In the ever-changing landscape of SARS-CoV-2, the eye care sector’s rapid implementation of the COVID-19 Urgent Eyecare Service (CUES) has been exemplary, with many of our colleagues at the frontline, triaging or managing true ocular emergencies. In times such as these, both collaboration and local access to eye care in primary care has never been more vital and sight-saving.
When primary eye care is streamlined and directed with one focus upon the prevention of avoidable sight loss, all non-urgent ophthalmic appointments are being postponed or prioritised in a way that means the progression or development of existing or latent diseases are likely.
With such non-acute vision loss likely to increase without due consideration, now would appear to be the perfect time to reflect upon the impact of sight loss on the nation and why ophthalmic health needs to be a priority consideration.
Holistic Approach
Disseminating messages about the importance of access to and uptake of eye care services feels vital, urgent and necessary. Are signs and symptoms of changing ocular health being ignored in our current climate of social distancing? Do we understand our local population and their eye care needs? Are we trying to reach the groups at increased risk of sight loss with key eye health and prevention of sight loss messages?
With the news of the closure of Vision UK, the umbrella organisation bringing all eye health and sight loss organisations together for a single focus upon eye health and support for those with visual impairment, how might we maintain a unified strategy in tackling sight loss in these turbulent times?
Recently, I had a catch-up conversation with Poonam Sharma, Lead Optometric Advisor to NHS England. We agreed that current priorities, CUES, were important. But what of the importance of understanding the impact of Covid -19 on the physical and mental health of people with a visual impairment? And the importance of targeted care for those where the future risk of sight loss is great, who have co-morbidities, and who are most likely to fall out of the system? What about the eye health of individual people?
Poonam Sharma
Sharing such a whole-person approach was what first brought Sharma and I together, way back in 2011 when ophthalmic public health was being discussed as a priority in the health sector.
Eye Health Needs
During my time as Eye Health Advisor to the RNIB, Sharma and I further crossed paths working on a number of different initiatives to detect early ocular disease and prevent avoidable sight loss. The most memorable of these was a community engagement project, initiated by RNIB, which reached out to the African/Caribbean community in Hackney in an effort to improve the detection of glaucoma. An ‘Eye Health Needs Assessment’ of the local area informed our understanding of the local population demographics, confirming a community up to eight times more likely to develop open angle glaucoma some 10 to 15 years earlier than people of other ethnic heritage.
Collaboration across primary and secondary care, among public health workers, local commissioners, the voluntary sector, independent evaluators, and figures within the community all united to establish an evidence-based and targeted project to address glaucoma. Quite different from the somewhat opportunistic GOS sight test approach. This and other examples teach us that ophthalmic public health strives to prevent avoidable sight loss with tailored early intervention.
Vision 2020
Launched in 1999, the mission of the World Health Organisation’s Vision 2020 global initiative was to eliminate the main causes of all preventable and treatable blindness as a public health issue by the year 2020 – check the calendar.
The UK’s initial response to the WHO Vision2020 initiative championed collaboration between the eye care and sight loss sector, promoting partnership and stakeholder engagement. As a sector, I would argue we were exemplary in our approach, with other sectors taking the lead from our work in eye health. The UK Vision Strategy and, more recently, Vision UK brought the professional bodies, the voluntary sector, industry and health and social care organisations together under a single umbrella. The overall strategy was to prevent sight loss and support people with visual impairment.
Our collaboration was effective and successful in engaging policy makers at both national and local levels. We succeeded in securing a Public Health Indicator for Eye Health in England and Wales. Ophthalmic public health research groups and networks were established. There was a strategic call for each local authority to develop its own Eye Health Needs Assessment; to understand the local population demographic, with a focus on groups at increased risk of sight loss and cross-referenced with key public health priorities. These included such risks to eye health as smoking, diabetes and cardiovascular disease.
The prevention of sight loss was increasingly being recognised as a priority. Collaboration, political lobbying, compilation of evidence and whole sector engagement had energised the UK’s response to the WHO’s mission to eliminate avoidable sight loss by 2020. Prevention of sight loss was a key priority for VisionUK.
What Now?
As a public health optometrist previously championing the profile of eye health across England and the devolved nations, I have struggled to understand why ophthalmic public health, previously such a high priority, seems to have drifted away from focus.
Discussion with Sharma highlighted to me just how much changed following the 2013 commissioning changes, when Primary Care Trusts were abolished and Clinical Commissioning Groups introduced. The shift in focus from a population eye health seems ironic almost, as the purpose of the CCGs was to plan and commission health care services for their local area; an ideal opportunity to ‘hook’ eye health messages onto other key public health priorities such as smoking, diabetes and cardiovascular disease.
Commissioning variation, a focus on clinical pathways and organisational strategic change have diminished the emphasis upon the prevention of sight loss and community eye health. Undoubtedly, there are fundamental problems with the business model to safeguard the eye health of our communities, and both commissioners and contractors have significant disincentives to address to rectify this. Pockets of excellent work do continue, of course, and there are so many examples across the four nations of initiatives that successfully raise the profile of eye health. However, organisational priorities and strategic aims previously focused on collaboration across the sector have definitely faded.
A Way Forward?
The 2019 Deloitte report highlighted the need to understand local demographics with equity profiles for eye health in order to prevent, diagnose and enable early access to treatment for the main causes of avoidable global visual impairment. Socioeconomic factors that result in inequalities in general health outcomes also apply to eye health. The purpose of an eye examination is poorly understood, with many thinking it is predominantly to correct vision with the supply of spectacles.
Fundamentally, the ‘business model’ for optometry, where the sale of spectacles cross-subsidises clinical assessment, perpetrates socioeconomic inequalities in the uptake of eye examinations And further extends the ‘social gradient’ discussed in the 2020 Marmot review.
The 2016 Ophthalmic Research Group report highlighted the importance of utilising primary eye care data to understand both the uptake and outcomes of NHS sight tests and inform ophthalmic public health policy.
In a global pandemic of the magnitude of Covid-19, when we have stepped up to the plate in key NHS-supporting roles, when we have showcased what eye health professionals can contribute to the wider health landscape; the time is now to unite in an opportunity to call for significant systemic change. And, at last, truly to integrate eye care within NHS structures. In the wake of the closure of VisionUK, never has the need for collaboration across the sector been more important.
Let us call for a paradigm shift in the provision of eye care, to better serve our local communities; just as we have recently been lectured is a key priority in the daily Covid government briefings. With eye care practices embedded within local communities, we are already so invested and aware of what our local health priorities are.
Understanding our local population will enable us to tag eye health messages to the most important public health priorities effectively, such as targeting strategies for smoking and diabetes. By disseminating tailored information to those communities at greatest risk of sight loss, we can transform how eye care is delivered. As champions of health, and eye health, let us be accountable to our local communities’ health, rather than to contractors whose investments lie elsewhere.
The vast progress we had made as a sector to raise the profile of eye health as a public health priority has drifted off course. It is time to reignite the passion and drive we had invested in the eye health and sight loss arena. After all, is that not what we, as clinicians want and what we qualified for?
Sonal Rughani is a specialist Public Health Optometrist, passionate about the prevention of sight loss. She works with SeeAbility, supporting the provision of eye examinations for people with learning disabilities and as well as a specialist low vision optometrist. She was an Eye Health Advisor to RNIB’s research and policy strategy and strongly advocates for the integration of eye health messages into broader public health priorities.
- Any comments? Send them to bill.harvey@markallengroup.com