Accessible Eye-care Making the most of community optometry

1. Accessible Eye-careMaking the most of community optometry Gordon Ilett Optometrist gordonilett@gmail.com

2. “Vision testing should precede any assessment of mental ability” O’Hara and Sperlinger 1997

3. Outline • Why are people with learning disability a special group? • Can eye examinations be done? • Why is service provision using existing pathways sub-optimal? • Creating solutions.

4. Why are people with learning disability a special group? • To access and benefit from eye-care we must: • Identify there is a problem with our eyes or vision • Communicate our concern to others • Understand and act on advice given • People with learning disabilities may lack the skills to allow them to do this • There may be difficulties for carers and non-specialist professionals in identifying behaviour relating to possible visual impairment and/or diagnostic overshadowing • Eye disease is often painless and signs may be overlooked even by the patient

5. Increased PrevalenceSeeAbility – From Emerson & Robertson 2011 • People with learning disabilities are 10x more likely to have serious sight problems • 60% will need spectacles and may need support to get used to them • 9.3% meet the criteria for sight impaired or serious sight impairment (partial sight or blind) registration • Those with severe and profound learning disabilities are most likely to have sight problems

6. A Clear Vision: Eye-care for children and young people in Special Schools in Wales: Maggie Woodhouse, Barbara Ryan, Nathan Davies, Aideen, McAvinchey • Study on children in special schools in Wales – June 2012 • 39/44 schools involved • 33% of pupils had never had a sight test • 6% had visual problems in Statements of SEN • 20% were found to have visual impairment likely to impact on ability to learn • 50% of pupils needed spectacles • Only 30% had them

7. Is there a Need for Screening? • Wilson-Jungner Criteria WHO 1968 • The condition being screened for should be an important health problem • The natural history of the condition should be well understood • There should be a detectable early stage • Treatment at an early stage should be of more benefit than at a later stage • A suitable test should be devised for the early stage • The test should be acceptable • Intervals for repeating the test should be determined • Adequate health service provision should be made for the extra clinical workload resulting from screening • The risks, both physical and psychological, should be less than the benefits • The costs should be balanced against the benefit • No single screening test is suitable for detecting the range of eye conditions which may be present – a full eye examination on a regular basis is needed for this patient group

8. Can Eye Examinations be done? • Yes

9. Acuity Tests • Functional Assessment • Cardiff Acuity Test • Kay Picture Test • Letter Matching

10. Ophthalmoscopy:Internal eye examination • Direct • Indirect • Slit-lamp BIO • Fundus camera

11. Retinoscopy • Objective method of finding strength of glasses • May need cycloplegic drops • Can measure accommodation –focussing ability • Autorefractors?

12. Subjective : Better 1st or 2nd ? • Often full subjective possible • Larger Changes? • Speed

13. Success Rates v Severity of LD D McCulloch

14. Prescribing and ManagementBest practice • Decide • Is the prescription necessary? • Will the patient appreciate change? • Are they normalised to blur? • Will an adaptation programme be needed? – 60% success wearing without, 75% + with • Detail behavioural changes in referrals to inform treatment decisions • Optometrists may need to act as advocate for the patient • Written information on outcome of examination should be given to patients, carers and other professionals as needed • ‘Health passports’ should be completed

15. Community Eye Care • So why is access to eye care an issue for people with learning disabilities? • Lack of education of patients and carers • Lack of education of professionals • Restrictions of General Ophthalmic Services (England) • Sight test fee £20.70 (20-30 minutes for typical patient) • No payment for incomplete test • No payment for repeat examination • No change in fee for extended examination • Sale of spectacles expected to support business • Learning Disability is not an entitlement to NHS sight-test • Most current business models do not allow time for adequate eye examinations and communication of the results • However most optical practices do have the facilities and much of the equipment needed to provide eye examinations for people with learning disability

17. Actions Needed • Appointment of local ‘champion’ to case find, educate and advocate for patients eg specialist rehabilitation worker • Functional Vision Assessment of all clients where visual status is uncertain • Document visual abilities of every client • Commission LOCSU pathway to facilitate extended eye exams • Ensure regular 2 yearly eye examinations • Allow entitlement to NHS sight tests for those on LD registers • Work with Secondary Care Providers to ensure equal access • Document outcomes and advice given

18. Pathway Support • Local patient champion and advocate • Pre examination reporting – Telling the Optometrist about me form – SeeAbility • Appropriate facilities and equipment – desensitisation visits • Include domiciliary services in pathways and funding • Feedback forms and reporting – SeeAbility forms or PHP/Health Passports completed • Information leaflets on Eye health and Spectacles - SeeAbility

19. LOCSU Pathway

20. Cost to CCG/Local Authority • Whose budget? • CCG Health • Local Authority screening and Public Health • No Service • Risk of claim for lack of ‘reasonable adjustments’. Equality Act, Human Rights Act etc. Potential high level awards • Basic service – optometrist extended exams • 400 extended exams /year @ £60 each = £20k • Gold standard service – Specialist worker plus extended exams • Specialist worker £30k pa (including, overhead, expenses and NI) • 500 extended exams/year @ £60 each = £30k TOTAL £60k • Savings: • Hypothesis - If 10% of clients have 2 hour reduction in support/week @ £15/hour then £78k savings

21. Remember • Assess Visual Function • Record Functional Ability • Organise Eye Examinations • Create Pathways • Record Results • Modify Care Plans • Empower Individuals