Memorandum by the Royal National Institute
for the Blind
RELATIONSHIP BETWEEN HEALTH AND SOCIAL SERVICES
(HSS 8)
2. THE PROCESS
IN DETAIL
2.1 The onset of visual impairment
A person suspecting that their sight is failing
or that they have an eye condition is likely to report either
to an optometrist/optician or to their GP. If there is cause for
concern then the GP is likely to refer the person to the local
ophthalmic consultant to wait for a first appointment. GPs should
not automatically assume that the sight loss is due to the ageing
process and that therefore nothing can be done medically or from
the rehabilitation perspective. Further, research has shown that
older people with failing sight tend not to define themselves
as having a sight loss. This is especially significant considering
the larger numbers of older people with a visual impairment.
THE ISSUES
At this point there may be a need for social
care services as the visual impairment may already be affecting
the person's daily life and undermining their confidence and emotional
state. Whilst timely social care/rehabilitation cannot prevent
deterioration in the condition of a person's eyesight, it can
minimise the degree of loss of function. If independence can be
retained it will not need to be regained at a later stage. Direct
referral to Social Services at this stage is unusual although
it has been demonstrated in some authorities that a system can
be established and that open referral can be successful. An example
of this is the current practice in some authorities where services
to visually impaired people are based on need rather than registration
status. This is not to underestimate the importance of registration
which is at the moment in many areas still a passport to services
and benefits. Such early and timely intervention could prevent
expensive residential care and home care and sometimes hospital
admission. Accidents in the home can be prevented if the person
is suitably rehabilitated after their loss of sight.
2.2. Outpatient Appointments
The visually impaired person then awaits an
appointment at the ophthalmic clinic. The waiting time for this
first appointment is crucial and at present waiting times range
from two weeks at the optimum time to 48 weeks at the longest
time. This demonstrates the variation in service which can occur.
Whilst waiting for an appointment sight loss may increase and
the effect on daily life may be becoming more pronounced. Confidence
will be diminishing, mobility will be reducing and the emotional
aspects of sight loss will be making themselves felt. There will
also be an increasing element of risk (Coles at al, 1997).
THE ISSUES
Waiting lists and times for first appointments
need to be reviewed and support provided whilst the wait is occurring.
2.3 Surgical Waiting Lists
The visually impaired person may then be placed
on another waiting list for treatment and again the amount of
time varies due to geographical variations, different clinical
practices and differing day case rates for cataract surgery.
THE ISSUES
The waiting list for ophthalmic treatment should
be reviewed, with people losing their sight expedited. Access
to social care should be available at this stage, by way of information,
advice, emotional support and through assessment of need under
Community Care legislation. Further, when a patient is in or attending
hospital, rehabilitation services should be available. Hospital
discharge arrangements should address the difficulties that someone
with a visual impairment may face in being discharged home or
to supported accommodation. This is particularly relevant for
older people.
2.4 Treatment not Possible or Unsuccessful
If there is no way of recovering or stabilising
the sight of loss or impairment, consideration should be given
to certifying the visually impaired person as blind or partially
sighted, and referring them to Social Services with a view to
them offering the person the opportunity of registration. Registration
still acts as a trigger for services in many local authorities
as well as providing access to a range of financial and other
benefits. There is sometimes a reluctance by medical advisors
to suggest that patients should be certified and registered, as
the breaking of this news is a difficult task and is sometimes
seen as a "failure" on the part of the medical profession.
Often, a patient will be attending an ophthalmic clinic for "surveillance"
perhaps for as long as another two years before certification
becomes inevitable. During this time the individual's needs must
be met.
Accessible information is critical at all stages
in the ophthalmic journey. The individual must be able to access
information at a time when they are ready to do so and have this
supported by someone knowledgeable to whom they can speak.
Access to emotional support is key at this stage,
with the responsibility for providing counselling services often
falling between health and social care. This must be supported
by social rehabilitation. At this stage, individuals often want
access to support groups and local services. Informing the people
responsible for supporting and signposting these individuals is
key to their rehabilitation. One model of providing this support
is the peer group and professional support which has been developed
and is now being promoted by RNIB, where newly visually impaired
people have the opportunity to undertake structured, therapeutic
group work with others in like positions and alongside their carers.
THE ISSUES
Registration can be presented in a positive
way and much depends on how the news is broken to the patient
that their visual loss is not recoverable. Many people who are
blind or partially sighted remember the day that they were told
this as the worst day of their lives. Adequate support and information
must be available at the ophthalmic clinic to ensure that the
individual receives appropriate support throughout this very difficult
time. This helps people to accept their sight loss, come to terms
with what it means for them and to start to adjust to their new
way of life. There should be trained staff available at all ophthalmic
clinics to provide information, assist with referral to Social
Services departments and to arrange further advice and support
if necessary.
2.5 The Transfer of Form BD8 to Social Services
Departments
It is important that completed BD8 forms should
be sent to Social Services Departments as soon as possible in
order to ensure that in those areas where the form acts as a trigger
for services there is as little delay as possible. Guidance has
been published on optimum times for this transfer to occur but
RNIB has evidence that delays of weeks or even months can take
place at this stage. RNIB also knows models of good practice where
jointly agreed targets for transfer of form BD8 between health
and social care providers and subsequent action are set and monitored.
When the form arrives at Social Service Departments it is important
that it is seen as an important document with implications both
for the individual and for the service. It should not be regarded
purely as an administrative procedure but as a referral for service
and should be treated as a request for support.
It is also important that the ophthalmologists
provide the right level of information on the form BD8 to enable
Social Services departments to prioritise referrals. For instance,
the person's domestic circumstances and additional disabilities
could place the person at significant risk. There are sections
on the form for this, but often the information is not recorded.
THE ISSUES
The DOH should issue formal guidance to local
authorities regarding the handling of form BD8 which should always
trigger a comprehensive assessment. Forms should be handled by
member(s) of staff at Social Services departments who are aware
of the needs of blind and partially sighted people. Temporary
clerical staff are often used for this role and this is not acceptable.
2.6 Social Care
At this point the Social Services Department
should visit the newly visually impaired person to begin a comprehensive
assessment of need and to offer registration. Too often this does
not occur. Sometimes visually impaired people are sent letters
from Social Services Departments stating that if they need help
they can get in touch. This is not adequate as each person on
the register should receive an assessment visit by a member of
the SSD trained in visual impairment so that the person's full
range of needs can be assessed, and an individual care plan produced
in order for those needs to be met appropriately. There should
be targets set for swiftness of response. RNIB knows of local
authorities where this is customary practice.
THE ISSUES
From this point the Social Services Department
should take responsibility for the user living in the Community.
A full community care assessment should be offered so that all
aspects of need can be identified. The assessment should take
account of relevant medical, social and environmental factors
which, combined with visual impairment, put newly visually impaired
people at risk. Staff undertaking assessments should have appropriate
training in the needs of blind and partially sighted people. Service
and support can then be provided to enable people to live as independently
as possible in their own homes.
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