A vision of the future

1. A vision of the future Professor Frank Kee UKCRC Centre of Excellence for Public Health

2. Overview • Demographic context • The case for change • New ways of working • Charting a path

3. Confidence

4. The current and future challenge • RNIB estimates that two million people in UK have significant sight loss. • Half is preventable or due to treatable causes • There will be rising numbers of older….whose lives we can make better !

5. Demographic trends in N.I. • Population ageing is a sign of success • Ageing is becoming a central focus of governments • In the UK people aged 60+ outnumber those aged less than 16 • N.I population is younger than other UK regions but this is set to change

6. Predicted population growth in those aged 60+ • By 2025 number of people aged 60+ will increase by 37%. • Number aged 75+ expected to increase by 61% • By 2031 more than 25% of the NI population will be over 60.

7. The challenge of an ageing population. • “the number of people who are visually impaired will double in the next twenty years just as an effect of the ageing population” (Taylor & Keefe, 2001)

8. Association between visual impairment and….. • Increased mortality • Increased morbidity / falls / fractures • Increased road accidents • Increased anxiety & depression • Poorer self care & independence • Greater need for community & institutional resources • Social isolation - quality of life • Loss of income

9. Social proof The mere knowledge of a fact is pale; but when you come to realize a fact, it takes on colour. It is all the difference of hearing of a man being stabbed to the heart and seeing it done. Mark Twain A Connecticut Yankee in King Arthur’s Court

10. Ageing is not the only challenge: The impact of obesity on eye care services • Prevalence of obesity has reached epidemic proportions in many countries • Obesity has major impact on overall health • Obesity has been linked to age-related cataract, glaucoma, age-related maculopathy and diabetic retinopathy

11. Blindness: Vision 2020 - The Global Initiative for the Elimination of Avoidable Blindness • disease prevention and control • training of personnel • strengthening of the existing eye care infrastructure • use of appropriate and affordable technology • mobilisation of resources

12. What is the UK vision strategy? • Launched in April 2008 • Response to World Health Resolution of 2003 • Urges the design & implementation of plans to tackle vision impairment • A united approach across all relevant sectors is key

13. What is the UK Vision Strategy • Strategy outcomes • Improve the eye health of the people of the UK • Eliminate avoidable sight loss & deliver support for people with sight loss • Inclusion, participation & independence for people with sight loss

14. Values underpinning the strategy • Fair & equitable access • Person centred • Evidence-based • Awareness of & respect for people with sight loss & compliance with equality legislation.

15. The economic argument • RNIB estimate total UK costs at £4.9 billion per year. • Economic burden associated with sight loss similar to Cancer, Dementia and Arthritis (Frick & Kymes, 2006) • Australian study estimates that vision disorders cost an estimated 0.6% of GDP and every $1 spent on eye care can bring a $5 return to the community ( Taylor et al, 2006)

16. The UK vision Strategy • RNIB estimate approximately 980,000 people in UK have certifiable sight loss. • Main causes are • Age related Macular Degeneration (AMD) • Glaucoma • Diabetic Retinopathy • Cataract

17. Design Principles • Make best use of available resources • Have fewer steps for the user • Make more effective use of professional resource • Drive up standards of clinical care to ensure good outcomes • Improve access and deliver greater patient choice • Evidence based

18. Care Pathways Designed to Achieve: • Integrated eye care services • Better use of skills in primary care • Care for all in accessible settings • Increased role for professional groups • in primary care

19. The NHS Eye care Pathway Pilots • To develop proposals for the modernisation of NHS eye care services in England and Wales. • first priority to develop model pathways for: • cataract • glaucoma • low vision • age related macular degeneration

20. The NHS Eye care Pathway Pilots: a possible solution? • Set up by the Department of Health in 2002, with representatives of: • ophthalmologists • optometrists and dispensing opticians • primary care • orthoptists • ophthalmic nurses • patient organisations • health, social care & policy organisations

22. Do disciplines even want to see eye to eye ?

23. Previous Cataract Pathway • Patient reports sight problem to GP • Patient goes to optometrist/OMP for sight test and optometrist/OMP refers patient to GP • Patient goes to GP, referred to HES • Patient seen at HES, cataract confirmed, decision to operate, and put on waiting list • Patient attends HES for pre-op assessment • Patient attends HES for day case surgery • Patient attends HES for 24 hr check • Patient attends HES for 6 week check, 2nd eye discussed • Patient attends optometrist for sight test and new specs.

24. Proposed Cataract Pathway Start Finish • 1. Patient attends optometrist • Sight test, cataract diagnosed and discussed • General risks and benefits of surgery discussed • Patient wishes to proceed, information given etc • Patient offered choice of hospital and appointment agreed • 4. Patient attends HES • or Optometrist • Final check • Sight test • Discharged or • 2nd eye discussed and • appointment arranged • 2. Patient attends HES • Outpatient appointment with • ophthalmologist* • pre-assessment (with nurse?) • Date for surgery arranged/agreed • (* details of medication etc • received from optometrist, GP or • patient as per local protocols ) • 3. Patient attends HES • Day case surgery undertaken

26. Previous Glaucoma Pathway(Hospital Based Care) • Single screening opportunity by community optometrists with no standardised protocols • Diagnosis and continued care for life of all glaucoma (and many suspects) within Hospital Eye Service by ophthalmologists

27. Proposed Glaucoma Pathway Start • 1. Patient attends community optometrist (CO) • Sight test, IOP over 21 (applanationtonometry) and/or visual field defect and/or excavated discs • Patient/optometrist makes appointment with optometrist with special interest in glaucoma (OSI) or OMP • 4. OSI/OMP manages patient in community setting • Regular reviews set in place • OSI/OMP relay data to hospital if significant progression for HES review if needed • 2. Patient attends OSI or OMP • Full history and assessment carried out according to protocol • Decision taken as to whether patient has ocular hypertension (OSI/OMP reviews) or can be discharged (return to CO) or has glaucoma (treat or refer to HES) • Patient advised, given information etc and further appropriate appointments made if needed • 3. OSI/OMP relays data to HES • HES reviews data, advises OSI/OMP regarding management and sets up review at HES if needed

28. “The futility of isolated initiatives…” Foresight: 2007

30. Risk Factors for AMD • Researchers have discovered several risk factors that appear to be associated with AMD: • Age • Cigarette Smoking • Early Menopause • Hypertension (high blood pressure) and/or cardiovascular disease • A diet high in certain vegetable fats, especially those found in snack foods like potato chips • Prolonged sun exposure • Heredity • Race

31. AMD: A Growing Problem • Burden recognised by government • NSF for Older People • Vision impairment is an intrinsic risk factor for falls • NICE: Recent guidance on PDT for wet-AMD • In meeting future demand, service will have to respond to increasing patient numbers and delivering new therapies

32. Previous AMD Pathway • Patient reports visual problem • GP refers patient to HES • OR • Patient is referred to an optometrist • AMD is diagnosed • Patient is referred to HES via GP • Fluorescein angiography carried out • Any credible treatment option considered • Patient managed by HES or by Low Vision Service • Patient registered • Referred for Social Service & • Rehabilitation support

33. The ‘NEW’ AMD Pathway SELF REFERRAL REFERRED BY ANOTHER CLINICIAN OR CARER OTHER SOURCE PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSIS SYMPTOMS SUGGESTIVE OF ARMD NOT AMD APPROPRIATE CARE AS INDICATED ‘DRY’ (NON-NEOVASCULAR) AMD ‘WET’ (NEOVASCULAR) OR SUSPECTED ‘WET’ AMD OPTICAL / OPHTHALMIC LOW VISION SERVICES COUNSELLING SOCIAL SERVICE SUPPORT REHABILITATION BD8/LV1 AS REQUIRED DIRECT REFERRAL TO HES FOR FLUORESCEIN AGIOGRAPHY AND FURTHER INVESTIGATION UNTREATABLE ACCESS TO TREATMENT TREATABLE

34. Previous Low Vision Pathway • Fragmented • Wide variation re access & quality • Referral from optometrist (often via GP) to HES • Uni-disciplinary • Lack of information, signposting & awareness • Long waiting times • Initiation of LV services ONLY after ophthalmological assessment

35. Proposed Low Vision Pathway Start 4. Service enables re-access • 1. Patient referred to Low Vision Service (LVS) • Referral may be from secondary care, GP, social worker, rehabilitation officer, community nurse, OT etc or may be self referral • Patient may have an LVI, RVI or CVI • All patients are contacted by LVS within 10 working days • 3. Patient has follow up visits as needed • Visits may take place in the patient’s home or elsewhere • Visit will be by appropriate member of the LV team • 2. Patient attends LVS • Service is seamless across health, social care and the voluntary sector • A full sight test forms part of assessment • Patient is given information on eye condition, entitlements etc as well as local services • Counselling and advice on employment or education is available • Spectacles, LV aids, advice (esp. lighting, contrast and size) and home adaptations are discussed and made available as appropriate • Referral to other areas of health and social care as needed, including certification

37. All politics is local Tip O’Neill 1912-1994

38. Conclusions • Our population is ageing • Increasing need and demand for services • Primary care opthalmic services, based on partnerships, need to be developed to meet demand • Investment required • Existing services need to be used effectively

39. Conclusions Benefits for patients Benefits for NHS • Better care • Access to services • Speed • Convenience • Shorter waiting times • Better use of skills • Better value for money

40. Eye care in the UK “A growing number of the most vulnerable people in this country experience a quality of life that is significantly, but unnecessarily, diminished for the want of basic, relatively inexpensive health care” (RNIB 1999)

41. “And should there be a sudden loss of consciousness during this meeting oxygen masks will drop from the ceiling”