Health CommitteeWritten evidence from The College of Optometrists (LTC 19)

Summary

The main causes of sight loss in the UK are long term conditions: age-related macular degeneration, diabetic retinopathy and glaucoma. Reducing preventable sight loss from these conditions is an objective in the Public health outcomes framework.1

Our ageing population and the introduction of new treatments mean that demand for services to treat these eye conditions is increasing.

Services’ ability to diagnose and treat people quickly and effectively varies across the country meaning that people in some areas are probably losing their sight to preventable causes.

Local Eye Health Networks alongside better use of community eye care and data sharing have key roles to play in minimising preventable sight loss from long term eye conditions.

1. Long term eye conditions: rising numbers and the impact of sight loss

1.1 Three long term conditions are responsible for most cases of sight loss in the UK: age-related macular degeneration (AMD), diabetic retinopathy and glaucoma.

1.2 AMD is the biggest cause of sight loss in the UK. A recent study estimated that 2.4% of people in the UK aged 50 years or more had advanced wet AMD, increasing to 4.8% of those aged 65 years or more and 12.2% of those aged 80 years or more.2 Smokers are three times more likely to suffer AMD.3

1.3 The following table shows how the number of people with advanced AMD is predicted to rise by a third to 679,000 this decade (the middle line shows prevalence amongst women and the bottom line prevalence amongst men):

1.4 Diabetic retinopathy is the biggest cause of sight loss amongst people of working age in the UK. It occurs when diabetes weakens the blood vessels in the eye. People with diabetes are 25 times more likely than the general population to become blind.4 Diabetes UK estimates that by 2025 there will be five million people in England with diabetes5 and for each year someone lives with diabetes, their risk of retinopathy increases.

1.5 Glaucoma is estimated to affect about half a million people in England. The prevalence of glaucoma rises steeply with advancing age. African-Caribbean people are at particular risk. More than half of those glaucoma cases are thought to be undetected6

1.6 The Government is committed to reducing preventable sight loss from these three long term conditions through an indicator in its Public health outcomes framework. We strongly support this.

1.7 Sight loss has a major impact on people’s well being. Sight is the sense people most fear losing. Over one-third of older people with sight loss are also living with depression.7 Two-thirds of registered blind and partially sighted people of working age are not in paid employment.8

1.8 People with a long term eye condition often have other health problems too. Sight loss is associated with a heightened risk of falls and fractures9 and people with a long term eye condition often have other long term conditions, such as dementia and diabetes.

2. The capacity of existing services to meet future demand

2.1 There is emerging evidence that eye care services are unable to meet current demand and will not meet rising demand in the future without significant improvements.

2.2 A recent survey found that half of all hospital eye units in England were unable to treat AMD patients within the recommended waiting times that would minimise their risk of sight loss.10

2.3 Professor Sir Bruce Keogh’s evidence to the Health Select Committee in January that cataract surgery was being rationed inappropriately by half of PCTs highlighted the strain hospital eye units are under as they struggle to meet existing demand, much of which is fuelled by long term conditions.

2.4 Our recent report, Better data, better care showed how the NHS’ reliance on paper forms for payment and referrals hindered care and wasted valuable time and resources in the fight to prevent sight loss from long term eye conditions.11 The failure to enable community and secondary care teams to share data is a major drag on the capacity of existing eye care services to meet demand now and in the future.

3. Taking advantage of community optometrists to redesign services, meet demand and integrate care around patients’ needs

3.1 There are examples of innovation, which if properly implemented across the NHS, would boost our capacity to meet the needs of people with long term eye conditions in the future.

3.2 Taking glaucoma care, for example, NICE recommends that patients at risk of glaucoma be monitored in the community by optometrists through “repeat measures” schemes rather than in hospitals. More advanced monitoring in the community (referral refinement) is also recommended by the College of Optometrists and the Royal College of Ophthalmologists.12 Together, these schemes improve glaucoma patients’ access to quality care by increasing the capacity of eye services. They keep less serious cases out of hospitals and take advantage of thousands of community optometrists already performing sight tests and caring for patients in the NHS. They can also save significant amounts of money; NHS Evidence found that moving repeat measurement for glaucoma in to the community in Bexley was 62% cheaper than the equivalent hospital tariff.13

3.3 To minimise sight loss from AMD, Gloucestershire has introduced a one stop shop model with integrated IT. Rather than assessing and treating patients over two visits, here assessment and treatment clinics run in parallel using non-consultant staff in particular nurse practitioners and optometrists. All clinical data is recorded electronically, allowing the consultant to make rapid treatment decisions for new and returning wet AMD patients using information on patient electronic medical records.14

3.4 In most of England, we do not know the answer to simple questions like, how many patients are we treating for glaucoma or if at risk groups get their eyes examined. Scotland has been particularly innovative in overcoming IT barriers by integrating the electronic systems of community optometrists and hospitals eye unit to improve access to better quality care and improve efficiency at the same time. Following a successful pilot, the Scottish Government is committed to ensuring that 95% of referrals from community optometrists to hospitals are done electronically rather than in paper. Paper referrals are the norm in most of England. Moving to electronic referral means community and hospital clinicians can share much more information about their patients over time with the aim of improving the continuity of care, reducing unnecessary referrals to the hospitals, improving efficiency and improving patient outcomes.

3.5 Scotland is also working towards making provider payment forms electronic. Electronic payment facilitates much better data collection about who is accessing eye care and how to design services that improve the care of populations with long term eye conditions. However, in England, most optometrists must submit their payment forms, which include potentially valuable public health data, in paper form making it extremely difficult to analyse the data to improve eye health services.

3.6 If accomplished, the Governments push for a paperless NHS offers great potential to improve eye care for people with long term conditions.

3.7 The move to involve clinicians more closely in commissioning also offers potential to improve care. NHS England is introducing Local Eye Health Networks in to each local team area to bring together commissioners, community and hospital clinicians and patient groups to work together to assess local need and improve the quality and efficiency of eye health services for their local population. We strongly recommend that commissioners take advantage of these networks and are supporting our members so they can contribute fully.

8 May 2013