Transcript A vision of the future - Northern Ireland Department of

Professor Frank Kee
UKCRC Centre of Excellence for Public Health
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Demographic context
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The case for change
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New ways of working
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Charting a path
Confidence
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RNIB estimates that two million people in
UK have significant sight loss.
Half is preventable or due to treatable
causes
There will be rising numbers of
older….whose lives we can make better !
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Population ageing is a
sign of success
Ageing is becoming a
central focus of
governments
In the UK people aged
60+ outnumber those
aged less than 16
N.I population is
younger than other UK
regions but this is set to
change
Figure 1. N.I. Population Projections 2009 - 2056
450
400
350
300
Population in 1000s
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250
2009
2031
2056
200
150
100
50
0
0-14
15-29
30-44
45-59
Age band
60-74
75+
350
300
250
200
60 - 74
150
75 and over
100
50
Year
2030
2028
2026
2024
2022
2020
2018
2016
2014
2012
2010
0
2008
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Figure 2. Predicted Population Growth for those aged
over 60 NI (2006 - 2031)
2006
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By 2025 number of
people aged 60+ will
increase by 37%.
Number aged 75+
expected to increase
by 61%
By 2031 more than
25% of the NI
population will be
over 60.
Population (in 1000s))
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“the number of people who are visually
impaired will double in the next twenty years
just as an effect of the ageing population”
(Taylor & Keefe, 2001)
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Increased mortality
Increased morbidity / falls / fractures
Increased road accidents
Increased anxiety & depression
Poorer self care & independence
Greater need for community & institutional
resources
Social isolation - quality of life
Loss of income
The mere knowledge of a fact is pale; but when you come
to realize a fact, it takes on colour. It is all the difference
of hearing of a man being stabbed to the heart and seeing
it done.
Mark Twain
A Connecticut Yankee in King Arthur’s Court
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Prevalence of obesity has
reached epidemic
proportions in many
countries
Obesity has major impact
on overall health
Obesity has been linked
to age-related cataract,
glaucoma, age-related
maculopathy and
diabetic retinopathy
Blindness: Vision 2020 - The Global
Initiative for the Elimination of Avoidable Blindness
•disease prevention and control
•training of personnel
•strengthening of the existing eye
care infrastructure
•use of appropriate and affordable
technology
•mobilisation of resources
•
Launched in April 2008
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Response to World Health
Resolution of 2003
Urges the design &
implementation of
plans to tackle vision
impairment
A united approach
across all relevant
sectors is key
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1.
2.
3.
Strategy outcomes
Improve the eye health
of the people of the UK
Eliminate avoidable
sight loss & deliver
support for people
with sight loss
Inclusion, participation
& independence for
people with sight loss

Fair & equitable access
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Person centred
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Evidence-based
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Awareness of & respect
for people with sight
loss & compliance with
equality legislation.
•
•
RNIB estimate total UK costs at £4.9 billion per year.
Economic burden associated with sight loss similar
to Cancer, Dementia and Arthritis
(Frick & Kymes, 2006)
•
Australian study estimates that vision disorders cost
an estimated 0.6% of GDP and every $1 spent on eye
care can bring a $5 return to the community
( Taylor et al, 2006)
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RNIB estimate approximately 980,000
people in UK have certifiable sight loss.
Main causes are
 Age related Macular Degeneration
(AMD)
 Glaucoma
 Diabetic Retinopathy
 Cataract
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Make best use of available
resources
Have fewer steps for the user
Make more effective use of
professional resource
Drive up standards of
clinical care to ensure good
outcomes
Improve access and deliver
greater patient choice
Evidence based
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Integrated eye care services
•Care for all in accessible settings
Better use of skills in primary
care
•Increased role for professional groups
in primary care
 To
develop proposals for the
modernisation of NHS eye care services
in England and Wales.
 first priority to develop model
pathways for:
 cataract
 glaucoma
 low vision
 age related macular degeneration
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Set up by the Department of Health in 2002,
with representatives of:
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ophthalmologists
optometrists and dispensing opticians
primary care
orthoptists
ophthalmic nurses
patient organisations
health, social care & policy organisations
Do disciplines even want to see eye to eye ?
1.
2.
3.
4.
5.
6.
7.
8.
9.
Patient reports sight problem to GP
Patient goes to optometrist/OMP for
sight test and optometrist/OMP refers
patient to GP
Patient goes to GP, referred to HES
Patient seen at HES, cataract
confirmed, decision to operate, and
put on waiting list
Patient attends HES for pre-op
assessment
Patient attends HES for day case
surgery
Patient attends HES for 24 hr check
Patient attends HES for 6 week check,
2nd eye discussed
Patient attends optometrist for sight
test and new specs.
Start
Finish
1. Patient attends optometrist
•Sight test, cataract diagnosed and discussed
•General risks and benefits of surgery discussed
•Patient wishes to proceed, information given etc
•Patient offered choice of hospital and appointment agreed
2. Patient attends HES
•Outpatient appointment with
ophthalmologist*
•pre-assessment (with nurse?)
•Date for surgery arranged/agreed
(* details of medication etc
received from optometrist, GP or
patient as per local protocols )
4. Patient attends HES
or Optometrist
•Final check
•Sight test
•Discharged or
nd
2 eye discussed and
appointment arranged
3. Patient attends HES
•Day case surgery undertaken
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Single screening
opportunity by
community optometrists
with no standardised
protocols
Diagnosis and continued
care for life of all
glaucoma (and many
suspects) within Hospital
Eye Service by
ophthalmologists
Start
1. Patient attends community optometrist (CO)
•Sight test, IOP over 21 (applanation tonometry) and/or
visual field defect and/or excavated discs
•Patient/optometrist makes appointment with optometrist
with special interest in glaucoma (OSI) or OMP
2. Patient attends OSI or OMP
•Full history and assessment carried out according
to protocol
•Decision taken as to whether patient has ocular
hypertension (OSI/OMP reviews) or can be
discharged (return to CO) or has glaucoma (treat
or refer to HES)
•Patient advised, given information etc and further
appropriate appointments made if needed
4. OSI/OMP
manages patient in
community setting
•Regular reviews set in
place
•OSI/OMP relay data to
hospital if significant
progression for HES
review if needed
3. OSI/OMP relays data to HES
•HES reviews data, advises OSI/OMP
regarding management and sets up
review at HES if needed
“The
futility of isolated initiatives…”
Foresight: 2007
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Researchers have discovered
several risk factors that
appear to be associated with
AMD:
 Age
 Cigarette Smoking
 Early Menopause
 Hypertension (high blood
pressure) and/or
cardiovascular disease
 A diet high in certain
vegetable fats, especially
those found in snack
foods like potato chips
 Prolonged sun exposure
 Heredity
 Race
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Burden recognised by government
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NSF for Older People
• Vision impairment is
an intrinsic risk factor for falls
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NICE: Recent guidance
on PDT for wet-AMD
In meeting future
demand, service
will have to respond to
increasing patient
numbers and delivering
new therapies
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Patient reports visual problem
GP refers patient to HES
OR
Patient is referred to an optometrist
AMD is diagnosed
Patient is referred to HES via GP
Fluorescein angiography carried out
Any credible treatment option considered
Patient managed by HES or by Low Vision Service
Patient registered
Referred for Social Service &
• Rehabilitation support
SELF
REFERRAL
REFERRED BY
ANOTHER CLINICIAN
OR CARER
OTHER SOURCE
PATIENT PRESENTS WITH VISUAL PROBLEM AND IS EXAMINED BY COMMUNITY
OPTOMETRIST IN TRIAGE CAPACITY – DIFFERENTIAL DIAGNOSIS
SYMPTOMS SUGGESTIVE OF ARMD
‘WET’ (NEOVASCULAR) OR
SUSPECTED ‘WET’
AMD
DIRECT REFERRAL TO HES
FOR FLUORESCEIN
AGIOGRAPHY AND
FURTHER INVESTIGATION
NOT
AMD
APPROPRIATE
CARE AS
INDICATED
‘DRY’ (NON-NEOVASCULAR)
AMD
OPTICAL / OPHTHALMIC
UNTREATABLE
LOW VISION SERVICES
COUNSELLING
SOCIAL SERVICE SUPPORT
TREATABLE
ACCESS TO TREATMENT
REHABILITATION
BD8/LV1 AS REQUIRED
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Fragmented
Wide variation re access &
quality
Referral from optometrist
(often via GP) to HES
Uni-disciplinary
Lack of information,
signposting & awareness
Long waiting times
Initiation of LV services
ONLY after
ophthalmological assessment
Start
4. Service enables re-access
1. Patient referred to Low Vision Service
(LVS)
•Referral may be from secondary care, GP, social worker,
rehabilitation officer, community nurse, OT etc or may
be self referral
•Patient may have an LVI, RVI or CVI
•All patients are contacted by LVS within 10 working
days
3. Patient has follow up
visits as needed
•Visits may take place in the
patient’s home or elsewhere
•Visit will be by appropriate
member of the LV team
2. Patient attends LVS
•Service is seamless across health, social care and the voluntary sector
•A full sight test forms part of assessment
•Patient is given information on eye condition, entitlements etc as well as local services
• Counselling and advice on employment or education is available
•Spectacles, LV aids, advice (esp. lighting, contrast and size) and home adaptations are
discussed and made available as appropriate
•Referral to other areas of health and social care as needed, including certification
All politics is local
Tip O’Neill
1912-1994
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Our population is
ageing
Increasing need and
demand for services
Primary care opthalmic
services, based on
partnerships, need to be
developed to meet
demand
Investment required
Existing services need
to be used effectively
BENEFITS FOR PATIENTS
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Better care
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BENEFITS FOR NHS
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Access to services
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Speed
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Convenience
Shorter waiting
times
Better use of skills
Better value for
money
“A growing number of the most vulnerable
people in this country experience a quality of
life that is significantly, but unnecessarily,
diminished for the want of basic, relatively
inexpensive health care”
(RNIB 1999)
“And should there be a sudden loss
of consciousness during this
meeting oxygen masks will drop
from the ceiling”