What more can we do for Mavis?

optometrists are often greeted with the situation where a pair of spectacles is not going to provide a solution to a patient's difficulties. Although referral to the hospital may be called for, this can be a long, drawn-out process and may leave the optometrist feeling frustrated that there are no means to provide the patient with help with daily tasks.
In some areas, optometrists have been able to set up links with social services and local societies to offer help, but in others this is not available. Often it is too easy to forget that the patient in the consulting room chair has to continue their life with impaired vision for many months before help is provided. The following example is typical of the experiences of many older people.
Mavis began to have problems making a cup of tea when her vision started to fade. She splashed her hands once or twice resulting in some scalding. Assuming that she needed a stronger prescription, she made an appointment with her usual optician for some new glasses. The optometrist, realising that her visual problems were uncorrectable, referred her to the local ophthalmology department for a more detailed assessment.
When her appointment came through Ð after three months Ð the consultant quickly diagnosed age-related macular degeneration. Mavis was asked to come back in six months to have her condition monitored. The consultant suspected that at this stage she would certify the patient as being eligible to be registered with social services.
Six months later the consultant completed a BD8 certificate and Mavis was upset to know that nothing could be done to save her sight. Following the normal procedures, the form was then sent to the social services department (SSD). This meant that Mavis had been having difficulties for almost a year before the agency responsible for providing social support, such as rehabilitation skills training and equipment such as liquid level indicators, was notified.
If Mavis had known that services and equipment were available to help her cope with her sight problems, she could have contacted social services herself and sought the help she clearly needed. Prolonged delays in obtaining the necessary help often result in loss of confidence, with independence being steadily eroded and depression setting in.
The current model for certification and registration follows a very linear route and the patient normally only receives any help at the end of the process. A recent review of the system led by the DoH has looked at whether the linear route is essential or whether other approaches could be taken.

new model of care
In September last year, health minister Dr Stephen Ladyman announced on BBC Radio's In Touch programme the outcome of a comprehensive review of the BD8 process. The review panel included representatives of optometrists, ophthalmologists, patients and social services. There was a College of Optometrists' representative on the original review and the College approves of the principles behind the new system. The aim was to find and create a mechanism that would ensure that people whose lives are affected by visual impairment are not only identified at an early stage, but that they are also given early opportunities to obtain help with their vision loss. These changes apply to England only.
Rather than being dependent on the linear process, an alternative model would be that continuing ophthalmic care and social care could occur in parallel. This would not only ensure that people continue to have access to the best possible medical care but that they would be linked to social care and rehabilitation much earlier than under the previous BD8 system.
Optometrists have all the necessary skills to detect visual impairment. By simply alerting appropriate patients to a straightforward 'self-referral' process, they can help them to find the assistance they need. The involvement of optometrists in this process is a very positive move in the recognition of their widening professional role. Social services departments and the voluntary sector will be looking to the optometric professional to assist in the implementation of this new system in a clear and strategic manner.
This optometric role is not onerous, and practitioners in several areas are already issuing the new self-referral document (LVI) to their patients. When handled as part of the discussion with the patient at the end of the consultation, it should not produce any significant impact on workload.
The new system was introduced in November 2003. The documents and the 'patient pathways' have been scrutinised and endorsed by the NHS Gateway Team and the DoH. The system was promoted through the NHS Chief Executive's Bulletin and documents and guidance notes for their completion are available on the DoH website. Unfortunately, since the initial web address was advertised, the DoH site has been radically overhauled.
Although this has made it much easier for people with sight problems to adjust the content of the site to a font size they can read, it has also meant that many people have been unable to find the documents as the old links no longer work. Information on the 'identification and notification of sight loss', including downloads of all the relevant documents can be found by following the link via: www.dh.gov.uk/ PolicyAndGuidance/HealthAndSocialCare Topics/Optical/fs/en

Communication difficulties
Information about the new system and requests for feedback has only really been made available on the DoH website, so many people have been unaware of the details of the changes or their responsibilities.
For many practitioners, the internet remains an unfamiliar medium for the dissemination of such information, and consequently some have been left feeling they have been unable to raise their comments and concerns. However, it is essential that optometrists and opticians become accustomed to checking the DoH's website for updates.
In some areas, there has been little or no thought about how to 'roll-out' the LVI, RVI and CVI and while in others the old BD8 is still being used.
Confusion has arisen about who should produce the LVI, RVI and CVI and what additional training or information might be needed so that best use is made of the new system. In addition, there has been a misunderstanding about the use of the LVI. It is important to appreciate that optometrists and opticians are only required to hand over a letter/leaflet to patients, although many may feel that it is their duty of care to do more.
In view of this, as well as concerns expressed by hospital eye departments, the DoH has extended the review period until the end of June 2004 and is considering establishing a cut-off date after which the BD8 can no longer be used. The review will provide the much-needed opportunity for optometrists and opticians to explain how the system is working on the high street. It is hoped that the DoH may also initiate a series of 'road-shows' across the country to advise people and organisations about the changes.
The new system is important in the provision of services for people with sight loss, whether these are services such as low vision or social care based. For optometrists, these responsibilities should not be regarded as optional, but undertaken as a routine part of their professional duties. Failure to inform people of their right to contact social services for support could be seen as a breach of professional conduct.
A recent case in Stockport highlighted a situation where a person, who lost their sight suddenly, was not offered support services at the time of need. In this case it was Stockport Social Services' procedures that attracted criticism from the local government ombudsman, but in future the criticism may rest with the optical profession.

taking practical steps
The Association of Directors of Social Services (ADSS) is aware of the new scheme and local SSDs have been advised to contact LOCs and to discuss the new arrangements. For social services planners there are many issues that need consideration and optometrists and opticians across the country will need to be aware of local differences.
Social services departments in England are now obliged to apply eligibility criteria to all adult referrals for social care, grading people's needs and associated risks to independence as either 'critical', 'substantial', 'moderate' or 'low'. Fair Access to Care Services (or FACS) was introduced as few councils (if any) can afford to provide a service to everyone referred to them, and councils were using their own criteria to establish eligibility for help.
FACS has standardised the criteria, although all councils have a duty to assess an individual's needs before determining whether or not they should provide a service. All councils provide a service to people whose needs fall into the critical or substantial bands. Most provide some level of service to people whose needs fall into the moderate category. Not many will provide a service to people whose needs fall into the low band, though the council will direct people to other sources of help, information or advice. In other words, there is no guarantee that once referred to the local authority for help, a person will receive a comprehensive package of support, but the council should consider their current and potential needs.
The LVI should contain the following statement for patients. 'Your council has a legal duty to:

Advise you of the range of services available to people with sight problems
Carry out an assessment of your needs.'

Further details on FACS can be found at: www.dh.gov.uk/PolicyAndGuidance/ HealthAndSocialCareTopics/SocialCare/ FairAccessToCare/fs/en

Clearly the new scheme of identification will have an impact on services Ð both in terms of numbers and relationships. LOCs around the country have an ideal opportunity to be involved in the process. At the very least the LOC should be initiating discussions with SSDs to discuss use of the LVI and mechanisms for data collection and audit. These discussions will ensure that the opinions of local optical practitioners are taken into account.
It is extremely important that local optometrists and opticians are informed about the changes and made aware of their duties. ABDO, the AOP and the College of Optometrists are ideally placed to provide advice and assistance on these matters and continuing education organisers should ensure that they are included as part of their programme.
Many LOCs are in the process of demonstrating the 'added value' of using optometrists in the management of patients' health needs in the community and this is a simple way of reinforcing this message. If optometrists and opticians are seen to be able to accommodate and respond to new roles linking with social care, this can only reflect positively on the ability of optometrists to respond to an expansion of their health-care responsibilities in the future.

Local opportunities
In light of these issues and in view of other opportunities for development of the role and skills of the optometrist, it seems clear that local optometrists should welcome this opportunity. It should be used to demonstrate their ability to respond to demands to expand in their role and demonstrate the obvious maturity of the optometric profession.
This more co-ordinated approach to the identification and notification of vision loss should mean that people with failing sight will be able to get the help they need, when they need it.
For information on the sort of help available from social services and other background information on the changes, visit www.sightlossmatters.com and follow the various links available on this site managed by the University of Central England.

Anita Lightstone is head of low vision services at the RNIB. Mary Bairstow and Carl Freeman were members of the review group on the Identification and Notification of Sight Loss Ð representing the College of Optometrists and the RNIB respectively
optometrists are often greeted with the situation where a pair of spectacles is not going to provide a solution to a patient's difficulties. Although referral to the hospital may be called for, this can be a long, drawn-out process and may leave the optometrist feeling frustrated that there are no means to provide the patient with help with daily tasks.
In some areas, optometrists have been able to set up links with social services and local societies to offer help, but in others this is not available. Often it is too easy to forget that the patient in the consulting room chair has to continue their life with impaired vision for many months before help is provided. The following example is typical of the experiences of many older people.
Mavis began to have problems making a cup of tea when her vision started to fade. She splashed her hands once or twice resulting in some scalding. Assuming that she needed a stronger prescription, she made an appointment with her usual optician for some new glasses. The optometrist, realising that her visual problems were uncorrectable, referred her to the local ophthalmology department for a more detailed assessment.
When her appointment came through Ð after three months Ð the consultant quickly diagnosed age-related macular degeneration. Mavis was asked to come back in six months to have her condition monitored. The consultant suspected that at this stage she would certify the patient as being eligible to be registered with social services.
Six months later the consultant completed a BD8 certificate and Mavis was upset to know that nothing could be done to save her sight. Following the normal procedures, the form was then sent to the social services department (SSD). This meant that Mavis had been having difficulties for almost a year before the agency responsible for providing social support, such as rehabilitation skills training and equipment such as liquid level indicators, was notified.
If Mavis had known that services and equipment were available to help her cope with her sight problems, she could have contacted social services herself and sought the help she clearly needed. Prolonged delays in obtaining the necessary help often result in loss of confidence, with independence being steadily eroded and depression setting in.
The current model for certification and registration follows a very linear route and the patient normally only receives any help at the end of the process. A recent review of the system led by the DoH has looked at whether the linear route is essential or whether other approaches could be taken.

new model of care
In September last year, health minister Dr Stephen Ladyman announced on BBC Radio's In Touch programme the outcome of a comprehensive review of the BD8 process. The review panel included representatives of optometrists, ophthalmologists, patients and social services. There was a College of Optometrists' representative on the original review and the College approves of the principles behind the new system. The aim was to find and create a mechanism that would ensure that people whose lives are affected by visual impairment are not only identified at an early stage, but that they are also given early opportunities to obtain help with their vision loss. These changes apply to England only.
Rather than being dependent on the linear process, an alternative model would be that continuing ophthalmic care and social care could occur in parallel. This would not only ensure that people continue to have access to the best possible medical care but that they would be linked to social care and rehabilitation much earlier than under the previous BD8 system.
Optometrists have all the necessary skills to detect visual impairment. By simply alerting appropriate patients to a straightforward 'self-referral' process, they can help them to find the assistance they need. The involvement of optometrists in this process is a very positive move in the recognition of their widening professional role. Social services departments and the voluntary sector will be looking to the optometric professional to assist in the implementation of this new system in a clear and strategic manner.
This optometric role is not onerous, and practitioners in several areas are already issuing the new self-referral document (LVI) to their patients. When handled as part of the discussion with the patient at the end of the consultation, it should not produce any significant impact on workload.
The new system was introduced in November 2003. The documents and the 'patient pathways' have been scrutinised and endorsed by the NHS Gateway Team and the DoH. The system was promoted through the NHS Chief Executive's Bulletin and documents and guidance notes for their completion are available on the DoH website. Unfortunately, since the initial web address was advertised, the DoH site has been radically overhauled.
Although this has made it much easier for people with sight problems to adjust the content of the site to a font size they can read, it has also meant that many people have been unable to find the documents as the old links no longer work. Information on the 'identification and notification of sight loss', including downloads of all the relevant documents can be found by following the link via: www.dh.gov.uk/ PolicyAndGuidance/HealthAndSocialCare Topics/Optical/fs/en

Communication difficulties
Information about the new system and requests for feedback has only really been made available on the DoH website, so many people have been unaware of the details of the changes or their responsibilities.
For many practitioners, the internet remains an unfamiliar medium for the dissemination of such information, and consequently some have been left feeling they have been unable to raise their comments and concerns. However, it is essential that optometrists and opticians become accustomed to checking the DoH's website for updates.
In some areas, there has been little or no thought about how to 'roll-out' the LVI, RVI and CVI and while in others the old BD8 is still being used.
Confusion has arisen about who should produce the LVI, RVI and CVI and what additional training or information might be needed so that best use is made of the new system. In addition, there has been a misunderstanding about the use of the LVI. It is important to appreciate that optometrists and opticians are only required to hand over a letter/leaflet to patients, although many may feel that it is their duty of care to do more.
In view of this, as well as concerns expressed by hospital eye departments, the DoH has extended the review period until the end of June 2004 and is considering establishing a cut-off date after which the BD8 can no longer be used. The review will provide the much-needed opportunity for optometrists and opticians to explain how the system is working on the high street. It is hoped that the DoH may also initiate a series of 'road-shows' across the country to advise people and organisations about the changes.
The new system is important in the provision of services for people with sight loss, whether these are services such as low vision or social care based. For optometrists, these responsibilities should not be regarded as optional, but undertaken as a routine part of their professional duties. Failure to inform people of their right to contact social services for support could be seen as a breach of professional conduct.
A recent case in Stockport highlighted a situation where a person, who lost their sight suddenly, was not offered support services at the time of need. In this case it was Stockport Social Services' procedures that attracted criticism from the local government ombudsman, but in future the criticism may rest with the optical profession.

taking practical steps
The Association of Directors of Social Services (ADSS) is aware of the new scheme and local SSDs have been advised to contact LOCs and to discuss the new arrangements. For social services planners there are many issues that need consideration and optometrists and opticians across the country will need to be aware of local differences.
Social services departments in England are now obliged to apply eligibility criteria to all adult referrals for social care, grading people's needs and associated risks to independence as either 'critical', 'substantial', 'moderate' or 'low'. Fair Access to Care Services (or FACS) was introduced as few councils (if any) can afford to provide a service to everyone referred to them, and councils were using their own criteria to establish eligibility for help.
FACS has standardised the criteria, although all councils have a duty to assess an individual's needs before determining whether or not they should provide a service. All councils provide a service to people whose needs fall into the critical or substantial bands. Most provide some level of service to people whose needs fall into the moderate category. Not many will provide a service to people whose needs fall into the low band, though the council will direct people to other sources of help, information or advice. In other words, there is no guarantee that once referred to the local authority for help, a person will receive a comprehensive package of support, but the council should consider their current and potential needs.
The LVI should contain the following statement for patients. 'Your council has a legal duty to:

Advise you of the range of services available to people with sight problems
Carry out an assessment of your needs.'

Further details on FACS can be found at: www.dh.gov.uk/PolicyAndGuidance/ HealthAndSocialCareTopics/SocialCare/ FairAccessToCare/fs/en

Clearly the new scheme of identification will have an impact on services Ð both in terms of numbers and relationships. LOCs around the country have an ideal opportunity to be involved in the process. At the very least the LOC should be initiating discussions with SSDs to discuss use of the LVI and mechanisms for data collection and audit. These discussions will ensure that the opinions of local optical practitioners are taken into account.
It is extremely important that local optometrists and opticians are informed about the changes and made aware of their duties. ABDO, the AOP and the College of Optometrists are ideally placed to provide advice and assistance on these matters and continuing education organisers should ensure that they are included as part of their programme.
Many LOCs are in the process of demonstrating the 'added value' of using optometrists in the management of patients' health needs in the community and this is a simple way of reinforcing this message. If optometrists and opticians are seen to be able to accommodate and respond to new roles linking with social care, this can only reflect positively on the ability of optometrists to respond to an expansion of their health-care responsibilities in the future.

Local opportunities
In light of these issues and in view of other opportunities for development of the role and skills of the optometrist, it seems clear that local optometrists should welcome this opportunity. It should be used to demonstrate their ability to respond to demands to expand in their role and demonstrate the obvious maturity of the optometric profession.
This more co-ordinated approach to the identification and notification of vision loss should mean that people with failing sight will be able to get the help they need, when they need it.
For information on the sort of help available from social services and other background information on the changes, visit www.sightlossmatters.com and follow the various links available on this site managed by the University of Central England.

Anita Lightstone is head of low vision services at the RNIB. Mary Bairstow and Carl Freeman were members of the review group on the Identification and Notification of Sight Loss Ð representing the College of Optometrists and the RNIB respectively
optometrists are often greeted with the situation where a pair of spectacles is not going to provide a solution to a patient's difficulties. Although referral to the hospital may be called for, this can be a long, drawn-out process and may leave the optometrist feeling frustrated that there are no means to provide the patient with help with daily tasks.
In some areas, optometrists have been able to set up links with social services and local societies to offer help, but in others this is not available. Often it is too easy to forget that the patient in the consulting room chair has to continue their life with impaired vision for many months before help is provided. The following example is typical of the experiences of many older people.
Mavis began to have problems making a cup of tea when her vision started to fade. She splashed her hands once or twice resulting in some scalding. Assuming that she needed a stronger prescription, she made an appointment with her usual optician for some new glasses. The optometrist, realising that her visual problems were uncorrectable, referred her to the local ophthalmology department for a more detailed assessment.
When her appointment came through Ð after three months Ð the consultant quickly diagnosed age-related macular degeneration. Mavis was asked to come back in six months to have her condition monitored. The consultant suspected that at this stage she would certify the patient as being eligible to be registered with social services.
Six months later the consultant completed a BD8 certificate and Mavis was upset to know that nothing could be done to save her sight. Following the normal procedures, the form was then sent to the social services department (SSD). This meant that Mavis had been having difficulties for almost a year before the agency responsible for providing social support, such as rehabilitation skills training and equipment such as liquid level indicators, was notified.
If Mavis had known that services and equipment were available to help her cope with her sight problems, she could have contacted social services herself and sought the help she clearly needed. Prolonged delays in obtaining the necessary help often result in loss of confidence, with independence being steadily eroded and depression setting in.
The current model for certification and registration follows a very linear route and the patient normally only receives any help at the end of the process. A recent review of the system led by the DoH has looked at whether the linear route is essential or whether other approaches could be taken.

new model of care
In September last year, health minister Dr Stephen Ladyman announced on BBC Radio's In Touch programme the outcome of a comprehensive review of the BD8 process. The review panel included representatives of optometrists, ophthalmologists, patients and social services. There was a College of Optometrists' representative on the original review and the College approves of the principles behind the new system. The aim was to find and create a mechanism that would ensure that people whose lives are affected by visual impairment are not only identified at an early stage, but that they are also given early opportunities to obtain help with their vision loss. These changes apply to England only.
Rather than being dependent on the linear process, an alternative model would be that continuing ophthalmic care and social care could occur in parallel. This would not only ensure that people continue to have access to the best possible medical care but that they would be linked to social care and rehabilitation much earlier than under the previous BD8 system.
Optometrists have all the necessary skills to detect visual impairment. By simply alerting appropriate patients to a straightforward 'self-referral' process, they can help them to find the assistance they need. The involvement of optometrists in this process is a very positive move in the recognition of their widening professional role. Social services departments and the voluntary sector will be looking to the optometric professional to assist in the implementation of this new system in a clear and strategic manner.
This optometric role is not onerous, and practitioners in several areas are already issuing the new self-referral document (LVI) to their patients. When handled as part of the discussion with the patient at the end of the consultation, it should not produce any significant impact on workload.
The new system was introduced in November 2003. The documents and the 'patient pathways' have been scrutinised and endorsed by the NHS Gateway Team and the DoH. The system was promoted through the NHS Chief Executive's Bulletin and documents and guidance notes for their completion are available on the DoH website. Unfortunately, since the initial web address was advertised, the DoH site has been radically overhauled.
Although this has made it much easier for people with sight problems to adjust the content of the site to a font size they can read, it has also meant that many people have been unable to find the documents as the old links no longer work. Information on the 'identification and notification of sight loss', including downloads of all the relevant documents can be found by following the link via: www.dh.gov.uk/ PolicyAndGuidance/HealthAndSocialCare Topics/Optical/fs/en

Communication difficulties
Information about the new system and requests for feedback has only really been made available on the DoH website, so many people have been unaware of the details of the changes or their responsibilities.
For many practitioners, the internet remains an unfamiliar medium for the dissemination of such information, and consequently some have been left feeling they have been unable to raise their comments and concerns. However, it is essential that optometrists and opticians become accustomed to checking the DoH's website for updates.
In some areas, there has been little or no thought about how to 'roll-out' the LVI, RVI and CVI and while in others the old BD8 is still being used.
Confusion has arisen about who should produce the LVI, RVI and CVI and what additional training or information might be needed so that best use is made of the new system. In addition, there has been a misunderstanding about the use of the LVI. It is important to appreciate that optometrists and opticians are only required to hand over a letter/leaflet to patients, although many may feel that it is their duty of care to do more.
In view of this, as well as concerns expressed by hospital eye departments, the DoH has extended the review period until the end of June 2004 and is considering establishing a cut-off date after which the BD8 can no longer be used. The review will provide the much-needed opportunity for optometrists and opticians to explain how the system is working on the high street. It is hoped that the DoH may also initiate a series of 'road-shows' across the country to advise people and organisations about the changes.
The new system is important in the provision of services for people with sight loss, whether these are services such as low vision or social care based. For optometrists, these responsibilities should not be regarded as optional, but undertaken as a routine part of their professional duties. Failure to inform people of their right to contact social services for support could be seen as a breach of professional conduct.
A recent case in Stockport highlighted a situation where a person, who lost their sight suddenly, was not offered support services at the time of need. In this case it was Stockport Social Services' procedures that attracted criticism from the local government ombudsman, but in future the criticism may rest with the optical profession.

taking practical steps
The Association of Directors of Social Services (ADSS) is aware of the new scheme and local SSDs have been advised to contact LOCs and to discuss the new arrangements. For social services planners there are many issues that need consideration and optometrists and opticians across the country will need to be aware of local differences.
Social services departments in England are now obliged to apply eligibility criteria to all adult referrals for social care, grading people's needs and associated risks to independence as either 'critical', 'substantial', 'moderate' or 'low'. Fair Access to Care Services (or FACS) was introduced as few councils (if any) can afford to provide a service to everyone referred to them, and councils were using their own criteria to establish eligibility for help.
FACS has standardised the criteria, although all councils have a duty to assess an individual's needs before determining whether or not they should provide a service. All councils provide a service to people whose needs fall into the critical or substantial bands. Most provide some level of service to people whose needs fall into the moderate category. Not many will provide a service to people whose needs fall into the low band, though the council will direct people to other sources of help, information or advice. In other words, there is no guarantee that once referred to the local authority for help, a person will receive a comprehensive package of support, but the council should consider their current and potential needs.
The LVI should contain the following statement for patients. 'Your council has a legal duty to:

Advise you of the range of services available to people with sight problems
Carry out an assessment of your needs.'

Further details on FACS can be found at: www.dh.gov.uk/PolicyAndGuidance/ HealthAndSocialCareTopics/SocialCare/ FairAccessToCare/fs/en

Clearly the new scheme of identification will have an impact on services Ð both in terms of numbers and relationships. LOCs around the country have an ideal opportunity to be involved in the process. At the very least the LOC should be initiating discussions with SSDs to discuss use of the LVI and mechanisms for data collection and audit. These discussions will ensure that the opinions of local optical practitioners are taken into account.
It is extremely important that local optometrists and opticians are informed about the changes and made aware of their duties. ABDO, the AOP and the College of Optometrists are ideally placed to provide advice and assistance on these matters and continuing education organisers should ensure that they are included as part of their programme.
Many LOCs are in the process of demonstrating the 'added value' of using optometrists in the management of patients' health needs in the community and this is a simple way of reinforcing this message. If optometrists and opticians are seen to be able to accommodate and respond to new roles linking with social care, this can only reflect positively on the ability of optometrists to respond to an expansion of their health-care responsibilities in the future.

Local opportunities
In light of these issues and in view of other opportunities for development of the role and skills of the optometrist, it seems clear that local optometrists should welcome this opportunity. It should be used to demonstrate their ability to respond to demands to expand in their role and demonstrate the obvious maturity of the optometric profession.
This more co-ordinated approach to the identification and notification of vision loss should mean that people with failing sight will be able to get the help they need, when they need it.
For information on the sort of help available from social services and other background information on the changes, visit www.sightlossmatters.com and follow the various links available on this site managed by the University of Central England.

Anita Lightstone is head of low vision services at the RNIB. Mary Bairstow and Carl Freeman were members of the review group on the Identification and Notification of Sight Loss Ð representing the College of Optometrists and the RNIB respectively
optometrists are often greeted with the situation where a pair of spectacles is not going to provide a solution to a patient's difficulties. Although referral to the hospital may be called for, this can be a long, drawn-out process and may leave the optometrist feeling frustrated that there are no means to provide the patient with help with daily tasks.
In some areas, optometrists have been able to set up links with social services and local societies to offer help, but in others this is not available. Often it is too easy to forget that the patient in the consulting room chair has to continue their life with impaired vision for many months before help is provided. The following example is typical of the experiences of many older people.
Mavis began to have problems making a cup of tea when her vision started to fade. She splashed her hands once or twice resulting in some scalding. Assuming that she needed a stronger prescription, she made an appointment with her usual optician for some new glasses. The optometrist, realising that her visual problems were uncorrectable, referred her to the local ophthalmology department for a more detailed assessment.
When her appointment came through Ð after three months Ð the consultant quickly diagnosed age-related macular degeneration. Mavis was asked to come back in six months to have her condition monitored. The consultant suspected that at this stage she would certify the patient as being eligible to be registered with social services.
Six months later the consultant completed a BD8 certificate and Mavis was upset to know that nothing could be done to save her sight. Following the normal procedures, the form was then sent to the social services department (SSD). This meant that Mavis had been having difficulties for almost a year before the agency responsible for providing social support, such as rehabilitation skills training and equipment such as liquid level indicators, was notified.
If Mavis had known that services and equipment were available to help her cope with her sight problems, she could have contacted social services herself and sought the help she clearly needed. Prolonged delays in obtaining the necessary help often result in loss of confidence, with independence being steadily eroded and depression setting in.
The current model for certification and registration follows a very linear route and the patient normally only receives any help at the end of the process. A recent review of the system led by the DoH has looked at whether the linear route is essential or whether other approaches could be taken.

new model of care
In September last year, health minister Dr Stephen Ladyman announced on BBC Radio's In Touch programme the outcome of a comprehensive review of the BD8 process. The review panel included representatives of optometrists, ophthalmologists, patients and social services. There was a College of Optometrists' representative on the original review and the College approves of the principles behind the new system. The aim was to find and create a mechanism that would ensure that people whose lives are affected by visual impairment are not only identified at an early stage, but that they are also given early opportunities to obtain help with their vision loss. These changes apply to England only.
Rather than being dependent on the linear process, an alternative model would be that continuing ophthalmic care and social care could occur in parallel. This would not only ensure that people continue to have access to the best possible medical care but that they would be linked to social care and rehabilitation much earlier than under the previous BD8 system.
Optometrists have all the necessary skills to detect visual impairment. By simply alerting appropriate patients to a straightforward 'self-referral' process, they can help them to find the assistance they need. The involvement of optometrists in this process is a very positive move in the recognition of their widening professional role. Social services departments and the voluntary sector will be looking to the optometric professional to assist in the implementation of this new system in a clear and strategic manner.
This optometric role is not onerous, and practitioners in several areas are already issuing the new self-referral document (LVI) to their patients. When handled as part of the discussion with the patient at the end of the consultation, it should not produce any significant impact on workload.
The new system was introduced in November 2003. The documents and the 'patient pathways' have been scrutinised and endorsed by the NHS Gateway Team and the DoH. The system was promoted through the NHS Chief Executive's Bulletin and documents and guidance notes for their completion are available on the DoH website. Unfortunately, since the initial web address was advertised, the DoH site has been radically overhauled.
Although this has made it much easier for people with sight problems to adjust the content of the site to a font size they can read, it has also meant that many people have been unable to find the documents as the old links no longer work. Information on the 'identification and notification of sight loss', including downloads of all the relevant documents can be found by following the link via: www.dh.gov.uk/ PolicyAndGuidance/HealthAndSocialCare Topics/Optical/fs/en

Communication difficulties
Information about the new system and requests for feedback has only really been made available on the DoH website, so many people have been unaware of the details of the changes or their responsibilities.
For many practitioners, the internet remains an unfamiliar medium for the dissemination of such information, and consequently some have been left feeling they have been unable to raise their comments and concerns. However, it is essential that optometrists and opticians become accustomed to checking the DoH's website for updates.
In some areas, there has been little or no thought about how to 'roll-out' the LVI, RVI and CVI and while in others the old BD8 is still being used.
Confusion has arisen about who should produce the LVI, RVI and CVI and what additional training or information might be needed so that best use is made of the new system. In addition, there has been a misunderstanding about the use of the LVI. It is important to appreciate that optometrists and opticians are only required to hand over a letter/leaflet to patients, although many may feel that it is their duty of care to do more.
In view of this, as well as concerns expressed by hospital eye departments, the DoH has extended the review period until the end of June 2004 and is considering establishing a cut-off date after which the BD8 can no longer be used. The review will provide the much-needed opportunity for optometrists and opticians to explain how the system is working on the high street. It is hoped that the DoH may also initiate a series of 'road-shows' across the country to advise people and organisations about the changes.
The new system is important in the provision of services for people with sight loss, whether these are services such as low vision or social care based. For optometrists, these responsibilities should not be regarded as optional, but undertaken as a routine part of their professional duties. Failure to inform people of their right to contact social services for support could be seen as a breach of professional conduct.
A recent case in Stockport highlighted a situation where a person, who lost their sight suddenly, was not offered support services at the time of need. In this case it was Stockport Social Services' procedures that attracted criticism from the local government ombudsman, but in future the criticism may rest with the optical profession.

taking practical steps
The Association of Directors of Social Services (ADSS) is aware of the new scheme and local SSDs have been advised to contact LOCs and to discuss the new arrangements. For social services planners there are many issues that need consideration and optometrists and opticians across the country will need to be aware of local differences.
Social services departments in England are now obliged to apply eligibility criteria to all adult referrals for social care, grading people's needs and associated risks to independence as either 'critical', 'substantial', 'moderate' or 'low'. Fair Access to Care Services (or FACS) was introduced as few councils (if any) can afford to provide a service to everyone referred to them, and councils were using their own criteria to establish eligibility for help.
FACS has standardised the criteria, although all councils have a duty to assess an individual's needs before determining whether or not they should provide a service. All councils provide a service to people whose needs fall into the critical or substantial bands. Most provide some level of service to people whose needs fall into the moderate category. Not many will provide a service to people whose needs fall into the low band, though the council will direct people to other sources of help, information or advice. In other words, there is no guarantee that once referred to the local authority for help, a person will receive a comprehensive package of support, but the council should consider their current and potential needs.
The LVI should contain the following statement for patients. 'Your council has a legal duty to:

Advise you of the range of services available to people with sight problems
Carry out an assessment of your needs.'

Further details on FACS can be found at: www.dh.gov.uk/PolicyAndGuidance/ HealthAndSocialCareTopics/SocialCare/ FairAccessToCare/fs/en

Clearly the new scheme of identification will have an impact on services Ð both in terms of numbers and relationships. LOCs around the country have an ideal opportunity to be involved in the process. At the very least the LOC should be initiating discussions with SSDs to discuss use of the LVI and mechanisms for data collection and audit. These discussions will ensure that the opinions of local optical practitioners are taken into account.
It is extremely important that local optometrists and opticians are informed about the changes and made aware of their duties. ABDO, the AOP and the College of Optometrists are ideally placed to provide advice and assistance on these matters and continuing education organisers should ensure that they are included as part of their programme.
Many LOCs are in the process of demonstrating the 'added value' of using optometrists in the management of patients' health needs in the community and this is a simple way of reinforcing this message. If optometrists and opticians are seen to be able to accommodate and respond to new roles linking with social care, this can only reflect positively on the ability of optometrists to respond to an expansion of their health-care responsibilities in the future.

Local opportunities
In light of these issues and in view of other opportunities for development of the role and skills of the optometrist, it seems clear that local optometrists should welcome this opportunity. It should be used to demonstrate their ability to respond to demands to expand in their role and demonstrate the obvious maturity of the optometric profession.
This more co-ordinated approach to the identification and notification of vision loss should mean that people with failing sight will be able to get the help they need, when they need it.
For information on the sort of help available from social services and other background information on the changes, visit www.sightlossmatters.com and follow the various links available on this site managed by the University of Central England.

Anita Lightstone is head of low vision services at the RNIB. Mary Bairstow and Carl Freeman were members of the review group on the Identification and Notification of Sight Loss Ð representing the College of Optometrists and the RNIB respectively