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«Commissioned by Public Health from Hirji Associates Dr Nizar K. Hirji Optometrist Consultant July 2014 Key Authors Dr Nizar K. Hirji – Hirji ...»

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EYE HEALTH NEEDS ASSESSMENT

WALSALL

Although the information in this document is from sources believed to be reliable, no

warranty express or implied is made or assumed regarding accuracy, adequacy,

completeness, legality, reliability or usefulness of any such information, and any and

all such warranties are expressly disclaimed. This disclaimer applies to both isolated

and aggregate uses of the information. The author furthermore disclaims liability for any loss or damage which may arise as a consequence of any person relying on the information contained in this document.

Commissioned by Public Health from Hirji Associates Dr Nizar K. Hirji Optometrist Consultant July 2014 Key Authors Dr Nizar K. Hirji – Hirji Associates Dr Paulette Myers – Consultant in Public Health, Walsall Council Matthew Fung – Specialty Registrar in Public Health, Walsall Council 2 Contents Acknowledgements Executive Summary

1. Introduction Aim…………………………………………………..……Page 16 1.1 The Population…………………………………………..Page 16 1.2 Eye Health…………………………………………….…Page 17 1.3

2. Methodology Estimates of the prevalence of Eye Disease…………Page 19 2.1 The Population Data……………………………………Page 20 2.2 Literature…………………………………………………Page 20 2.3 Ophthalmic Activity Data……………………………….Page 20 2.4

3. Policy Drivers

3.1 UK Vision Strategy……………………………………...Page 21

3.2 The Royal College of General Practitioners………….Page 21

3.3 Public Health Outcomes Framework

NHS Outcomes Framework 2013/14…………………Page 22 3.4

3.5 Quality Innovation Productivity and Prevention (QIPP) Program………………………………………………….Page 24 Social Care Outcomes Framework……………………Page 24 3.6 3

4. Demographics Age………………………………………………………..Page 26 4.1 Ethnicity…………………………………………………..Page 27 4.2

4.3 Deprivation……………………………………………….Page 30 Obesity…………………………………………………...Page 32 4.4 Smoking………………………………………………….Page 33 4.5 Alcohol Consumption…………………………………...Page 35 4.6 Literacy and Learning Difficulties……………………...Page 36 4.7 Economic Disadvantage………………………………..Page 37 4.8 Other Aspects……………………………………………Page 38 4.9

5. Eye Health Workforce Primary care practitioners……………………………...Page 40 5.1 Secondary care practitioners…………………………..Page 43 5.2 General Ophthalmic Services – Primary Care……….Page 44 5.3 Ophthalmic activity in Primary Care…………………..Page 49 5.4 Outcomes of GOS sight tests………………………….Page 54 5.5 Hospital Eye Services – Secondary Care…………….Page 55 5.6

6. Sight loss, it’s prevalence, detection and treatment Refractive Errors………………………………………...Page 64 6.1 Cataracts…………………………………………………Page 65 6.2

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Glaucoma………………………………………………..Page 72 6.4 Diabetic Eye Disease…………………………………...Page 75 6.5 Squints and Amblyopia…………………………………Page 79 6.6 Referral Procedures…………………………………….Page 82 6.7 6.7.1 Referral activity from primary care to the hospital eye service

7. Visual Impairment Definition of Visual Impairment………………………..Page 88 7.1 Severely Sight Impaired and Sight Impaired…………Page 89 7.2 7.2.1 Low Vision………………………………………...Page 94 Public Health Indicator………………………………….Page 97 7.3

7.4 Burden of Visual Impairment…………………………Page 100

8. Public Perceptions of Eye Health

9. Recommendations

10. Glossary

11. References

12. Appendices

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Arnold, Garry – Contracts Manager, Walsall CCG, Walsall Bhatnagar, Ajay - Lead Ophthalmologist, Manor Hospital, Walsall Bhogal, Bhogal S - Principal Optometrist, New Cross Hospital, Wolverhampton Borman, Natalie - Commissioning Manager Disabilities, Joint Commissioning Unit, Walsall Council and NHS, Walsall Brazier, Dawn - Head Orthoptist, Walsall Healthcare NHS Trust, Walsall Manor Hospital, Walsall Brown, David - Optometry Lead, NHS England, Birmingham Solihull and Black Country Area Team Birmingham Ewin, Martin - Public Health Intelligence Manager, Public Health Walsall, Walsall Fung, Matthew - Specialist Registrar, Public Health Walsall, Walsall Gill, Amrik - Chairman, Walsall CCG, Walsall Gillis, Isabel - Director of Public Health, Public Health, Walsall Godwin, Wendy - Lead Commissioner Planned Care, Walsall CCG, Walsall Hewitt, Julie - Information Intelligence Manager, NHS Walsall CCG, Walsall Hughes, David - Public Health Intelligence Analyst, Public Health Walsall Jeewa, Aisha - Secretary, Walsall LOC, Walsall Myers, Paulette - Consultant in Public Health, Public Health Walsall Patel, Bharat - Head of Medicines Management and Primary Care, Walsall CCG, Walsall Perry, Craig - Project Manager, Planned & Unscheduled Care, Joint Commissioning Unit, Walsall CCG, Walsall Reed, Amanda - Chief executive, Walsall Society for the Blind, Walsall 6 Sahota, Narinder - Assistant Director for Clinical Strategy Medical, Birmingham, Solihull and the Black Country, Birmingham Sarah, Slade - Chair, National Optometric Advisors Association Saunders, Bob - Prescribing Advisor, Walsall CCG, Walsall Shun-Shin, G - Ophthalmologist, Manor Hospital, Walsall Soomal, Satvinder S - Walsall LOC Member, Walsall Stevens, Dave - Treasurer, Walsall LOC, Walsall Swift, Rebecca - Regional campaigns Officer, West Midlands, RNIB, Birmingham Thomas, Emma - Public Health Intelligence Team, Public Health Walsall Williamson, Annette - Interim Screening and Immunisation Manager, Public Health England, Birmingham Warrender, Anita - Walsall Eyes, Walsall Wright, Ann-Marie - Senior Accountant – Commissioning, Walsall CCG, Walsall Yang, Yit - Lead Ophthalmologist, New Cross Hospital, Wolverhampton

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The Joint Strategic Needs Analysis (JSNA) for Walsall 2013, identifies demographic, lifestyle characteristics, and health determinants in Walsall’s population. However it makes no direct reference to eye health.

This Eye Health Needs Assessment (EHNA) is aimed at enabling Public

Health Walsall and its partner organisations to:

1. To improve local knowledge of eye health in relation to the perceived, current and predicted, needs of the resident population of Walsall

2. To use this local knowledge to influence current eye care services and commissioning of future eye care services and to better manage avoidable sight loss.

Its recommendations will endeavour to:

1. Identify priorities for improving eye health

2. Reduce eye health inequalities

3. Outline the direction for the development of NHS eye care services It reviews the needs of specific high risk groups and draws on existing data wherever possible. It concentrates on the main causes of sight loss and draws from the key publications and findings of the JSNA published by Walsall Public Health.

Visual impairment (VI) (when a person has sight loss such that the level of corrected vision is below that which the individual requires for their everyday tasks) has a very significant impact on the quality of life.

8 Ageing, ethnicity, obesity, deprivation, alcohol consumption, learning disability, smoking, the demographic and lifestyle characteristics identified in the population of Walsall are known risk factors in one or

more of the following eye conditions that cause visual impairment:

 Refractive Errors - an error in the focussing of light by the eye to a sharp focus precisely on the retina, resulting in a blurred retinal image  Cataract - a loss of clarity the eye’s normally clear lens, causing difficulties in seeing clearly.

 Age-Related Macular Disease (AMD) – a deterioration of part of the back of the eye responsible for the sharp, central vision needed to see detail e.g. reading (using the macula).

 Glaucoma - a group of eye diseases often associated with abnormal internal eye pressure, leading to damage of the optic nerve at the back of the eye and consequently sight loss  Diabetic Retinopathy – abnormal and/or damaged blood vessels at the back of the eye (retina) caused by changing blood sugar levels.

Key Messages Visual impairment affects people of all ages, but its prevalence increases with age.

Ethnicity is a major factor in eye disease, with some groups more at risk than others.

Area and individual level deprivation are both associated with late presentation of eye disease (Fraser et al 2001).

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The link between smoking and Age Related Macular Degeneration (AMD), a major cause of visual impairment in the UK, is as strong as the link between smoking and lung cancer. Smoking also accelerates formation of cataracts.

Drinking large quantities of alcohol may cause nutritional problems and may lead to toxic amblyopia (lazy eye), and optic nerve disease. Alcohol consumption during pregnancy can lead to foetal alcohol syndrome, which can lead to ocular anomalies in the baby.

People with learning disabilities are 10 times more likely to have serious sight problems than other people.

The evidence on falls, suggests that people with visual impairment are

1.7 times more likely to have a fall and 1.9 times more likely to have multiple falls compared with fully sighted people. When VI is actively addressed as part of a falls reduction plan, falls can be reduces by up to 14%.

There are an estimated 7,310 people living with sight loss in Walsall and there will be an estimated 8,350 people living with sight loss in 2020 if matters carry on as they are.

There are an estimated 2,460 people living with cataracts in Walsall and we know due to the ageing population this is going to grow rapidly.

There is a significant increase of direct referrals for cataract surgery from optometric practices but the conversion rate is only about 50%.

10 The National Eye Health Epidemiological Model (NEHEM) suggests that there are 6156 people in Walsall who are living with Age-related Macular Disease.

The mean NEHEM estimate of prevalence of glaucoma in Walsall is 1.45% which is most likely underestimate and a more realistic figure would be be almost 3% of the population based on other work conducted in Bradford. There are an estimated 2,290 people living with glaucoma in Walsall.

There are 5080 people living with diabetic retinopathy in Walsall. The screening service manages to screen for retinopathy in 67.7% of Walsall’s diabetic population placing the service in the bottom (4th quintile) nationally for performance.

Substantially more male than female optometric practitioners are performers in Walsall compared to the national average in the profession.

There are fewer practitioners per 100k population in Walsall compared to the national picture and substantially lower than a neighbouring statistically equivalent PCT.

Fewer practices are located in the East of the Borough and outside the inner ring road where the majority of the older population live and considerable areas of Walsall are not within 15 minutes walking distance to an optometric practice.

Optometrists are the major provider of General Ophththalmic Services (GOS) in England. The same is true for GOS providers in Walsall.

There is a steady increase over the past 5 years of 9% for total NHS sight tests and 17% for Domiciliary NHS sight tests which account for

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There is a significant decrease in the over 60s taking up their NHS sight tests in Walsall.

There is no data available or collated on referrals from GOS sight tests specifically for Walsall.

In secondary care eye clinics at the Manor and New Cross hospitals, there is a rapidly-growing demand for their services due to new and emerging treatments for eye diseases.

The school vision screening programme in Walsall follows the National Screening Committee’s (NSC) recommended vision screening programme of children and there is no evidence to suggest changing this service.

A pilot of a Community Based Ophthalmology Triage service for a cluster of GP practices in Walsall, judged on cost effectivity, was deemed not to be viable in its current format and will cease in April 2014.

There is significant under reporting of sight impaired(SSI) and severely sight impaired(SI) patients in Walsall which has 760 people on the SSI register, 845 on the SI register. Based on the information provided by Walsall Society for the Blind (WSftB), the “preventable sight loss” indicator for Walsall was 59% for 2011 and 67% for 2012 indicating a worsening outcome.

There is currently no Low Vision Services Committee (LVSC) to develop and oversee the provision of low vision services in Walsall.

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A survey of 4,000 adults in the UK commissioned by the College of Optometrists in 2012 found that the public are not well-versed about eye health.

Key Recommendations

1. Educate local people about eye care and encourage at risk groups to have regular eye tests with an Optometrist.

2. Review access to optometry to ensure that older people in Walsall who are at risk from sight loss are able to get easy access to regular sight tests.

3. Ensure that children and young people who are identified as having special educational needs (SEN) or learning difficulties have a routine sight test once a year.

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