Health and Social Care Bill

Memorandum submitted by All Party Parliamentary Group on Eye Health and Visual Impairment (HS 130)

We and our fellow Officers of the All Party Parliamentary Group on Eye Health and Visual Impairment are writing to the Committee with a few key observations around the Bill, the previous NHS White Paper consultations and the current Public Health White Paper. These observations are informed by the dialogue that Officers of the APPG have with organisations dealing with vision, eye health, prevention of sight loss and providing support to people living with sight loss.

We submitted evidence to the consultations on the NHS White Paper and received a very helpful response from the Secretary of State, which we attach with our submission for the Committee's information.

Summary

Outcomes Framework: We welcome the principle of a clear outcomes framework. However, we believe that quality measures for prevention should be explored further.

Primary ophthalmic services and the NHS Commissioning Board

We welcome the decision to retain General Ophthalmic Services as a national service with the National Commissioning Board rather than devolving responsibility from PCTs to GP Commissioning consortia

Commissioning for Patients

The White Paper was one of the first government papers to include references to commissioning community eye care services from optical practices. We welcome this recognition of the effective role the community optical sector can play in delivering eye care services and in reducing costs for the NHS and social services

Public Health Service

We welcome plans to create a Public Health Service in England. It is important to ensure that eye health is better represented in Joint Strategic Needs Assessments and we hope that the increased co-operation between health and social care will facilitate this.

Eye health- a key public health issue

We are concerned that Public Health White Paper makes no reference to eye health as a public health issue. Nor does it mention primary care eye health professionals as a group that needs to be closely involved in safeguarding the sight of the population.

Social care

We welcome the Government’s focus on breaking down barriers between health and social care funding to encourage preventative action. We look forward to the proposals by the Dilnot Commission and the Social Care White Paper in the autumn.

NICE Guidance

We are concerned about the impact of the decision to move away from NICE guidance being mandatory. There is an obvious risk that patients across England and Wales will be faced with a postcode lottery in relation to access to new health technologies

NHS information revolution and patient choice

It is essential for any health information that is being provided to sighted patients to be available to blind and partially sighted people in their preferred format. It is not sufficient to just produce large print versions or rely on web browsers to allow access.

Transition

We are particularly concerned about the transition period to the new arrangements. Eye health services and support services for people with sight loss are often overlooked and this might well be the case with GP commissioners whose main focus will be on the historically larger areas of PCT spending.

Our detailed comments

Outcome framework

The eye health and vision community has welcomed the principle of a clear outcomes framework. For eye care, the key outcomes should focus on vision correction, prevention of avoidable blindness and timely support for people with visual impairment or blindness. For community eye care, appropriate subordinate measures would include the percentage of the population receiving sight tests, and percentages of patients receiving timely referral and care for glaucoma, diabetic retinopathy, wet age-related macular degeneration and cataract.

These measures are amenable to simple clinical assessment and/or Patient Reported Outcome Measures, and the sector would welcome the opportunity to work with government to develop the relevant sections of the Outcomes Framework.

For outcome measures to work effectively, they must be feasible and it is important that they are not complex and expensive to operate. A simple system based on the collection of patient experiences, reporting adverse outcomes and tracking indicators of the nation’s health improvement is required.

The five domains don’t appear to address public health issues around keeping people well and preventing ill health. For example, there is considerable evidence to show a link between poor vision and falls in older people – optometrists can play a lead role in addressing this as a front line provider. Quality measures for prevention should be explored further.

Primary ophthalmic services and the NHS Commissioning Board

We welcome the decision to retain General Ophthalmic Services as a national service with the National Commissioning Board rather than devolving responsibility from PCTs to GP Commissioning consortia. We are pleased to see GP consortia will continue to develop Local Enhanced Services (LES) in eye care, for example, glaucoma referral refinement schemes, stable diabetic and glaucoma monitoring as well as emergency/acute eye care referral. This would allow resource to be better focussed to meet patient need and reduce the burden on the Hospital Eye Service. Similar services may need to be developed to cope with the increasing number of patients, with an ageing population, who will require continued monitoring and treatment for wet age-related macular degeneration and other retinal diseases.

Commissioning for Patients

The White Paper was one of the first government papers to include references to commissioning community eye care services from optical practices. We welcome this recognition of the effective role the community optical sector can play in delivering eye care services and in reducing costs for the NHS and social services.

Throughout the country there are examples of excellent practice of joint working between the NHS and Local Optical Committees (LOCs) representing local NHS eye care contractors and practitioners. The Optical Confederation would be happy to prepare some best practice guidance based on this evidence for both GP Consortia and LOCs to support engagement between the two.

The sector welcomes the commitment to improving health inequalities. Outreach services must be developed in areas of relative deprivation if world class eye services are to be achieved.

Public Health Service

We welcome plans to create a Public Health Service in England that recognises the importance of health and wellbeing, the prevention of ill health and the need to tackle health inequalities holistically, taking into account the impact of a wide range of policies (social care, transport, environment, welfare, etc) rather than focusing exclusively on health.

We welcome the plan to increase further the number of Directors of Public Health who are appointed jointly by the NHS (and in future the Public Health Service) and Local Authorities. We are keen to see eye health better represented in Joint Strategic Needs Assessments and hope that the increased co-operation between health and social care will facilitate this. Only a thorough analysis of the eye health and support needs of their local population will allow providers to identify those most at risk of unnecessary sight loss (the elderly, minority ethnic populations, people with learning disabilities as well as those on low incomes) and take targeted action to minimise their risk.

Generally, GP consortia and individual GPs can only be expected to respond to health needs that have been identified in JSNAs or public health strategies. Eye health is rarely receives specific mention in JSNAs (or in any of the current performance frameworks or policy documents). This needs to change to ensure that this significant health need of the population is no longer neglected.

Eye health- a key public health issue

We are, however, concerned that Public Health White Paper makes no reference to eye health as a public health issue. Nor does it mention primary care eye health professionals as a group that needs to be closely involved in safeguarding the sight of the population. This is a concerning omission given the Government’s support for the UK Vision Strategy.

We strongly believe that the forthcoming public health outcomes framework needs to make specific reference to eye health under domains 3 (health improvement and the promotion of healthy lifestyles), and 5 (healthy life expectancy).

Without concerted efforts to prevent avoidable sight loss the number of people suffering ill health and a lack of wellbeing due to visual impairment is likely to double in the next 40 years from the current 1.8 million to almost 4 million in 2050. Only preventative action through primary prevention, improved case finding, access to treatment and appropriate support for blind and partially sighted people will help reduce the burden of disease associated with eye disease and visual impairment that has been estimated to have cost the NHS and wider society £22 billion in 2008. [1]

Social care

We welcome the Government’s focus on breaking down barriers between health and social care funding to encourage preventative action. We look forward to the proposals by the Dilnot Commission and the Social Care White Paper in the autumn.

We will be particularly keen to see how any new arrangements will facilitate a more preventative approach to supporting people in the community as tightening eligibility criteria for social care support have tended to focus resources on those with needs deemed to be critical or substantial and away from those with perceived "low level" needs, such as people with sight loss. As the needs of those with sight loss tend to be underestimated by those who have no sensory training or expertise, a focus on multi-agency collaboration and prevention is warmly welcomed.

NICE

We believe that the importance of sight loss prevention should be recognised in the context of tackling health inequalities. Unless eye health is recognised as a major public health issue there is a very real risk that it will get lost among other major health priorities such as heart disease, stroke and dementia. Conditions such as age-related macular degeneration have been shown to have a similar impact on quality of life as coronary artery disease and stroke.

The cost of eye disease and sight loss to the economy runs into billions of pounds. When as much as 50% of all sight loss is preventable, early detection and access to treatment should be a priority area as it is an important way of saving significant health and social care costs.

We are concerned that the pressure on NICE to produce 150 Quality Standards within five years could result in the re-writing of existing guidelines without a proper chance to review evidence and points made during consultation. More significantly, in areas where no NICE clinical guidelines exist, development of Quality Standards should be prioritised.

In addition, we would like to raise the issue of access to information in relation to all Quality Standards. The reasonable adjustment duty within the Equality Act, 2010 emphasises the obligation on service providers to provide information in accessible formats. At present, every Quality Standard contains a standard paragraph that encourages service providers to make information accessible. We believe that this paragraph needs to be strengthened to remind service providers of their legal obligations.

NHS information revolution and patient choice

It is essential for any health information that is being provided to sighted patients to be available to blind and partially sighted people in their preferred format. It is not sufficient to just produce large print versions or rely on web browsers to allow access. Under the Equality Act patients have a right to accessible information and for some people that will be large print but for others it will be Braille, audio or email. This is particularly important when it comes to the choice of treatment or the clinical team providing treatment. It will also be vital for health providers to have a field code on patients' format requirements in their medical records.

While physical access to services and an inability or unwillingness to travel will affect many older people with disabilities, the issue of accessible information is unique to blind and partially sighted people and should be highlighted as such in the forthcoming White Paper on the ‘Information revolution’.

Transition

We are particularly concerned about the transition period to the new arrangements. Eye health services and support services for people with sight loss are often overlooked and this might well be the case with GP commissioners whose main focus will be on the historically larger areas of PCT spending.

The many excellent services provided by NHS hospitals, community optometry schemes, eye clinic liaison officers and independent living co-ordinators need to be protected and extended to cover all patients with eye disease.

March 2011


[1] Access Econonomics: Future sigh t loss UK (1): The economic impact of partial sight and blindness in the UK adult population. July 2009 available at: www.rnib.org.uk