should be strong local links between health, education and social care services. The CVISTA scheme in Tayside is given as a model of good practice. All of the helping agencies in the area work together in a single network, which is coordinated by a community paediatrician. This gives the families of visually impaired children a single point of contact and a guide through what can be a confusing array of statutory and voluntary organisations.
The emphasis on the inclusion of visually impaired children in mainstream education is welcomed, but the working group's recommendations stress some of the practical issues involved in making social and educational inclusion a reality. Some of the essential building blocks are: the teaching of mobility and independent living skills at an early age; the availability of specialist equipment, both at home and at school; and a guarantee that curriculum material is in an accessible format. Underpinning all of these essential services is the employment of specialist staff. A summary of the workforce implications of implementing the community eyecare review is given in annex D.
The inclusion of children and young people in the certification and registration system was debated at some length. It is estimated that less than 50% of children are currently registered, which calls into question the relevance of the system. However, there has been some concern expressed about children and their families losing out on benefits that are linked to registration. It is recommended that visually impaired children remain within the scope of the system until the changes in certification and registration have been made. The working group recommended a notification system, to assist local support networks to identify visually impaired children in their area and to facilitate the collection of accurate national data.
Locality-based interagency work
One of the recommendations of the "Sensing Progress" report was that local authorities should consider the establishment of interagency sensory impairment centres. There are some examples of good practice in Scotland and one of the objectives of the eyecare review was to examine the validity of the locality interagency model of working. A study was set up on three sites: Edinburgh, Fife and Forth Valley. In each area there was a good level of joint working between health, social work and the voluntary sector.
An initial audit was carried out on the nature and quality of the services provided in each of the three localities. The audit included a survey of a sample of service users. In each locality, a management group was established, with representatives of the local service providers. They were invited to identify weak points in the system and the Health Department allocated pump-priming money to assist with setting up the study. Progress was monitored by the management groups, supported by an external consultant and an advisor from the Health Department.
At the end of the six-month period, a second audit was undertaken to measure progress. The audit included a second survey of service user's views. The conclusions of the study are set out in the form of key elements for a successful locality interagency model. These are derived from the assessment of the work undertaken in the three localities and they have been discussed in detail with the three local management groups. Details of the assessment of the three localities can be found in annex F.
In summary, the study demonstrated the benefits for both patients and staff of attempting to provide a seamless local service. There were variations in the configuration of services on the three sites, as they adapted to local circumstances. However all three shared a common objective: to provide a continuum of care that covered every stage in the patient journey. For example, a community optometry assessment might result in the issue of low vision equipment to deal with an immediate problem. A referral from the optometrist to the ophthalmologist could take place in parallel with the involvement of a social worker or rehabilitation worker and it might lead to a more detailed assessment of long term needs and the provision of a more extensive package of care. In all three sites information services were developed to ensure that patients and carers could be kept well informed at every stage in the journey. This is particularly important at the critical point when the ophthalmologist diagnoses permanent visual impairment. For example, one site developed a personalised information summary which could be given to the patient, detailing the diagnosis of the eye condition, the prognosis and the help available to cope with the impact of sight loss.
Joint working on a shared site encouraged mutual learning and reduced the gaps between services for the patient. The advantages were apparent both in a hospital-based setting with social care on site and in community settings with facilities for regular ophthalmology clinics. In two of the localities, community optometry networks were successful in extending the reach of the joint service and providing an improved first point of contact for individuals, particularly those who were in the early stages of coping with sight problems. Above all, the approach was to design local services around the patient, rather than sending patients on a journey around a range of disjointed services.
Setting national standards
When the Interim Report of the Eyecare Review was published for consultation in October 2005, there was strong support for the proposal that one of the outcomes of the review should be: "setting and maintaining national standards that can be adapted and implemented locally".
A working group was formed to look in more detail at national standards. ( Membership of the working group is shown in Annex A). The work of the group was informed by the study of interagency work in the three localities and by other examples of good practice. The members of the group decided that standards should be expressed in terms of outcomes for patients. They devised a framework of service outcomes that is described in detail in annex I.
In summary, the framework sets out the maximum time a patient should have to wait for an initial assessment of need and, if required, a complex assessment. It is recommended that simple services, like the provision of low vision equipment, be provided without delay. Lengthy and bureaucratic referral procedures should be avoided and there should be a facility for fast tracking of urgent cases between partners in the eyecare network. Where a complex support package is provided there should be regular reviews to ensure that the assistance matches the changing needs of the patient. Clear, personalised information about current and future care arrangements should be provided. The particular needs of members of minority ethnic groups should be taken into account when planning services.
In order to achieve consistent standards across Scotland, the working group identified four key elements that should be present in all local service planning for visual impairment. Service delivery should be based on an integrated model of health and social care, with enhanced communication and joint infrastructure. At the core of service planning is the need for a workforce with the competencies, capacity and capability to meet the health and social care needs of visually impaired adults and children. There must be integration with local performance management and accountability arrangements, to ensure continuous performance and quality improvement which is the subject of periodic external review. Finally, and crucially, planning must include the involvement of service users in the shaping and fine tuning of local services.