Professor Frank KeeUKCRC Centre of Excellence for Public Health

Demographic context

The case for change

New ways of working

Charting a path

Confidence

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 !

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

Figure 1. N.I. Population Projections 2009 - 2056

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0-14 15-29 30-44 45-59 60-74 75+

Age band

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in 1

000s

2009

2031

2056

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.

Figure 2. Predicted Population Growth for those aged over 60 NI (2006 - 2031)

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2008

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60 - 74

75 and over

“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)

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

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 TwainA Connecticut Yankee in King Arthur’s Court

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

•disease prevention and control

•training of personnel

•strengthening of the existing eye care infrastructure

•use of appropriate and affordable technology

•mobilisation of resources

Blindness: Vision 2020 - The GlobalInitiative for the Elimination of Avoidable Blindness

• 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

Strategy outcomes1. Improve the eye

health of the people of the UK

2. Eliminate avoidable sight loss & deliver support for people with sight loss

3. Inclusion, participation & independence for people with sight loss

Fair & equitable access

Person centred

Evidence-based

Awareness of & respect for people with sight loss & compliance with equality legislation.

• 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)

RNIB estimate approximately 980,000 people in UK have certifiable sight loss.

Main causes are Age related Macular Degeneration (AMD)

Glaucoma Diabetic Retinopathy Cataract

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

• 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

To develop proposals for the modernisation of NHS eye care services in England and Wales.

first priority to develop model pathways for:

cataractglaucomalow visionage related macular degeneration

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

Do disciplines even want to see eye to eye ?

1. Patient reports sight problem to GP2. Patient goes to optometrist/OMP for

sight test and optometrist/OMP refers patient to GP

3. Patient goes to GP, referred to HES4. Patient seen at HES, cataract

confirmed, decision to operate, and put on waiting list

5. Patient attends HES for pre-op assessment

6. Patient attends HES for day case surgery

7. Patient attends HES for 24 hr check8. Patient attends HES for 6 week

check, 2nd eye discussed9. Patient attends optometrist for sight

test and new specs.

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

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

4. Patient attends HESor Optometrist

•Final check•Sight test

•Discharged or2nd eye discussed andappointment arranged

Start Finish

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

1. Patient attends community optometrist (CO)•Sight test, IOP over 21 (applanation tonometry) and/or

visual field defect and/or excavated discs•Patient/optometrist makes appointment with optometrist

with special interest in glaucoma (OSI) or OMP

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

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

Start

“The futility of isolated initiatives…”Foresight: 2007

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

• 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

• 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

PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSISCOMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSIS

PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSISCOMMUNITY OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSIS

SELFSELFREFERRALREFERRAL

SELFSELFREFERRALREFERRAL

REFERRED BY REFERRED BY ANOTHER CLINICIAN ANOTHER CLINICIAN

OR CAREROR CARER

REFERRED BY REFERRED BY ANOTHER CLINICIAN ANOTHER CLINICIAN

OR CAREROR CARER

OTHER SOURCEOTHER SOURCEOTHER SOURCEOTHER SOURCE

NOT NOT AMDAMDNOT NOT AMDAMD APPROPRIATE APPROPRIATE

CARE ASCARE ASINDICATEDINDICATED

APPROPRIATE APPROPRIATE CARE ASCARE AS

INDICATEDINDICATED

SYMPTOMS SUGGESTIVE OF SYMPTOMS SUGGESTIVE OF ARMDARMD

SYMPTOMS SUGGESTIVE OF SYMPTOMS SUGGESTIVE OF ARMDARMD

‘‘DRY’ (NON-DRY’ (NON-NEOVASCULAR)NEOVASCULAR)

AMDAMD

‘‘DRY’ (NON-DRY’ (NON-NEOVASCULAR)NEOVASCULAR)

AMDAMD

‘‘WET’ (NEOVASCULAR) OR WET’ (NEOVASCULAR) OR SUSPECTED ‘WET’SUSPECTED ‘WET’

AMDAMD

‘‘WET’ (NEOVASCULAR) OR WET’ (NEOVASCULAR) OR SUSPECTED ‘WET’SUSPECTED ‘WET’

AMDAMD

DIRECT REFERRAL TO HES DIRECT REFERRAL TO HES FOR FLUORESCEIN FOR FLUORESCEIN AGIOGRAPHY ANDAGIOGRAPHY AND

FURTHER INVESTIGATIONFURTHER INVESTIGATION

DIRECT REFERRAL TO HES DIRECT REFERRAL TO HES FOR FLUORESCEIN FOR FLUORESCEIN AGIOGRAPHY ANDAGIOGRAPHY AND

FURTHER INVESTIGATIONFURTHER INVESTIGATION

TREATABLETREATABLETREATABLETREATABLE

UNTREATABLEUNTREATABLEUNTREATABLEUNTREATABLE

ACCESS TO ACCESS TO TREATMENTTREATMENT

ACCESS TO ACCESS TO TREATMENTTREATMENT

OPTICAL / OPHTHALMICOPTICAL / OPHTHALMIC

LOW VISION SERVICESLOW VISION SERVICES

COUNSELLINGCOUNSELLING

SOCIAL SERVICE SUPPORTSOCIAL SERVICE SUPPORT

REHABILITATIONREHABILITATION

BD8/LV1 AS REQUIREDBD8/LV1 AS REQUIRED

OPTICAL / OPHTHALMICOPTICAL / OPHTHALMIC

LOW VISION SERVICESLOW VISION SERVICES

COUNSELLINGCOUNSELLING

SOCIAL SERVICE SUPPORTSOCIAL SERVICE SUPPORT

REHABILITATIONREHABILITATION

BD8/LV1 AS REQUIREDBD8/LV1 AS REQUIRED

• 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

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

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

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

Start

All politics is localTip O’Neill1912-1994

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

BENEFITS FOR PATIENTS BENEFITS FOR NHS

Better care

Access to services

Speed

Convenience

Shorter waiting times

Better use of skills

Better value for money

“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)

“And should there be a sudden loss of consciousness during

this meeting oxygen masks will drop from the ceiling”