«Framework for provision of eye care in special schools in England 1. Introduction This paper produced by SeeAbility, the Association of British ...»
Framework for provision of eye care in special schools in England
This paper produced by SeeAbility, the Association of British Dispensing Opticians,
the British and Irish Orthoptic Society, the College of Optometrists, the Local
Optical Committee Support Unit (LOCSU) and the Royal College of
Ophthalmologists, supported with advice from the Children’s Vision Service
Advisory Group in Wales, provides a framework whereby all children and young
people in special schools in England gain equitable access to regular eye care.
A list of contributors to the paper is included in Appendix F.
The Clinical Council for Eye Health Commissioning has given its endorsement for a comprehensive and targeted programme of eye care for children and young people in special schools in England.
For matters of equality this paper strongly recommends a nationally funded programme to achieve universal coverage across England.
2. The prevalence of sight problems amongst children with disabilities It is well documented that children with neurodevelopmental impairments are at greatly increased risk of significant visual problems when compared to the general population. There are high levels of refractive error and strabismus which are both treatable conditions providing they are identified. In some cases more serious pathology and ocular abnormalities, such as cataract will be found. Other visual problems resulting from brain pathology rather than ocular abnormality, including reduced visual acuity, visual field defects, oculomotor abnormalities, impairments of visual attention and perceptual difficulties are also likely to present in this group of children.
Further information is shown in Appendix A.
3. The case for operating an eye health care service in special schools in England There is strong evidence that children and young people with learning disabilities have problems accessing community eye care services. Often there is a risk of diagnostic overshadowing, that is, that difficulties arising from behaviours caused by a visual problem are mis-attributed to a learning disability. In addition because of the many other challenges this group of children and young people face, visual difficulties may be overlooked. SeeAbility’s work indicates around 4 in 10 of children who attend the special schools it works in have no previous eye care history. An earlier study of children attending five special schools in Wales found a history of previous eye care was reported for only 62% of children for whom historical eye care information was available. Further information and other studies are also referenced in Appendix A.
The evidence from existing exemplar services operating in special schools (e.g.
Warrington), and from pilot projects (SeeAbility) shows that providing eye care in the special school setting when it is appropriate to do so has a number of significant advantages over community or secondary care. As well as targeting the children and young people that need eye care the most, it addresses the inequalities and barriers to access that many experience.
Currently, it appears that the General Ophthalmic Services Contract (‘GOS’)1 is a nationally funded programme that many children and young people are not accessing. The fee for a standard GOS sight test is £21.31. The General Ophthalmic Service’s primary ‘reasonable adjustment’ for eligible persons who are unable to leave their home unaccompanied because of physical or mental illness or disability is a domiciliary fee of £37.56 on top of the standard £21.31 fee in respect of each of the first and second sight tests provided. This equates to £58.87 for a sight test a child or young person may receive at home.
However, SeeAbility has been unable to establish if any children benefit from domiciliary sight testing. The figures are not collected centrally2 and SeeAbility has not come across any child that has accessed eye care at home during its work in special schools.
General Ophthalmic Services Contracts (Payments) Directions 2015 www.gov.uk/government/uploads/system/uploads/attachment_data/file/453367/Ophthalmic_payments_directio ns_2015_acc.pdf See Hansard 5 March 2015 www.parliament.uk/business/publications/written-questions-answersstatements/written-question/Commons/2015-02-26/225539 Changes in vision are a common occurrence during childhood and adolescence and will have a significant impact on a child’s ability to interact and on their education. Developmentally normal children are more likely to report deteriorating vision and access eye care via the GOS and community optometry. Children who attend special schools are less likely to do so because of communication difficulties as well as other barriers discussed in Appendix B.
The alternative is bringing children into hospital eye clinics at potentially much greater cost. At time of writing, first attendance tariffs for paediatric ophthalmology are £149 then £100 for a single professional follow up attendance3, while local tariffs may be agreed or exist for each hospital optometry or orthoptic clinic visit not counted under the national tariff costs. For children with learning disabilities, multiple attendances for different professionals and different checks are likely.
An in-school model supports the move towards preventative, early health care, which includes restorative treatment and preventing unnecessary sight loss. The model is also a more financially efficient way of working. Having a core team (which for the purposes of this paper we will call a ‘Special Schools Ophthalmic Team’), that delivers as much eye care as possible in the school environment, throughout a child and young person’s school life, can help achieve cost savings, particularly around ongoing ophthalmic care that can be managed at a lower cost in a school setting.
SeeAbility’s first year of service has been costed at £854 per sight test. In Warrington, substantial cost savings have also been estimated from transferring the hospital model into two special schools (Greenwood).
Other benefits of operating this model are outlined in Appendix B.
4. Services currently operating in England Good, appropriately funded, services exist in a small minority of areas and it is vital that these existing exemplar services in special schools are supported and not dismantled or eroded. However in the vast majority of areas no in-school services exist or provision is only limited to school entry.
There may in some areas be a vision-screening programme at school entry5 but this paper does not recommend it as a tool for the special school population.
National tariff payment system 2014/15. See www.gov.uk/government/publications/national-tariff-paymentsystem-2014-to-2015 Indicative, there is more work that SeeAbility will be doing on its second year of costings 5 The National Screening Committee recommends “Screening for visual impairment between 4 and 5 years of age should be offered by an orthoptic-led service. Although refractive error and strabismus would be detected by screening, amblyopia is the most likely condition to be detected in this age defined population.” See http://legacy.screening.nhs.uk/vision-child This is because this population of children are much less likely to be able to cooperate with National Screening Committee recommended tests and are also much more likely to have visual/ocular problems.
It is also important to note that SeeAbility has been awarded an ‘additional services’ GOS contract to operate in two NHS England areas (London and Thames Valley) to cover schools in the Children in Focus project, but this only pays a £21.31 sight test fee which is provided for in the directions for eligible persons attending day centres (vouchers to cover spectacle costs can also be claimed through this contract). SeeAbility is only able to operate with this payment because it is charitably funding the remainder of the costs – something that is not sustainable in the long term.
5. Principles for a framework
For reasons of equality, and in light of the significantly increased incidence of ocular and visual problems, it is important that what is made available to children and young people who attend special school is equal to what children and young people have a right to access under the General Ophthalmic Services contract (i.e.
the right to a free NHS primary care sight test) and under clinical guidelines.
Further details are outlined in Appendix C.
The framework is a reasonably adjusted, child-centred model that:
Achieves equity of access irrespective of a child’s disability and age Maximises uptake and overcomes issues of consent Avoids unnecessary travel, distress and time out of school Reduces anxiety and stress for parents/carers Minimises burden on hospital eye clinics, by reducing the need for onward referral and allows for safe discharge Ensures educational involvement Has effective feedback and communication systems Supports continuity of care from eye care professionals in the school Finds solutions to problems e.g. a process for children in transition
6. Recommended clinical protocols A flowchart illustrating the pathway is shown in Appendix D
6.1 Consent It is recommended that the service operates an opt-out policy and that schools at the start of each academic year distribute consent forms. This will maximise use of and access to the service.
The only proviso is where cycloplegia is used opt-in consent must be obtained from a parent or guardian with parental responsibility. A protocol will be developed to ensure there is a failsafe mechanism for the children for whom the team feel that examination under cycloplegic is indicated.
Parents should be notified that if they do not opt-out of the service, information on their child’s eyes and vision and any associated recommendations will be put into their child’s annual report and shared amongst professionals as necessary to support their child. Options for the dispensing of spectacles should form part of the consent. Where spectacles are needed, families should have the choice of allowing the Special Schools Ophthalmic Team and school staff to choose spectacles with the child, to attend themselves to choose spectacles or to take a spectacle prescription voucher to an optician to get spectacles fitted.
An up to date and appropriate kit of tests and equipment for visual assessment, refraction, eye health and fundus checks, spectacle fitting and dispensing/repairs will be necessary for all services. It is recognised all up to date recommendations from the relevant professional bodies should be adhered to with respect to equipment/tests used.
A recommended equipment list is outlined in Appendix E.
6.3 Clinic history taking and information gathering Before appointments with new starters at the school, efforts will be made to gain relevant information from parents, ideally in written format. This should include past ophthalmic history (hospital and optometric dates and outcomes of previous appointments), history of spectacle wear, notes on general health and medication, family history of eye problems, birth history and parental/teacher/support staff concerns and observations.
The following form produced by SeeAbility can be used to collate this information www.seeability.org/uploads/files/Children_in_Focus_campaign/About_your_childs_ eyes.pdf.
6.4 Tests At school entry (4-5 years old) or at any point where the child enters school for the first time, and then at least annually* the following tests should be attempted with
Habitual vision (visual acuity with glasses if worn or vision without glasses if glasses are not habitually worn) / for distance and near, monocularly and, where indicated, binocularly. Or, where this is not possible, functional visual assessment using tests appropriate to the child.
Assessment of binocular vision (ability to use both eyes together) using cover test/ prism fusion ranges/10 or 20 base out prism and measurement of stereopsis (depth perception).
Assessment of ocular movements to include: fixation (ability to look directly at a target) and eye movement extent and control (ability to make appropriate, smooth and accurate eye movements in all directions and accurate saccadic eye movements between targets).
Refraction by retinoscopy, under cycloplegia where indicated**.
Accommodation (focusing for near tasks) by dynamic retinoscopy.
Visual fields (extent of ‘all-round’ vision).
Internal and external eye health examination by ophthalmoscopy using dilation where indicated (see references to cycloplegic examination).
Intraocular pressures if clinically required.
* Colour vision and contrast sensitivity do not need to be an annual test. These should be undertaken at an appropriate point and when clinically indicated.
** The only proviso would be that for the first refraction it is advised this is under cycloplegia. Where this is not possible or practical the practitioner should record the reasons.
The framework allows for clinical judgment in terms of an increased frequency of examination if indicated (for example in cases of inconclusive findings, therapy for amblyopia, following provision of a first prescription) and for referral onwards (see 6.6). Wherever a test is attempted but is not possible this should be clearly recorded.
It is acknowledged that a good fundal view is not always possible due to limited cooperation from a child or to avoid causing them distress. Where this is the case it should be clearly recorded and reasons stated.
6.5 Leavers This will include young people up to the age of 25.
The Special Schools Ophthalmic Team should engage with local community optometrists and dispensing opticians to facilitate transition to community based care on leaving school. A final eye care and vision report should be issued for all leavers with advice on seeking ongoing care in the community.
Ideally there should be a local enhanced pathway for adults with learning disabilities that allows referral into suitable eye care providers in the area. For example Warrington has developed a transition pathway and a vision passport and in a growing number of areas LOCSU Community Eye Care Pathways for Adults and Young People with Learning Disabilities are being commissioned.