1. Accessible Eye-care Making the most of community optometry Gordon Ilett Optometrist gordonilett@gmail.com

2. “Vision testing should precede any assessment of mental ability” O’Hara and Sperlinger 1997

3. Outline Why are people with learning disability a special group? Can eye examinations be done? Why is service provision using existing pathways sub-optimal? Creating solutions.

4. Why are people with learning disability a special group? To access and benefit from eye-care we must: Identify there is a problem with our eyes or vision Communicate our concern to others Understand and act on advice given People with learning disabilities may lack the skills to allow them to do this There may be difficulties for carers and non-specialist professionals in identifying behaviour relating to possible visual impairment and/or diagnostic overshadowing Eye disease is often painless and signs may be overlooked even by the patient

5. Increased Prevalence SeeAbility – From Emerson & Robertson 2011 People with learning disabilities are 10x more likely to have serious sight problems 60% will need spectacles and may need support to get used to them 9.3% meet the criteria for sight impaired or serious sight impairment (partial sight or blind) registration Those with severe and profound learning disabilities are most likely to have sight problems

6. A Clear Vision: Eye-care for children and young people in Special Schools in Wales : Maggie Woodhouse, Barbara Ryan, Nathan Davies, Aideen, McAvinchey Study on children in special schools in Wales – June 2012 39/44 schools involved 33% of pupils had never had a sight test 6% had visual problems in Statements of SEN 20% were found to have visual impairment likely to impact on ability to learn 50% of pupils needed spectacles Only 30% had them

7. Is there a Need for Screening? Wilson-Jungner Criteria WHO 1968 The condition being screened for should be an important health problem The natural history of the condition should be well understood There should be a detectable early stage Treatment at an early stage should be of more benefit than at a later stage A suitable test should be devised for the early stage The test should be acceptable Intervals for repeating the test should be determined Adequate health service provision should be made for the extra clinical workload resulting from screening The risks, both physical and psychological, should be less than the benefits The costs should be balanced against the benefit No single screening test is suitable for detecting the range of eye conditions which may be present – a full eye examination on a regular basis is needed for this patient group

8. Can Eye Examinations be done? Yes

9. Acuity Tests Functional Assessment Cardiff Acuity Test Kay Picture Test Letter Matching

10. Ophthalmoscopy: Internal eye examination Direct Indirect Slit-lamp BIO Fundus camera

11. Retinoscopy Objective method of finding strength of glasses May need cycloplegic drops Can measure accommodation – focussing ability Autorefractors?

12. Subjective : Better 1 st or 2 nd ? Often full subjective possible Larger Changes? Speed

13. Success Rates v Severity of LD D McCulloch

14. Prescribing and Management Best practice Decide Is the prescription necessary? Will the patient appreciate change? Are they normalised to blur? Will an adaptation programme be needed? – 60% success wearing without, 75% + with Detail behavioural changes in referrals to inform treatment decisions Optometrists may need to act as advocate for the patient Written information on outcome of examination should be given to patients, carers and other professionals as needed ‘Health passports’ should be completed

15. Community Eye Care So why is access to eye care an issue for people with learning disabilities? Lack of education of patients and carers Lack of education of professionals Restrictions of General Ophthalmic Services (England) Sight test fee £20.70 (20-30 minutes for typical patient) No payment for incomplete test No payment for repeat examination No change in fee for extended examination Sale of spectacles expected to support business Learning Disability is not an entitlement to NHS sight-test Most current business models do not allow time for adequate eye examinations and communication of the results However most optical practices do have the facilities and much of the equipment needed to provide eye examinations for people with learning disability

16. Business ModelIs this Sustainable with Extended Exams & patient choice? High volume low cost of product Overhead high to attract and sustain numbers Rapid throughput Need high sales % to create profit Yes – Only if ‘profit’ per ‘lost’ examination slot compensated. Low volume high product cost (or supplementary exam fee) Overhead high to attract quality Extended exam time the norm Income depends on hourly rate Yes – if hourly rate can be met Low volume low product cost Low overhead Risk of under investment Time for complex patients Welcome additional services income Yes – but providers business will fail if GOS is the only income stream Stand alone specialist service High set up cost Flexible appointments No GOS funding No Depends on other funding Denies choice But may be suitable for patients with high level needs

17. Actions Needed Appointment of local ‘champion’ to case find, educate and advocate for patients eg specialist rehabilitation worker Functional Vision Assessment of all clients where visual status is uncertain Document visual abilities of every client Commission LOCSU pathway to facilitate extended eye exams Ensure regular 2 yearly eye examinations Allow entitlement to NHS sight tests for those on LD registers Work with Secondary Care Providers to ensure equal access Document outcomes and advice given

18. Pathway Support Local patient champion and advocate Pre examination reporting – Telling the Optometrist about me form – SeeAbility Appropriate facilities and equipment – desensitisation visits Include domiciliary services in pathways and funding Feedback forms and reporting – SeeAbility forms or PHP/Health Passports completed Information leaflets on Eye health and Spectacles - SeeAbility

19. LOCSU Pathway

20. Cost to CCG/Local Authority Whose budget? CCG Health Local Authority screening and Public Health No Service Risk of claim for lack of ‘reasonable adjustments’. Equality Act, Human Rights Act etc. Potential high level awards Basic service – optometrist extended exams 400 extended exams /year @ £60 each = £20k Gold standard service – Specialist worker plus extended exams Specialist worker £30k pa (including, overhead, expenses and NI) 500 extended exams/year @ £60 each = £30k TOTAL £60k Savings: Hypothesis - If 10% of clients have 2 hour reduction in support/week @ £15/hour then £78k savings

21. Remember Assess Visual Function Record Functional Ability Organise Eye Examinations Create Pathways Record Results Modify Care Plans Empower Individuals