Accessible Eye-careMaking the most of community optometryGordon IlettOptometristgordonilett@gmail.com

“Vision testing should precede any assessment of mental ability”

O’Hara and Sperlinger 1997

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.

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

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

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

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

Can Eye Examinations be done?

• Yes

Acuity Tests

• Functional Assessment• Cardiff Acuity Test• Kay Picture Test• Letter Matching

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

Retinoscopy• Objective method of finding

strength of glasses• May need cycloplegic drops• Can measure accommodation –

focussing ability• Autorefractors?

Subjective : Better 1st or 2nd ?

• Often full subjective possible

• Larger Changes?• Speed

Success Rates v Severity of LD

D McCulloch

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

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

Business Model Is this Sustainable with Extended Exams & patient choice?

High volume low cost of productOverhead high to attract and sustain numbersRapid throughputNeed high sales % to create profit

Yes – Only if ‘profit’ per ‘lost’ examination slot compensated.

Low volume high product cost (or supplementary exam fee)Overhead high to attract qualityExtended exam time the normIncome depends on hourly rate

Yes – if hourly rate can be met

Low volume low product costLow overheadRisk of under investmentTime for complex patientsWelcome additional services income

Yes – but providers business will fail if GOS is the only income stream

Stand alone specialist serviceHigh set up costFlexible appointmentsNo GOS funding

NoDepends on other fundingDenies choice But may be suitable for patients with high level needs

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

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

LOCSU Pathway

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

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