Low vision service provision in Scotland: review

Introduction

The Scottish Government is committed to improving services for sensory impaired people in Scotland ( See Hear strategy) (Scottish Government, 2014). This review has been commissioned to determine the current provision of low vision services.

This review aligns with the Community Eyecare Review (insert link to document) (Scottish Government, 2017), published alongside this report, which has identified the need to improve access to low vision services across Scotland. It also responds to calls to consider service redesign to provide patient care closer to home and optimise the roles of all clinicians to deliver safe and effective patient care, as outlined in the Modern Outpatient: A Collaborative Approach 2017-2020 (Scottish Government, 2016).

Anecdotal reports suggest that there is an under-provision and inequality of low vision services across Scotland. Furthermore, access to services can be delayed by geographical location of services and long waiting times. Therefore, it is timely to have a comprehensive study of current services as a basis for future service development.

1.0 Defining low vision and registration

1.0.1 Low Vision

In the UK 'low vision' has not been defined in legislation. However, a definition was adopted by the Low Vision Services Consensus Group (1999).

"A person with low vision is one who has an impairment of visual function for whom full remediation is not possible by conventional spectacles, contact lenses or medical intervention and which causes restriction in that persons everyday life."

This definition uses the person's functional ability rather than any specific level of acuity or other clinical measurements of function to define low vision. It goes on to say:

"This definition includes but is not limited to those who are registered as blind and partially sighted."

This definition acknowledges that there are individuals who are facing restriction in their life due to poor vision, but who are not yet at the stage of registration.

1.0.2 Registration

The statutory definition for the purposes of registration as a "blind" person under the National Assistance Act (1948) is that the person is "so blind as to be unable to perform any work for which eyesight is essential". "Partial sight" is not defined in the act but a guideline for functional definition is given as: "substantially and permanently handicapped by defective vision caused by congenital, illness or injury". In Scotland the current registration form ( BP1) is undergoing review and will be replaced by The Certificate of Vision Impairment ( CVI) form (Scotland). This form is for those people aged 16 and over (younger people are notified under the Visual Impairment Network for Children and Young People ( VINCYP)). The CVI (Scotland) form will perform the same function as the BP1, in that it formally certifies someone as partially sighted or as blind (the proposed updated terms being 'sight impaired' or 'severely sight impaired', respectively) so that the local council can place their name on the register of sight impaired people. Registration provides the patient access to support and services, in addition to providing diagnostic and other data that may be used for epidemiological analysis.

Guidelines are given on the registration form about the level of impairment (including visual acuity and visual field) which help make the registration process more objective. However, it should be noted that these are only guidelines and the final decisions about who can be certified are made by a Consultant Ophthalmologist who is advised to take other circumstances (such as whether the person lives alone or if they also have a hearing impairment) into account.

1.1 The number of people with low vision in Scotland

To date, there is no data which accurately identifies the number of people in Scotland who have low vision. The best estimate is provided by Scottish Government registration data statistics. These were last published in 2010 and show 34,492 people are registered blind or partially sighted. However, as registration is optional, this number underestimates the true picture. Indeed, it has been suggested that registration data may only reflect 23-38% of eligible people ( RNIB, 2013).

1.1.1 Future projections of the prevalence of low vision

The number of people with low vision is expected to increase in the future. Age is known to be a significant risk factor for vision loss and the number of people living in Scotland aged 65 and over is projected to increase by 53% over the next 25 years (National Records of Scotland, 2015).

1.2 The causes of low vision in the UK

Age related macular degeneration is the leading cause of sight loss in adults, followed by glaucoma, cataracts and diabetic retinopathy. The major causes of blindness in children are distinctly different from those in the adult population. Prenatal factors (including genetic causes) are involved in over 60% of cases, and up to 77% of children with a visual impairment have either Cerebral Visual Impairment or Optic Nerve Disorders (Rahi and Cable, 2003). In the working age population, the ocular complications of diabetes and glaucoma are the most common causes of blindness, in addition to Retinitis Pigmentosa.

1.3 How does low vision affect people?

Low vision impacts on every part of a person's life. It is associated with:

• Falls (Black and Wood, 2005, Schwartz et al., 2005, Abdelhafiz and Austin, 2003, Ivers et al., 2003)
• reduced capacity to carry out everyday activities (Haymes et al., 2002)
• the need for residential care (Vu et al., 2005)
• one of the strongest risk factors for functional status decline in community-living people (Stuck et al., 1999)

However, because older people often have multiple health problems (Barnett et al., 2012), many of these individuals may also have additional health conditions which further compromise health and rehabilitation outcomes, including reduced quality of life, disability, increased healthcare costs, increased inpatient admissions and higher death rates (Marengoni et al., 2011).

1.4 Low vision services

In 1999, in the UK, the Low Vision Consensus Group which was made up of professional and user groups defined a low vision service:

"A low vision service is a rehabilitative or habilitative process, which provides a range of services for people with low vision to enable them to make use of their eyesight to achieve maximum potential." (Low Vision Services Consensus Group, 1999)

In 2002, the College of Optometrists further identified the aim of low vision services:

"The primary aim of low vision services is to enable people with loss of vision to regain or maintain as much independence and autonomy as possible. Low vision services achieve this through a wide range of tools depending on individuals needs including: rehabilitation, visual aids, emotional support and advice." ( The College of Optometrists, 2013)

Traditionally, low vision services were provided in hospitals by both optometrists and dispensing opticians (Silver and Thomsitt, 1977). Early low vision assessments focused largely on the provision of optical low vision aids (magnifiers) which provided the patient with access to conventional sized print (Bier, 1960). However, these services have evolved and now encompass a more holistic rehabilitative approach including: assessment of a patient's understanding of their ocular condition and its prognosis; discussion of needs and initial goal setting; assessment of vision; provision of low vision aids; advice about lighting and other methods of enhancing vision; provision of information about the ocular condition and other rehabilitative services; referral to such services, where necessary; re-appraisal of goals; and arrangement for follow up (Reeves et al., 2004).

Over a 25 year period, there has been considerable change to the assessment of the visual status of low vision patients in the United Kingdom (Culham et al., 2002). Indeed, it is no longer only the hospital who provide services. Low vision services in the UK are now supported by various providers who input different parts of care and support. Across the UK there are a variety of service models, which include hospital based clinics, multi-disciplinary services, primary care models and out-sourced hospital clinics. Funding for such services are generally via the NHS, local authorities and the third sector.

In 2002 low vision services were mapped nationally across the UK (Culham et al., 2002). The conclusion from that report was that the distribution of services was geographically uneven and there appears to be scarcity in some areas. Furthermore, it highlighted apparent inadequacies in service provision in terms of distribution, magnitude, and coordination. Nearly twenty years on from the collection of that mapping data, there is no current comprehensive overview of the state of low vision service provision in Scotland.

1.5 Aim of this project

The aim of this study is to provide an up-to-date review of low vision service provision in Scotland. This aim will be achieved by determining the nature, extent and geographical distribution of low vision services in the Scotland and to compare this with the location of older people.