HC 1048-III Health CommitteeWritten evidence from Royal National Institute of Blind People (PH 47)

Key Points

We welcome the creation of Public Health England with a stronger role for Local Authorities in the provision of public health services.

We deplore the fact that eye health is not mentioned as a major public health issue in the Public Health White Paper despite robust evidence that there are already two million people with sight loss in the UK today and that this number could more than double by 2050 unless effective preventative action is taken.

We believe that the current data on the certification of people as visually impaired or severely visually impaired provides a valid basis for an indicator to measure progress in the prevention of avoidable sight loss under domain four.

We urge the Health Select Committee to call on the Government to highlight eye health as an area of health inequalities in relevant forthcoming legislative proposals and to include eye health promotion in future Government funded health promotion initiatives.

About RNIB

RNIB is a membership organisation with over 10,000 members who are blind, partially sighted or the friends and family of people with sight loss. 80% of our Trustees and “UK Forum” Members are blind or partially sighted. We encourage members to be involved in our work and regularly consult with them on Government policy and their ideas for change.

As a campaigning organisation of blind and partially sighted people, we fight for the rights of people with sight loss in each of the UK’s countries.

During the next four years we want to tackle the isolation of sight loss by focusing on three clear priorities:

(1)Stopping people losing their sight unnecessarily.

(2)Supporting blind and partially sighted people to live independent lives.

(3)Creating a society that is inclusive of blind and partially sighted people.

Our response to this consultation is in relation to our first priority of stopping people losing their sight unnecessarily. We will focus on the questions that we feel most qualified to address.

The creation of Public Health England within the Department of Health

1. As signatories of the UK Vision Strategy response to the Public Health White Paper we would like to reiterate that we welcome the 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 the wider determinants of health and associated policies (in relation to social care, transport, environment, welfare, etc) rather than focusing exclusively on health.

2. The creation of the Public Health Department within the Department of Health appears to signal a desire to ensure strong links between public health and NHS policies. However, the move of accountability for the NHS from the Department of Health to the NHS Commissioning Board could undermine this desire, when integration across the whole patient pathway from prevention to treatment to social care is crucial to optimise outcomes and minimise costs.

3. As an organisation engaged in sight loss prevention as well as in the provision of support for blind and partially sighted people we are keen to ensure that Public Health England takes an active role in safeguarding sight as well as promoting the health and wellbeing of blind and partially sighted people and their access to any proposed initiatives.

4. We would like to highlight our disappointment with the failure of the Public Health White Paper to make any reference to eye health as a public health issue. This is an unfortunate omission given the Government’s frequently expressed support for the UK Vision Strategy, the sector-wide initiative to improve the eye health of the UK population, secure full support in all areas of life for people with sight loss and build a more inclusive society that fully embraces what blind and partially sighted people have to offer.

5. In the UK, about a quarter of sight loss in children and over half of all sight loss in adults is avoidable. For the approximately 18,000 children currently growing up with impaired sight, there is lifelong impact on well-being and social and economic prospects.

6. Without concerted efforts to prevent avoidable sight loss the number of adults suffering ill health and a lack of wellbeing due to visual impairment is likely to double from the current 2 million to almost 4 million by 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 more than £6 billion in 2008.

7. The costs relating to sight loss that starts in infancy or childhood have not been widely studied but can be anticipated to be high, given that these are incurred across the whole lifespan and there are additional costs due to loss of economic productivity. Importantly, there is clear evidence of inequalities in eye health, linked to late presentation in adults and children people from deprived backgrounds. The current lack of efforts to tackle these health inequalities needs to be addressed.

8. This evidence points to eye health being a public health challenge that needs to be recognised in the forthcoming Public Health Bill as well as in the outcomes and commissioning frameworks. We have long called for the appointment of a National Director for Eye Health to drive this agenda. As a minimum an ophthalmologist should be appointed to the panel advising the National Clinical Director. Now would be a good time for the Government to make this appointment to show that its support for eye health is not merely tokenistic.

The public health role of the Secretary of State

9. We welcome the strong role suggested for the Secretary of State, which signals a shift towards prevention at the highest political level and guarantees accountability to Parliament.

The future role of local government in public health (including arrangements for the appointment of Directors of Public Health; and the role of Health and Wellbeing Boards, Joint Strategic Needs Assessments and Joint Health and Wellbeing Strategies)

10. We feel strongly that local authorities, as advised by their public health directors, should take a leading role in ensuring that partnership takes place between the NHS, local government and the voluntary sector to secure the health and wellbeing of local people. The reorganisation of the public health service in England with local public health departments being placed in local authorities gives local government a tremendous opportunity to expand their role to the benefit of local people. Traditionally they have played a very important role as holders of the registers of blind and partially sighted people, as supporters of people already experiencing sight loss and as providers or funders of rehabilitation services. Their understanding of the impact of blindness and partial sight on the lives of affected people puts them in an excellent position to appreciate the need for improved prevention to minimise the number of people requiring social care support and relying on informal care with its knock-on effect on carer health and productivity. The new system will allow them to use this knowledge to facilitate steps that blind and partially sighted people may want to take to adopt a healthy lifestyle and avoid preventable diseases that affect the general population such as cancer, heart disease and stroke.

11. We welcome the recognition that Directors of Public Health need to continue to play a key role in the provision of public health services based on strengthened Joint Strategic Needs Assessments. An analysis of JSNAs conducted in 2010 revealed that only 13% of JSNAs in England made reference to the eye health needs of their local population. Given the prevalence of eye disease this is an omission that needs to be addressed, particularly in light of the intention to make it mandatory for Local Authorities to take account of JSNAs when developing their health and wellbeing strategies.

12. In relation to sight loss we would hope that joint working based on clearly identified local needs would lead to a situation where the NHS and Social Services provide joint funding for Eye Clinic Liaison Officers who:

Support people at the time of sight loss diagnosis.

Ensure those who reach the level of being eligible for registration as blind or partially sighted are certified and referred to Social Services.

Provide information to patients with sight loss about support services available in their area.

Arrangements for public health involvement in the commissioning of NHS services

13. We believe that provisions in the Health and Social Care Bill relating to joint working between the NHS, Public Health England and Local Authorities needs to be strengthened. Ideally, joint budgets should be made mandatory. Failing that, other mechanisms to foster joint working need to be explored. One way of doing that would be the development of NICE Quality Standards that cover the whole patient pathway. Commissioners should be encouraged to implement existing NICE public health guidance to maximise their chances of achieving the desired outcomes under the public health outcomes frameworks. In addition, concrete steps should be taken to link up all guidance relating to specific patient pathways to ensure that public health, the NHS and Social care services work in conjunction rather than in silos and that NICE Quality Standards in health and social care are complemented by action on prevention.

14. The current Quality Standard development does not seem to allow crossover between these different areas of care. This was illustrated in the development of the glaucoma quality standard. Two additional quality statements that were proposed by stakeholders to cover the whole pathway from case finding to social care support were not included in the final Quality Standard because it was felt that they were not within its remit. With no reference to these important issues in the Quality Standard it is likely that providers aiming to implement the Standard will not focus sufficiently on the areas of overlap between public health, the NHS and Social care.

Arrangements for commissioning public health services

15. In terms of the arrangements for commissioning public health services it will be important to secure the continuation of existing health promotion services (such as smoking cessation services) during the transition phase from the NHS to the new Public Health Service. Future health promotion campaigns should emphasise that smoking cessation, healthy diet and physical exercise are good for eye health. Messages around the link between smoking and blindness should be promoted as an effective way of encouraging smoking cessation as evidenced by experiences in Australia.

16. Health promotion is particularly important in relation to the screening of children for vision defects at school entry. This is currently funded by PCTs, yet we have evidence that in 2008 11% of 142 PCTs that responded to a Freedom of Information request from RNIB did not fund any children’s screening. We believe that given their role in school education Local Authorities are in an excellent position to take on this responsibility and ensure that all children are screened at school entry to prevent avoidable sight loss. This should be enshrined as mandatory in secondary legislation.

The structure and purpose of the Public Health Outcomes Framework

17. The proposed outcomes framework is coherent. The five outcome domains understandably focus on tackling avoidable causes of premature mortality. However, we welcome the inclusion of a domain focusing on the reduction in the number of people living with preventable ill health.

18. Action under this domain should focus on conditions that constitute a major burden on individuals and society as evidenced by epidemiological and public or patient survey data. That should include eye health and sight loss.

19. We are keen to work with NICE and the Department of Health in conjunction with the Royal College of Ophthalmologists and other stakeholders on an indicator to measure progress in preventing avoidable sight loss. The certification data collected by Hospital Eye Clinics provides a viable basis for the development of such an indicator (or indicators).

Arrangements for funding public health services (including the Health Premium)

20. We welcome the fact that the Government has decided to earmark funding for the Public Health Service to ensure that the money allocated is not used for different purposes. This is particularly important in times of severe funding cuts to Local Authority budgets. However, the predicted £4 billion to be spent on Public Health can only represent a starting point. Given the huge challenges of addressing health inequalities and improving early detection of a large number of diseases, including eye diseases, there is certainly room for scepticism as to whether the Public Health Service will achieve the change that is required on this limited budget. At a later date it might therefore be prudent for the expenditure to be audited to ascertain whether it has been invested in a cost-effective fashion securing measurable outcomes.

21. Many eye health interventions will either prevent further sight deterioration or will restore a proportion of sight loss. A number of national initiatives are already in existence and they should be recognised under national guidance on commissioning public health and securing better health outcomes. Promotion of these programmes to produce measurable eye health improvements could be rewarded. Even if some or all of these programmes are commissioned by GP consortia, ways need to be found to encourage GPs, eye health specialists, public health specialists and local authorities to co-operate in the interests of local people.

22. For example, the national programme for screening for diabetic retinopathy already helps people with diabetes to be screened for retinopathy and offered treatment in time to prevent more serious sight loss.

23. NICE has produced guidance on glaucoma. If patients recognise symptoms and present early enough their remaining sight can be preserved through daily use of eye drops and sometimes by surgery to relieve intra-ocular pressure. If left too late the sight loss can be irremediable. There is no national programme at present but work is underway to identify effective screening programmes for populations that are at an increased risk of developing the disease (ie those with first degree relatives with the disease and people from African and African/Caribbean background). Improved case finding has the potential to save the sight of tens of thousands of people of all ages.

24. Wet Age-related macular degeneration (AMD) can now be treated successfully in line with NICE guidance. The earlier it is caught the better the chances of retaining and even improving sight. Wet AMD affects 26,000 people each year, mainly but not exclusively of retirement age. It therefore seems appropriate for these eye conditions to be a focus for future public health leadership and action.

25. There is an existing national programme for tackling cataracts for which treatment on a day surgical basis is quick, cost-effective and beneficial to the patient.

26. Refractive error is not sight threatening, but affects a very large number of people of all ages. Prescription of spectacles or contact lenses usually solves the problem and reduces the risk of accidents in the home and on our roads, which add to the pressure on emergency services. When public health specialists participate in public safety campaigns led by local authorities then they could consider these factors for inclusion in campaigns.

27. Public health leaders will be looking for opportunities to integrate NHS, local authority and voluntary services to improve health outcomes. In many places these agencies already co-operate well in the field of eye care but they provide good opportunities for even better integration and financial incentives should be provided to make this co-operation happen.

How the Government is responding to the Marmot Review on health inequalities.

28. We believe that one benefit of moving responsibility for public health to Local Authorities is the ability they have to see the wider picture and the importance of tackling the wider determinants of health. People who lose their sight not only suffer the negative health consequences of their eye disease but they are also more likely to use more health resources because of the risk of developing depression and experiencing unemployment. A disproportionate number of blind and partially sighted people live on a low income, exposing them to additional health risks.

29. In addition, children from all ethnic minorities as well as those from socio-economically deprived backgrounds are at considerably increased risk (up to nine fold in some cases) of blindness and at least 10% of blind children die within a year of diagnosis.

30. Socio-economic deprivation has been strongly linked with late presentation for glaucoma and different ethnic minority groups are at a higher risk of sight loss from the main eye conditions. Asians have a greater risk of developing cataracts compared to the black and white populations, Black and Asian populations have a greater risk of developing diabetic eye disease compared to the white population and the relative risk of glaucoma is much higher for the black population compared to the white population.

31. Given the strong evidence for inequalities in eye health both in children and in adults and the importance of early detection local authorities with significant minority ethnic populations from these backgrounds should have an obligation to allocate part of their public health funding to initiatives to tackle these health inequalities as part of their activities to promote early presentation and diagnosis.

June 2011

Prepared 28th November 2011