Earlier this year, ABDO College, in conjunction with Canterbury Christ Church University, broadcast their first webinar. The subject was ‘Public Eye Health’ and the session was led by Professor Darren Shickle. In his talk, Shickle described the epidemiology of visual impairment and some developments in eye health services and policy. He also presented some of his research findings on why people do not attend for eye examinations. He proposed some issues for further debate including rethinking recommendations for frequency of eye examinations and separation of examinations from the dispensing of glasses and lenses. A recording of the webinar can be watched at www.abdocollege.org.uk/webinars.
There was time set aside at the end of the webinar for live posting and answering of questions. However, there was insufficient time to address all 147 comments and questions from the nearly 400 viewers logged into the session. Some of the unanswered questions have therefore been selected for Professor Shickle to address in writing.
? Which areas are lacking optometric services?
There are practices located within deprived communities that are financially viable. However, they are usually also dependent on other sources of income, for example, occupational health assessments and local enhanced services such as glaucoma referral refinement. Most practices are dependent on the sales of frames and other products to subsidise the cost of the eye examinations paid for privately or by the NHS GOS1 fee of £20.90. If you overlay a map showing the deprived areas of a locality, the practices are typically located in town/city centres or within the more affluent suburbs where customers can typically afford more expensive products with higher profit margins. It has been put to me that lack of geographical access within a deprived locality should not really be an issue, as everyone at some point visits a town/city centre, and hence would walk past an opticians while shopping. This is true, but research in Tower Hamlets in London showed that uptake of eye examinations dropped significantly the further away you lived from an opticians, and especially if more than a 15-minute walk. People may also not think ahead about booking an eye appointment when they plan a shopping trip, although I recognise that many practices may have an open appointment slot later in the day.
? I’m very concerned that ‘old people’ are not having an eye test because they have a fear they may ‘go blind’, and that puts them off. I need to rethink reminders to the elderly in my practice. Do you have any other ideas to change their thoughts?
It seems contradictory that people may on the one hand value their sight and be frightened of going blind, while on the other hand avoid accessing eye examinations which could detect preventable sight loss. Research has shown that many people do not know that sight loss is preventable and accept it as part of the ageing process. Many also only think of opticians as ‘glasses shops’ and do not realise that optometrists and dispensing opticians also have a preventive role. It is understandable that most advertisements within the sector focus on glasses and contact lenses. However, this just reinforces the message that all opticians can do is to offer optical appliances. It will take a sustained effort to change public perception of the role of optometrists and dispensing opticians, so they are seen as members of the primary healthcare team. Simple measures such as adding facts on letters to patients about preventable sight loss will help. Displaying posters in practices about eye health, rather than just advertisements for particular brands of frames and lenses, will also indicate that you have a wider healthcare role.
? The practice I work in is an independent. There is an area near us that is less affluent. What are the best ways to reach out to people who feel intimidated by a practice possibly perceived as upmarket or expensive?
It is right that opticians/optometrists should have pride in the appearance of their practice. A practice that takes the trouble to provide a quality experience in terms of seating, furnishings, decoration etc may also be thought to make similar effort to provide a quality clinical experience. However, many people will realise that the high cost of the furnishings will be associated with a high cost of product. Thus, people from more deprived communities may be less intimidated by a practice that has spent less on interior design. I think that the GOS contract is a limiting factor in reaching out to deprived communities. Domiciliary visits are a good solution for people who are house bound and are not able to visit an optometrist. However, I also see a case for providing eye examinations on an ad hoc basis in localities where it might be uneconomic to set up a permanent practice, for example in community centres, GP practices or via mobile vans.
? I was interested to hear that you have calculated that on a ‘not for profit’ basis that it was not possible to run an eye testing service just on NHS fees!
Given that research has consistently shown that some people are concerned about attending a commercial opticians/optometrists, we developed a business plan to explore the subsidy that would be needed to run a ‘not-for-profit’ service that was not dependent on a cross-subsidy from the sale of glasses. Not surprisingly, the £20.90 NHS GOS was insufficient for the service to be viable. However, an additional subsidy could be justified on the basis that the service would detect and refer for treatment cases of preventable sight loss, and hence save money in the future.
? Aren’t eye tests undervalued in the UK as private tests are so cheap?
I think that further research is needed to look at this. In other sectors, eg designer clothing, products are intentionally pitched at a higher price point to make them desirable. However, I think that the price of an eye examination should reflect the economic cost of delivering the service. I would make the observation, however, that there would be ways of minimising overheads, through alternative locations for delivering eye examinations.
? Should the sight test be moved from the high street, as in France?
Relocating away from the high street and shopping centres and perhaps co-locating with GPs or dentists would certainly signal that optician premises are healthcare providers rather than ‘glasses shops’. The location of GP practices is planned according to need and accessibility of the resident population.
? Do you think the opportunities to be involved in GP centred community eye health programmes may gradually change public perception to more appreciate the healthcare aspect of optometric outlets?
I think that this is very important. High street overheads can be high, and co-locating with other primary health care professionals in cheaper and more appropriate community locations will send clearer signals that visiting an optician/optometrist is about eye health rather than sale of glasses.
? I think it is important for GPs to recommend eye exams as a routine in their consultations.
I agree that health professionals have an important role in identifying individuals with visual impairment. There is also scope for training people working in other sectors who have regular contact with members of the public to be ‘eye health champions’, especially those who visit elderly and those who are housebound. There have been innovative schemes like this in different parts of the country.
? I work in an area that has just started a PEARS-type scheme. I have been astounded at the lack of knowledge pharmacists and GPs have in the work we do. Surely if they understood more, they could help spread the word for our profession?
As you may have guessed from my other answers, I am keen that opticians and optometrists become part of the primary care team. In addition to a change in the way the public think about opticians and optometrists, there would also hopefully be a change in the way that they are perceived by other primary healthcare professionals.
? How can you convince someone with an acute eye condition to go to an optometrist if they are in the position that they would have to pay, instead of going to their GP or A&E which will be free?
An optometrist with access to the appropriate training and equipment may be better placed to provide acute eye health advice than a GP or A&E doctor. But I think that the quick answer is that the majority of the public may not realise this. Practices which are focused on filling their appointments with people attending for eye examinations that may be converted into sales, may not be geared up to provide immediate care for people with acute problems. The increasing workload within hospital A&E departments in part reflects the problems that some patients experience in securing a same-day GP appointment.
? Why is there not national consistency for enhanced services, eg raised IOP follow ups, etc? Do you think there is any likelihood that more consistency will happen?
I have been a consistent critic of the variation in enhanced services between one area and another. On the one hand, local choices can lead to service provision according to local priorities. On the other hand it can lead to a postcode lottery. There needs to be evidence of cost-effectiveness (and affordability) for the services commissioned by the NHS. The National Institute for Health and Care Excellence guidance on the diagnosis and management of glaucoma led to most areas establishing a glaucoma referral refinement scheme, but there is no rationale for each have different fee structures, training requirements etc. If there was more consistency, it would also be easier to evaluate the various schemes.
? Would you agree that it would be good to have more media coverage of the impact of eye disease in a similar way in which we currently see a great deal of coverage about issues such as heart disease and cancer?
The Department of Health and the NHS do conduct health promotion campaigns in relation to healthy diet, smoking, safe alcohol consumption, identifying stroke etc. However, television advertisements are expensive and so I suspect that a television campaign specifically on eye health is unlikely. It may, however, be possible to piggy-back eye health messages onto other campaigns, such as against smoking. There is, however, significant investment in television advertising by the larger providers within the optical sector. The focus of these advertisements tends to be on the price of the product rather than quality of service. My impression is that independent optical practices try to focus on quality because they cannot compete on price. I hope that an advertising agency may eventually recommend a different approach and publicise the wider role of optometrists and opticians.
? Should we lobby the government to reinstate basic eye testing at schools? Prevention is better than cure etc, but also affording opportunity to educate, so that by the time a patient leaves school they are used to the process of visual screening?
As a school governor, I am concerned about the number of school children who either have not had an eye examination or do not wear glasses that have been prescribed or even dispensed. I believe that it is important to address bullying in schools so that children feel comfortable wearing glasses to help them achieve their educational potential. It is also true that establishing a regular pattern of eye examinations in childhood can establish behaviour that can continue into adulthood. However, I think that we should be focusing the NHS budget for optics according to those who have most to benefit, and routine screening for low risk individuals may not be a good use of scarce resources. I also recognise that orthoptic services have been cut back in many different parts of the country. Given that some parents do not take their children to have their eyes examined, even if the test and glasses are free, it seems unwise to depend on parents to act on a recommendation of an orthoptist that the parents should take their child for a cycloplegic examination.
? I wonder how many people who aren’t taking up an eye examination are driving below or on the border of the legal driving requirement.
The implementation of the European Directive, would have been an opportunity to require all drivers to have a proper eye examination. However, it is difficult to envisage that the government would make it a requirement of drivers to submit the results of a sight test on a regular basis as condition of revalidating their licence. In any case, it is likely that any such requirement would only be for a test of visual acuity rather than a full eye examination.
? Would the government save money long term by giving free eye examinations with a qualified optometrist as they have done in Scotland? (In your opinion, is a full eye examination better done by a qualified optometrist rather than a refraction trained dispensing optician?)
The experience of the change of policy in Scotland to offering free eye examinations has been disappointing. There was an increase in uptake of eye examinations in the year 2005 versus 2006, although the higher rate does not seem to have been maintained. Also, the policy has not made much impact on changing the behaviour of those who have not attended for an eye examination for many years. The cost of an eye test is not the limiting factor, as in England the cost of a private test is relatively low. People are concerned about the cost of any glasses that are recommended and not the cost of the test.
? Will the age-related test shift in line with people to retire at 68 years of age. Many people are still in employment now at 60?
The decision of the government to increase the age at which a State pension may be claimed is an economic one. From a public health perspective, the eligibility for NHS eye examinations should be on the basis of likelihood of detecting visual impairment, although social justice arguments would also influence decisions to facilitate access to beneficial healthcare for deprived groups.
? The cost of glasses has never been cheaper in some outlets and these are widely advertised. Can the cost of glasses still really be cited as valid reasons for not having an eye exam?
This may be true, but the cost of glasses is still commonly quoted by the public in research as a reason for not attending for an eye examination. Of course for the most deprived individuals, the prices advertised may still be more than they can afford. It will therefore be important to make it more widely known the eligibility for NHS vouchers and to ensure that there are a reasonable range of options at this price point. It is also important to remind sales staff that they should be sensitive to the budget that people have. Many people within the focus groups that I conducted described being encouraged to look at more expensive frames. The option of re-glazing existing frames is also frequently not presented or is dismissed if raised by the patient. The general public are also cynical about the advertised price, because they feel pressurised to agree to coatings which increase the bottom line price. My final comment arising out of my research, is that the public find the pricing structure and special offers confusing and struggle to work out the final cost until it is presented to them, at which point they find it difficult to back out. All of these factors add to a general mistrust of opticians and optometrists which impacts on uptake of eye examinations.
? Should all practices with a GOS contract have to provide an option of free spectacles covered by the voucher?
Research has shown that many practices do not provide a good selection of voucher level glasses. However, given that the business model for many practices depends on profits from the sale of more expensive products, there are disincentives for supplying glasses at this price level. ?
? Professor Darren Shickle is professor of public health at the University of Leeds