551915 research-article2014

RSH0010.1177/1757913914551915Current Topics & OpinionsCurrent Topics & Opinions

Current Topic & Opinion

Adopting a public health approach to eye care: how the Public Health Outcomes Framework is a tool for positive change Freelance researcher Dr Tammy Boyce, Shaun Leamon from RNIB, Dr Noman Mohamed from East Surrey Hospital and Dr Naeem Ahmed from NHS England examine how addressing preventable sight loss can benefit the wider health and social care domains of the Public Health Outcomes Framework and call on clinicians to ensure their data are accurate. Sight loss is a significant issue for public health. It affects approximately two million people in the UK, and this number of people living with sight loss will increase over the coming decade. One in five people aged 75 and over and one in two people aged 90 and over live with impaired vision in the UK, yet over 50% of sight loss can be avoided.1 The Public Health Outcomes Framework (PHOF), introduced by the Department of Health in April 2013, focuses on two high level outcomes: (1) increased healthy life expectancy and (2) reducing differences between life expectancy and healthy life expectancy between communities. In this new system in England, Directors of Public Health and their teams moved from the National Health Service (NHS) to local authorities, one of the most significant changes to the public health system since 1974. In addition to these changes, for the first time, there is a responsibility on commissioners of public health to tackle sight loss in their local communities. The PHOF includes an indicator directed at preventable sight loss, putting eye health alongside priority issues such as dementia and obesity. The indicator tracks the total number of people certified as blind or partially sighted and the numbers certified according to the three major causes of preventable sight loss (see Box 1).

Benefits to Public Health and Social Services The PHOF preventable sight loss indicator is a real opportunity to

improve eye care services at a population level. It provides Clinical Commissioning Groups (CCGs) in England with an opportunity to identify unmet need and address inequalities in provision, to create a more seamless pathway for patients and to improve the early detection and treatment of eye disease, central to the prevention of sight loss and blindness. There are strong links between sight loss and many public health priorities (see Box 2). Significant savings may be possible by reducing the complications of concomitant conditions resulting from the poor management of avoidable sight loss. NHS commissioners in England spent on average £40,900 per 1,000 head of population on problems with vision in 2010–2011.9 Improving eye health can improve performance against at least ten other indicators in the PHOF.10

Certification and Registration: The Importance of Knowing The Data Effective public health interventions need reliable epidemiological data, so it is important that the numbers certified with sight loss, and subsequently registered with social services, are accurate and reflect the need at a local level. Accurate data will mean services and support are better planned, commissioned and delivered to meet actual need. The PHOF preventable sight loss indicator is based on the numbers of Certificates of Vision Impairment (CVI) issued in the 12-month period, from April to March. A CVI is completed by an ophthalmologist in the hospital, and a copy is sent to the patient’s General Practitioner, the Certifications Office at Moorfields Eye Hospital – for national monitoring purposes and inclusion in the PHOF – and the patient’s social services department. When social services receive the CVI, they contact the patient to offer a needs assessment and to formally register the patient as severely sight impaired (blind) or sight impaired (partially sighted). The register of blind and partially sighted people

Box 1  The Public Health Outcomes Framework Preventable Sight Loss Indicator •  C  rude rate of sight loss due to Age Related Macular Degeneration (AMD) in persons aged 65 and over per 100,000 population •  C  rude rate of sight loss due to glaucoma in persons aged 40 and over per 100,000 population •  C  rude rate of sight loss due to diabetic eye disease in persons aged 12 and over per 100,000 population •  Crude rate of sight loss certifications per 100,000 population

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Current Topic & Opinion

attitude of certification, care pathways, perceived value of certification and payment for completing CVI forms. Eliminating inappropriate, artificial or unwarranted variation is a fundamental principal behind continuous quality improvement in health care.12 It is inevitable that if variations are reduced and coverage of certifications improve, numbers of new certifications in many areas will increase. This is analogous to the introduction of a screening programme and should not be seen as a failure of the service.

Understanding how many people in an area have a visual impairment and what services and support is available to blind and partially sighted people will help to improve practice. Health and Wellbeing Boards, with local authorities and CCGs, have a statutory obligation to carry out a Joint Strategic Needs Assessment (JSNA) of the health and social care needs in their area. Preventing sight loss can be addressed in JSNAs, Joint Health and Wellbeing Strategies and through commissioning. The UK Vision Strategy consortium has created JSNA guidance demonstrating the relationship between eye health, sight loss and other health determinants, showing that the prioritisation of eye health and sight loss intervention can help to meet locally identified strategic priorities and support service planning.13 In addition, the Royal National Institute of Blind People (RNIB)14 has produced a sight loss data tool providing data on the level of sight loss in each region and local authority in England. The PHOF sets out the Government’s priorities for the new public health system. The inclusion of the preventable sight loss indicator ensures that avoidable sight loss is recognised as a critical and modifiable public health issue.

The Future of the Indicator

Acknowledgements

Box 2  The link between sight loss and other public health priorities •  S  moking: Smoking doubles the risk of developing AMD, the United Kingdom’s leading cause of blindness.2 Cessation programmes which link sight loss and smoking bolster wider health promotion campaigns.3 •  O  besity: Obesity is linked to several eye conditions including cataracts and AMD, and there is a strong link to diabetes. Poorly managed diabetes can lead to the development of diabetic eye disease.4 •  S  troke prevention: Almost 70% of stroke survivors have some sort of visual dysfunction following stroke,5 yet 45% of stroke services do not provide a formal vision assessment.6 •  D  epression: People with sight loss are significantly more likely to experience depression than people without sight loss.7 •  F  alls: 47% of falls sustained by blind and partially sighted people are directly attributable to their sight loss.8

is voluntary; however, it is a precondition of certain financial benefits. Registration is not a prerequisite for all social services concessions, and this factor means that the number of people registered may underrepresent the number of people eligible for registration. The registration figures are collected on a triennial basis and are managed by the Information Centre for Health and Social Care. Certification and registration are, therefore, suitably different processes in the same patient journey and result in two sets of data. Certification rates differ widely in English Primary Care Trusts (PCTs), and there is an 11-fold difference between the highest and lowest rate.11 Reasons for this variation are uncertain, but it is likely much of the variation is due to factors including variation in clinician’s knowledge and

Eye health charities and professionals regard the preventable sight loss indicator as an opportunity to prioritise eye health in local communities.

We are grateful to Faheem Ahmed (MPH candidate, London School of Hygiene & Tropical Medicine) for comments on early drafts of this article.

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professionals (Last accessed 14th October 2013). Malik ANJ, Bunce C, Wormald R, Suleman M, Stratton I, Gray JAM. Geographical variation in certification rates of blindness and sight impairment in England, 2008–2009. BMJ Open 2012; 2: e001496. DOI: 10.1136/ bmjopen-2012-001496. Hanna TJ. Variation in health care – The roles of the electronic medical record. International Journal of Medical Informatics 1999; 54(2): 127–36. Commissioning Guide for Eye Care. Commissioning Guide for Eye Care and Sight Loss Services: Building on the QIPP Agenda. 2013. Available online at: http://www. commissioningforeyecare.org.uk/commhome. asp?section=167&;sectionTitle=The+eye+care +commissioning+cycle (Last accessed 14th October 2013). RNIB. Sight Loss Data Tool. 2013. Available online at: http://www.rnib.org.uk/ aboutus/Research/statistics/Pages/sight-lossdata-tool.aspx (Last accessed 11th October 2013).

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