Low vision service provision in Scotland: review

Discussion

This is the most comprehensive review of low vision service provision across Scotland ever conducted. The study has identified a range of service types, however, there is little consistency in terms of distribution, content of service and coordination. Indeed, there appears to be a scarcity and under provision of services in many areas.

Given the high response rate it is likely that our data provides an accurate reflection of low vision services available across Scotland. As previously mentioned, specialist teacher information was difficult to identify, and as such this group are likely to be underestimated in this report. However, the number of children with low vision is small compared to the older population, and whilst children may benefit from the services identified in this review, they will also have a range of services available to them from birth. The growing demand for low vision services will arise mainly from the elderly population and future planning of services will need to primarily respond to this need.

This study has identified that within Scotland the majority of low vision services are provided by NHS funded hospital based clinics and community-based LV schemes, local societies/charities and local authority funded services.

4.1 Key message 1: Access to low vision services are inequitable across Scotland

Based upon the evidence collated in this review, future planning of services should consider patient access, in terms of both geographical location, waiting times and aids.

a. Geographical location of services

The mapping of services ( figure 3) indicates a scarcity of services in rural areas. There is a higher prevalence of older individuals in the rural areas, suggesting a higher proportion of people with low vision needs compared to the urban areas. Unfortunately, we know that older people are also significantly more likely to have additional physical and mental co-morbidities, compared to younger individuals. This can create significant barriers in terms of access to services if those services are far from a person's home. Many of the services do not provide transportation, and as such this may lead to patients unable to access services.

Local access to services has been identified as a core principle in the Primary Care Vision in the Modern Outpatient Programme (Scottish Government, 2016) and is further supported by recommendations in the See Hear Strategy (Scottish Government, 2014). This type of service design will reduce geographical barriers to timely patient care. Therefore, future planning must ensure that there is fair and equitable access for these people to low vision services.

b. Waiting times

The review has also identified that there is a variability of waiting times (for an initial appointment). Early provision of services is important to enable these individuals to retain the maximum amount of independence possible. The majority of individuals accessing these services are older, and are experiencing restriction in their everyday life, whether that be preparing food, reading bills or recognising people's faces. This can lead to deterioration in physical health and increase feelings of isolation. Encouragingly, all community optometry services reported providing appointments within 2 weeks, but waiting times in some of the other services were up to 6 months. For an elderly patient with other co-morbidities, 6 months is a considerably long time to wait.

Future planning needs to consider the importance of providing timely access for patients to services. This reaffirms the priority actions of the Scottish Vision Strategy to "ensure habilitation/rehabilitation are available as soon as necessary and reflect the needs of the individual ( RNIB, 2013). Although relating to a different health condition, a good example of the impact of timely care upon patient outcomes can be seen in cases of Motor Neurone Disease. Timely care has been legislated for in cases of Motor Neurone Disease where services were often so slow in a very rapidly progressing condition that the patient was often dead before the aid was forthcoming. Although low vision may not be overtly so critical, the impact of delayed intervention for the patient can severely impede their ability to maintain independence and may compound the effects of other comorbidities. Consequently, this can lead to increased burden upon social care and other areas of the health service.

c. Low vision aids

The review identified that there is a lack of uniformity across (and within) service types concerning low vision aid provision. Of note, one third of services reported charging for aids.

4.2 Key message 2: The capacity of services is variable

In terms of future planning, consideration needs to be given to demand and current provision of services. There may well be workforce issues that need to be addressed.

The review identified a total of 45 services. However, three quarters of the current providers deliver 400 or less appointments per year, and over half (55%) provide less than 200. Of the 12 services which self-reported providing over 400+ appointments per year, the highest estimate of delivery was 1100 appointments per year (which was delivered by a community based LV scheme).

Although accurate estimates of people with low vision are unknown, we know that demand will continue to increase with an ageing population. Therefore, it is essential to consider how delivery capacity can be increased to meet patient need.

4.3 Key message 3: There is variability in service types/models

The review has identified that low vision services are being delivered via a variety of service types in Scotland. However, it is clear from the data that these services often integrate with each other and do not exist in isolation ( 3.9.2). Indeed, to provide a service which meets patient need, integration and patient pathways are required. It was beyond the scope of this review to analyse current integration, however it was surprising how many individuals were unaware of other service providers within their health board.

The See Hear document (Scottish Government, 2014) has identified the need to develop clear care pathways, which requires an integrated approach between service providers. This enables resources to be optimised and provides a more positive patient journey. Realistic Medicine (Scottish Government, 2017) encourages a reduction in unnecessary variation in practice and outcomes; patients should be able to access high quality low vision services across Scotland. Future planning needs to consider how services can be effectively integrated to allow the patient easy access to all the help they require.

4.4 Conclusions/future work

This review has identified that there is lack of uniformity of low vision services across Scotland. There is a scarcity in rural areas and inequality in terms of both waiting times and access to aids. To meet the needs of an ageing population, and to align with the See Hear strategy, future planning must consider how to provide equitable access to patients so that help is received in a timely manner.

Failure to respond to the current inequalities in service provision will potentially store up problems in other areas of the health service. This is largely an older population with a range of physical and mental comorbidities (Court et al., 2014). If a person is unable to manage their health condition due to low vision ( e.g. unable to see medications, unable to take exercise or prepare healthy meals), their condition may deteriorate which may increase the burden on other primary, community or secondary care services.

The review has identified that there is a need to provide increased accessibility to services in rural areas. The results show that there are many different service types in Scotland, and consideration should be given to which of these can help meet this need. The review has identified specifically that the community based LV schemes have the ability to deliver high capacity over a wide geographical area, and also provide short waiting times.

It would be pertinent to consider the option of increasing the provision of such schemes across Scotland. Scotland has an extremely capable and highly trained optometry workforce, who is well placed to provide services at a community level. Furthermore, there is strong evidence from Wales that a national community based LV scheme is an effective method of service delivery which delivers positive patient outcomes (Court et al., 2009, Court et al., 2010, Ryan et al., 2013, Ryan et al., 2010). This scheme embeds training for the eye care professionals and integrates patient-centred outcome measures to ensure a safe and quality service for patients. Importantly, such a service provides an easy access point for patients to low vision support, and a clear pathway and signposting to other service providers e.g. hospitals, social services and local societies/charities.

In conclusion, future planning requires policy makers to consider the current status of provision, and seek an evidenced-based solution which will improve the access and equality of low vision services to people in Scotland.