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Professor Frank KeeUKCRC Centre of Excellence for Public Health
Demographic context
The case for change
New ways of working
Charting a path
Confidence
RNIB estimates that two million people in UK have significant sight loss.
Half is preventable or due to treatable causes
There will be rising numbers of older….whose lives we can make better !
Population ageing is a sign of success
Ageing is becoming a central focus of governments
In the UK people aged 60+ outnumber those aged less than 16
N.I population is younger than other UK regions but this is set to change
Figure 1. N.I. Population Projections 2009 - 2056
0
50
100
150
200
250
300
350
400
450
0-14 15-29 30-44 45-59 60-74 75+
Age band
Pop
ulat
ion
in 1
000s
2009
2031
2056
By 2025 number of people aged 60+ will increase by 37%.
Number aged 75+ expected to increase by 61%
By 2031 more than 25% of the NI population will be over 60.
Figure 2. Predicted Population Growth for those aged over 60 NI (2006 - 2031)
0
50
100
150
200
250
300
350
2006
2008
2010
2012
2014
2016
2018
2020
2022
2024
2026
2028
2030
Year
Popu
latio
n (in
100
0s))
60 - 74
75 and over
“the number of people who are visually impaired will double in the next twenty years just as an effect of the ageing population” (Taylor & Keefe, 2001)
Increased mortality Increased morbidity / falls / fractures Increased road accidents Increased anxiety & depression Poorer self care & independence Greater need for community &
institutional resources Social isolation - quality of life Loss of income
The mere knowledge of a fact is pale; but when you come to realize a fact, it takes on colour. It is all the difference of hearing of a man being stabbed to the heart and seeing it done.
Mark TwainA Connecticut Yankee in King Arthur’s Court
Prevalence of obesity has reached epidemic proportions in many countries
Obesity has major impact on overall health
Obesity has been linked to age-related cataract, glaucoma, age-related maculopathy and diabetic retinopathy
•disease prevention and control
•training of personnel
•strengthening of the existing eye care infrastructure
•use of appropriate and affordable technology
•mobilisation of resources
Blindness: Vision 2020 - The GlobalInitiative for the Elimination of Avoidable Blindness
• Launched in April 2008
• Response to World Health Resolution of 2003
• Urges the design & implementation of plans to tackle vision impairment
• A united approach across all relevant sectors is key
Strategy outcomes1. Improve the eye
health of the people of the UK
2. Eliminate avoidable sight loss & deliver support for people with sight loss
3. Inclusion, participation & independence for people with sight loss
Fair & equitable access
Person centred
Evidence-based
Awareness of & respect for people with sight loss & compliance with equality legislation.
• RNIB estimate total UK costs at £4.9 billion per year.
• Economic burden associated with sight loss similar to Cancer, Dementia and Arthritis (Frick & Kymes, 2006)
• Australian study estimates that vision disorders cost an estimated 0.6% of GDP and every $1 spent on eye care can bring a $5 return to the community ( Taylor et al, 2006)
RNIB estimate approximately 980,000 people in UK have certifiable sight loss.
Main causes are Age related Macular Degeneration (AMD)
Glaucoma Diabetic Retinopathy Cataract
Make best use of available resources
Have fewer steps for the user
Make more effective use of professional resource
Drive up standards of clinical care to ensure good outcomes
Improve access and deliver greater patient choice
Evidence based
• Integrated eye care services
• Better use of skills in primary care
•Care for all in accessible settings
•Increased role for professional groups in primary care
To develop proposals for the modernisation of NHS eye care services in England and Wales.
first priority to develop model pathways for:
cataractglaucomalow visionage related macular degeneration
Set up by the Department of Health in 2002, with representatives of:
ophthalmologists optometrists and dispensing opticians primary care orthoptists ophthalmic nurses patient organisations health, social care & policy organisations
Do disciplines even want to see eye to eye ?
1. Patient reports sight problem to GP2. Patient goes to optometrist/OMP for
sight test and optometrist/OMP refers patient to GP
3. Patient goes to GP, referred to HES4. Patient seen at HES, cataract
confirmed, decision to operate, and put on waiting list
5. Patient attends HES for pre-op assessment
6. Patient attends HES for day case surgery
7. Patient attends HES for 24 hr check8. Patient attends HES for 6 week
check, 2nd eye discussed9. Patient attends optometrist for sight
test and new specs.
1. Patient attends optometrist•Sight test, cataract diagnosed and discussed
•General risks and benefits of surgery discussed•Patient wishes to proceed, information given etc
•Patient offered choice of hospital and appointment agreed
2. Patient attends HES•Outpatient appointment with
ophthalmologist*•pre-assessment (with nurse?)
•Date for surgery arranged/agreed
(* details of medication etc received from optometrist, GP or
patient as per local protocols )
3. Patient attends HES•Day case surgery undertaken
4. Patient attends HESor Optometrist
•Final check•Sight test
•Discharged or2nd eye discussed andappointment arranged
Start Finish
Single screening opportunity by community optometrists with no standardised protocols
Diagnosis and continued care for life of all glaucoma (and many suspects) within Hospital Eye Service by ophthalmologists
1. Patient attends community optometrist (CO)•Sight test, IOP over 21 (applanation tonometry) and/or
visual field defect and/or excavated discs•Patient/optometrist makes appointment with optometrist
with special interest in glaucoma (OSI) or OMP
2. Patient attends OSI or OMP•Full history and assessment carried out according
to protocol•Decision taken as to whether patient has ocular
hypertension (OSI/OMP reviews) or can be discharged (return to CO) or has glaucoma (treat
or refer to HES)•Patient advised, given information etc and further
appropriate appointments made if needed
3. OSI/OMP relays data to HES•HES reviews data, advises OSI/OMP
regarding management and sets up review at HES if needed
4. OSI/OMP manages patient in community setting•Regular reviews set in
place•OSI/OMP relay data to
hospital if significant progression for HES
review if needed
Start
“The futility of isolated initiatives…”Foresight: 2007
Researchers have discovered several risk factors that appear to be associated with AMD: Age Cigarette Smoking Early Menopause Hypertension (high blood
pressure) and/or cardiovascular disease
A diet high in certain vegetable fats, especially those found in snack foods like potato chips
Prolonged sun exposure Heredity Race
• Burden recognised by government• NSF for Older People
• Vision impairment is an intrinsic risk factor for falls
• NICE: Recent guidance on PDT for wet-AMD
• In meeting future demand, service will have to respond to increasing patient numbers and delivering new therapies
• Patient reports visual problem• GP refers patient to HES• OR• Patient is referred to an optometrist• AMD is diagnosed• Patient is referred to HES via GP• Fluorescein angiography carried out• Any credible treatment option considered• Patient managed by HES or by Low Vision
Service• Patient registered• Referred for Social Service &
• Rehabilitation support
PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSISCOMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSIS
PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSISCOMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSIS
SELFSELFREFERRALREFERRAL
SELFSELFREFERRALREFERRAL
REFERRED BY REFERRED BY ANOTHER CLINICIAN ANOTHER CLINICIAN
OR CAREROR CARER
REFERRED BY REFERRED BY ANOTHER CLINICIAN ANOTHER CLINICIAN
OR CAREROR CARER
OTHER SOURCEOTHER SOURCEOTHER SOURCEOTHER SOURCE
NOT NOT AMDAMDNOT NOT AMDAMD APPROPRIATE APPROPRIATE
CARE ASCARE ASINDICATEDINDICATED
APPROPRIATE APPROPRIATE CARE ASCARE AS
INDICATEDINDICATED
SYMPTOMS SUGGESTIVE OF SYMPTOMS SUGGESTIVE OF ARMDARMD
SYMPTOMS SUGGESTIVE OF SYMPTOMS SUGGESTIVE OF ARMDARMD
‘‘DRY’ (NON-DRY’ (NON-NEOVASCULAR)NEOVASCULAR)
AMDAMD
‘‘DRY’ (NON-DRY’ (NON-NEOVASCULAR)NEOVASCULAR)
AMDAMD
‘‘WET’ (NEOVASCULAR) OR WET’ (NEOVASCULAR) OR SUSPECTED ‘WET’SUSPECTED ‘WET’
AMDAMD
‘‘WET’ (NEOVASCULAR) OR WET’ (NEOVASCULAR) OR SUSPECTED ‘WET’SUSPECTED ‘WET’
AMDAMD
DIRECT REFERRAL TO HES DIRECT REFERRAL TO HES FOR FLUORESCEIN FOR FLUORESCEIN AGIOGRAPHY ANDAGIOGRAPHY AND
FURTHER INVESTIGATIONFURTHER INVESTIGATION
DIRECT REFERRAL TO HES DIRECT REFERRAL TO HES FOR FLUORESCEIN FOR FLUORESCEIN AGIOGRAPHY ANDAGIOGRAPHY AND
FURTHER INVESTIGATIONFURTHER INVESTIGATION
TREATABLETREATABLETREATABLETREATABLE
UNTREATABLEUNTREATABLEUNTREATABLEUNTREATABLE
ACCESS TO ACCESS TO TREATMENTTREATMENT
ACCESS TO ACCESS TO TREATMENTTREATMENT
OPTICAL / OPHTHALMICOPTICAL / OPHTHALMIC
LOW VISION SERVICESLOW VISION SERVICES
COUNSELLINGCOUNSELLING
SOCIAL SERVICE SUPPORTSOCIAL SERVICE SUPPORT
REHABILITATIONREHABILITATION
BD8/LV1 AS REQUIREDBD8/LV1 AS REQUIRED
OPTICAL / OPHTHALMICOPTICAL / OPHTHALMIC
LOW VISION SERVICESLOW VISION SERVICES
COUNSELLINGCOUNSELLING
SOCIAL SERVICE SUPPORTSOCIAL SERVICE SUPPORT
REHABILITATIONREHABILITATION
BD8/LV1 AS REQUIREDBD8/LV1 AS REQUIRED
• Fragmented• Wide variation re access
& quality• Referral from optometrist
(often via GP) to HES• Uni-disciplinary• Lack of information,
signposting & awareness• Long waiting times• Initiation of LV services
ONLY after ophthalmological assessment
4. Service enables re-access
1. Patient referred to Low Vision Service (LVS)
•Referral may be from secondary care, GP, social worker, rehabilitation officer, community nurse, OT etc or may
be self referral•Patient may have an LVI, RVI or CVI
•All patients are contacted by LVS within 10 working days
2. Patient attends LVS•Service is seamless across health, social care and the voluntary sector
•A full sight test forms part of assessment•Patient is given information on eye condition, entitlements etc as well as local services
• Counselling and advice on employment or education is available•Spectacles, LV aids, advice (esp. lighting, contrast and size) and home adaptations are
discussed and made available as appropriate•Referral to other areas of health and social care as needed, including certification
3. Patient has follow up visits as needed
•Visits may take place in the patient’s home or elsewhere•Visit will be by appropriate
member of the LV team
Start
All politics is localTip O’Neill1912-1994
Our population is ageing
Increasing need and demand for services
Primary care opthalmic services, based on partnerships, need to be developed to meet demand
Investment required Existing services need
to be used effectively
BENEFITS FOR PATIENTS BENEFITS FOR NHS
Better care
Access to services
Speed
Convenience
Shorter waiting times
Better use of skills
Better value for money
“A growing number of the most vulnerable people in this country experience a quality of life that is significantly, but unnecessarily, diminished for the want of basic, relatively inexpensive health care”
(RNIB 1999)
“And should there be a sudden loss of consciousness during
this meeting oxygen masks will drop from the ceiling”