Where have all the old folks gone? A report on access and uptake of NHS sight tests in the over 60s

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1 Where have all the old folks gone? A report on access and uptake of NHS sight tests in the over 60s Abstract Aim: Visual impairment affects people of all ages, but its prevalence increases with age. The aim of this initiative was to better understand the uptake of NHS sight tests in Walsall in the over 60s age group. Methods: The following data were analysed: i) NHS sight tests for England and Walsall Healthcare NHS Trust; ii) ophthalmic manpower in England and Walsall from April 2008 to March 2013; iii) the location of practices in the borough of Walsall. Results: We noted a steady increase in the uptake of NHS sight tests (9%) and domiciliary sight tests (17%) in England from April 2008 to March In Walsall, the uptake of NHS sight tests was marginally lower for the same period (8%), but showed an increase of 11.7% in domiciliary sight tests. There was a significant reduction in the uptake of NHS sight tests from the over 60s in Walsall, from 42.58% in 2008/09 to 23% in 2012/13. This in contrast to a steady uptake of about 44% over the same period in England for the same age group. We noted fewer practitioners per population in Walsall compared with the national picture and a neighbouring statistically equivalent primary care trust. Fewer practices are located in the east of the borough and outside the inner ring road, and considerable areas of Walsall are not within a 15-minute walking distance of an optometric practice a significant factor for attenuation of attendance. Conclusions: There has been a substantial decrease in the uptake of NHS sight tests in the over 60s in Walsall over a five-year period. The low uptake of sight tests among older people is a major shortcoming of present arrangements at meeting the eye health needs of Walsall residents. This is exacerbated by a lower than national average of ophthalmic practitioners per population in Walsall. Nizar K Hirji, optometrist consultant, Hirji Associates, UK and visiting research fellow, Academic Unit of Public Health, Faculty of Medicine and Health Sciences, University of Leeds, UK Paulette Myers, consultant in public health medicine and associate director of public health, Walsall Council, UK Visual impairment affects people of all ages, but its prevalence increases with age. In the UK, the NHS General Ophthalmic Services (GOS) provide government-funded sight tests through community optometrists to eligible groups of the population, including those aged 60 years or more. Despite this, older people in the UK do not necessarily take up their entitlement of a regular eye exam and 7 34% of older people may well be living with correctable visual impairment (Evans and Rowlands, 2004). Visual impairment is defined as existing when the level of vision is below that which the individual requires to perform everyday tasks and has a significant impact on quality of life (Klesert and Chang, 2005). The risk of having an unintentional injury is higher for people who are visually impaired compared with the fully sighted population (Legood et al, 2002). Visual impairment is commonly associated with: Falls Hip fractures (Ivers et al, 1998) Depression (Evans et al, 2007) A higher risk of suicide (Waern et al, 2002). The evidence on falls, which relates mainly to older people, 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. The odds of a hip fracture are between times greater for people with visual impairment (Legood et al, 2002). The Ethical Strategies (2003) study identified annual cost estimates associated with vision impairment in the elderly population at 4980 per person. Assuming at least 50% of this cost is from falls treated under the NHS and from the cost of residential care, which is shared between the NHS and local authorities, estimated annual future savings are 2490 per person per year. Approximately 17% of visual impairment in the over 65s (Reidy et al, 1998) and 30% in the over 75s (Evans et al, 2002) was found to be due to uncorrected refractive errors. Reidy et al (1998) reported that 73% of the over 65s had not visited an optometrist within the past 12 months despite their visual impairment. The Memorandum of Understanding between the Department of Health (DH) and the optometric profession recommends that those with low-risk aged 16 to 70 years should have an eye test every two years, and those over 70 years should attend for eye tests annually (DH et al, 2002). However, it is accepted that patients with diabetes and those with a family history of glaucoma who are aged 40 years and over should have an eye test every year; in addition, patients who have a clinical need should be examined more frequently. The Royal National Institute of Blind People (RNIB) (2007) recommends an annual eye exam for everyone over 60 years, which, under the current NHS eligibility rules, would be paid for by the NHS only if clinically necessary. The aim of this study was to better understand the provision and uptake of NHS sight tests by the over 60s population in Walsall. 225 Vol 5 No 6 December 2014/January 2015 International Journal of Ophthalmic Practice

2 Methods Activity data on NHS sight tests in England and Walsall Healthcare NHS Trust, as well as data on ophthalmic manpower in England and Walsall from April 2008 to March 2013 were analysed (Health and Social Care Information Centre (HSCIC), 2014a; 2014b). The locations of local optometric practices relative to a heat map of the residential density of the over 60s population in Walsall was mapped. Results Uptake of sight tests Results show that, from April 2008 to March 2013, there has been a steady increase in the uptake of both NHS sight tests (9%), under the mandatory contract, and domiciliary sight tests (17%), which account for about 3% of the total sight tests carried out under the GOS additional services contract. This may partly be explained by the greater incentive now provided on fees claimable from the NHS for domiciliary sight-testing services, which has led to specialist domiciliary firms emerging to provide this service (HSCIC, 2014a) (Figure 1). There was an 8% increase in the total uptake of NHS sight tests conducted in Walsall from April 2008 to March 2013 (marginally below the national average for the same period), with a peak in 2011/12 when social marketing activity to promote eye health was undertaken by the Communications Department of Walsall Healthcare NHS Trust and the principle author of this article. There was an 11.7% increase in the uptake of domiciliary sight tests in Walsall over the same period, which was considerably lower than the national average, suggesting there may be insufficient provision of such services for local residents. In Walsall, NHS domiciliary sight tests account for about 2.9% of the total number of NHS sight tests (Figure 2). We also found a reduction in the uptake of NHS sight tests in the over 60s in Walsall, from 42.58% in 2008/09 to 23% in 2012/13 (Figure 3). This compares with a steady uptake of about 44% over the same period nationally for the same age group (Figure 4). As NHS sight tests are funded by the Government, only one factor of eligibility (i.e. age) is normally taken into account and it is possible that patients aged 60 years and over may have been previously recorded as eligible for an NHS sight test under another category. This may account for shifting in terms of patient categorisation, but the change over the past five years is too substantial to be explained simply as a re-categorisation issue. This data is confounded by the possibility that some over 60s who may have attended for sight tests outside the borough are now deceased; a less likely possibility /09 Figure 1. NHS sight tests and domiciliary sight tests in England, /09 Number of NHS sight tests and domiciliary sight tests in England, / /11 Figure 2. NHS sight tests and domiciliary sight tests in Walsall, is that they may have elected to pay for their sight test privately. The low uptake of sight tests among older people in Walsall is a major shortcoming of present arrangements at meeting the eye health needs of Walsall residents. Ophthalmic manpower As shown in Figure 5, there are fewer practitioners per population in Walsall compared with the national picture and a neighbouring statistically equivalent primary care trust (Dudley). Eye health service coverage Figure 6 illustrates the poor coverage of sighttesting services for older people in Walsall, where a substantial number of the population live further than the 800-metre attendance attenuation threshold / /13 Mandatory sight tests 1000 Domiciliary sight tests 1000 Number of NHS sight tests and domiciliary sight tests in Walsall, / / /12 Mandatory sight tests Domiciliary sight tests /13 International Journal of Ophthalmic Practice Vol 5 No 6 December 2014/January

3 100% 90% 80% 70% 60% 50% 40% Distribution of NHS sight tests for eligible categories in England 5.2% 0.7% 5.4% % % 5% 3% 9% 4% 2 5% 3% 9% 5% 2 7% 2% 8% 4% 20% 7% 3% 9% 4% 19% Close relatives of people with glaucoma aged 40 years People who need complex lenses People with glaucoma or diabetes Registered as blind or partially sighted Low income certificate holders Jobseeksers Allowance tax credits income support found by Simmons (2009). Not enough practices are located in the east of the borough, outside the inner ring road, where the majority of the older population live, and considerable areas are not within a 15-minute walking distance to the optometric practice; this is denoted by the areas circled in Figure 6, which indicate a 15-minute (i.e. 800-metre) walking radius to the optometric practice. Discussion Location of service providers The current GOS mandatory contract to provide sight tests in primary care settings does not take into account the location of the provider with respect to the need for ophthalmic services at the location in question, nor the ease of access to the services for the local population, save for the requirement of compliance with all relevant legislation and [...] regard to all relevant guidance issued by the Board or the Secretary of State, which would cover disability access provisions (Association of Optometrists, 2013). At present, the contract encourages locating practices that provide GOS sight-testing services in commercial settings, which may not necessarily be where the need for sight testing is (i.e. the most visually vulnerable and the older patient). The actual GOS sight testing has paradoxically become a loss leader because of the underpayment of sight tests under the auspices of the NHS, which is then recouped by sales of spectacles, as evidenced by the disproportionately high levels of product-orientated promotional activity in the industry. 30% 20% 10% 0% 44.5% 44% 44% 45% 2008/ / / / /13 Figure 3. Distribution of NHS sight tests for eligible categories in England, % Students, age years Children, age 0 15 years Older adults, age 60 years Barriers to accessing sight tests Barriers to accessing sight tests by the general population include (RNIB, 2007): Lack of knowledge of entitlement and access to NHS sight tests Failure to recognise the importance of regular eye tests for combating eye disease Transport restrictions Concerns about the cost of glasses and/or prescriptions Fear of complications The cost of eye tests for those who do not receive free eye care services The Black and minority ethnic population faces additional barriers to accessing eye tests. These include (Johnson and Morjaria-Keval, 2007): A tendency to be more remote from statutory services and less well connected to mainstream service providers Language needs, such as interpretation, translation and information in community languages. 227 Vol 5 No 6 December 2014/January 2015 International Journal of Ophthalmic Practice

4 Hirji and Marsden (2012) found that older patients in Dudley were reluctant to attend eye examinations due to: A tacit acceptance that sight failure was a part of growing old Poor understanding of the range of conditions that can be discovered from the sight test The cost of spectacles. More recently, Shickle and Griffin s (2014) study in Leeds with participants mostly over 60 years confirmed much of what has been published about the barriers to attending for sight tests. In addition, they found that: Patients felt very vulnerable about getting the tests wrong and looking foolish Wearing spectacles was associated with appearing old and frail Many mistrusted optometrists Many had experienced hard sell techniques. The findings of this study suggest there is an urgent need for the effective social marketing of eye health and NHS sight tests to older people. A review of access to optometry for older people, including a more detailed survey of current locations of optometric practices, their opening hours, the services they provide, and the provision of domiciliary sight-testing services, is essential and should be key in deciding whether to award GOS sight-testing contracts or indeed renew current ones. There is a need to create opportunities for GOS sight-testing services to be provided in non-retail locations (e.g. general practices) and for mobile optometry service providers to provide GOS sighttesting services in settings and locations that do not currently have easy access to optometry services. It would not be out of place to suggest that Public Health England could consider incentivising potential optometry contractors to open optometry practices in locations that currently have poor or limited access to optometric services, or only authorising GOS contracts to optometric practices based on an independent eye health needs assessment of the area. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Distribution of NHS sight tests for eligible cagetgories in Walsall 3.74% 5.84% 2.54% % 4.42% % 4.45% 6.95% 14.12% 3.63% 21.0% 34.75% 4.34% % 8.23% 16.75% 5.22% 20.94% % 15.13% 5.18% 9.19% 18.24% 4.42% 18.94% 20.32% 6.33% 10.27% 5.84% % 19.55% 23.0% 2008/ / / / /13 Prisoners on leave Close relatives of people with glaucoma aged 40 years People who need complex lenses People with glaucoma or diabetes Registered as blind or partially sighted Low income certificate holders Jobseekers Allowance tax credits income support Students, age years Children, age 0 15 years Older adults, age 60 years Figure 4. Distribution of NHS sight tests for eligible categories in Walsall, Conclusions There has been a reduction in the over 60s taking up GOS sight tests in Walsall over a five-year period. The low uptake of sight tests among older people in Walsall is a major shortcoming of present arrangements at meeting the eye health needs of Walsall residents. This is exacerbated by a lower than national average of ophthalmic practitioners per population in Walsall. This study found that the provision of GOS sight tests in the borough of Walsall is inadequate, particularly for people aged 60 years and over. At present, there are insufficient numbers of ophthalmic practitioners in Walsall. Optometric practices are not located within easy access of older people, and there may well be inadequate provision of domiciliary sight-testing services as well. IJOP Conflict of interest: none declared. International Journal of Ophthalmic Practice Vol 5 No 6 December 2014/January

5 Ophthalmic practitioners per population, Number of practitioners (per ) Year Dudley England Walsall Figure 5. Ophthalmic practitioners per population, From: Health and Social Care Information Centre, 2014b Figure 6. Location of NHS sight test contractors relative to the over 60s population in Walsall From: Walsall Council, 2014 References Association of Optometrists (2013) GOS Contract. aop.org.uk/regulation/gos-england/gos-contract (accessed 5 December 2014) Department of Health, Association of Optometrists, Federation of Ophthalmic and Dispensing Opticians (2002) Memorandum of Understanding: Frequency of GOS Sight Tests. (accessed 5 December 2014) Ethical Strategies (2003) The Costs of Blindness. An Analysis of the Costs of Visual Impairment and Blindness in the United Kingdom. php?id=35#894 (accessed 5 December 2014) Evans JR, Fletcher AE, Wormald RP et al (2002) Prevalence of visual impairment in people aged 75 years and 229 Vol 5 No 6 December 2014/January 2015 International Journal of Ophthalmic Practice

6 older in Britain: results from the MRC trial of assessment and management of older people in the community. Br J Ophthalmol 86(7): Evans BJ, Rowlands G (2004) Correctable visual impairment in older people: a major unmet need. Ophthalmic Physiol Opt 24(3): Evans JR, Fletcher AE, Wormald RP (2007) Depression and anxiety in visually impaired older people. Ophthalmology 114(2): Health and Social Care Information Centre (2014a) General Ophthalmic Services, Activity Statistics 2013/14. ly/1wcanpi (accessed 5 December 2014) Health and Social Care Information Centre (2014b) General Ophthalmic Services, Workforce Statistics, England and Wales. (accessed 5 December 2014) Hirji NK, Marsden, R (2012) Social Marketing Better Vision for Better Health. (accessed 5 December 2014) Ivers RQ, Cumming RG, Mitchell P, Attebo K (1998) Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Am Geriatr Soc 46(1): Johnson MRD, Morjaria-Keval A (2007) Ethnicity, sight loss and invisibility. Br J Vis Impair 25(1): Klesert TR, Chang T (2005) Quality of Life in Age-Related Macular Degeneration: Effect of Treatment on Quality of Life in AMD. (accessed 5 December 2014) Legood R, Scuffham P, Cryer C (2002) Are we blind to injuries in the visually impaired? A review of the literature. Inj Prev 8(2): doi: /ip Reidy A, Minassian DC, Vafidis G et al (1998) Prevalence of serious eye disease and visual impairment in a north London population: population based, cross sectional study. BMJ 316: Royal National Institute of Blind People (2007) Older People and Eye Tests. (accessed 5 December 2014) Shickle D, Griffin M (2014) Why don t older adults in England go to have their eyes examined? Ophthalmic Physiol Opt 34(1): doi: /opo Simmons M (2009) Care Needs Assessment: Eye Health Findings and Recommendations. Public Health Action Support Key points Visual impairment affects people of all ages, but its prevalence increases with age. Despite this, older people in the UK do not necessarily take up their entitlement of a regular eye examination and 7 34% of older people may be living with correctable visual impairment The low uptake of sight tests among older people in Walsall is a major shortcoming of present arrangements at meeting the eye health needs of Walsall residents There is an urgent need for effective social marketing of eye health and NHS General Ophthalmic Services (GOS) sight tests to older people A review of access to optometry for older people, including a more detailed survey of current locations of optometric practices, their opening hours, the services they provide, and the provision of domiciliary sight-testing services, is essential and should be key in deciding whether to award GOS sight-testing contracts or renew current ones There is a need to create opportunities for GOS sight-testing services to be provided in non-retail locations (e.g. general practices) and for mobile optometry service providers to provide GOS sight-testing services in settings and locations that do not currently have easy access to optometry services. Sight test Access Eye care Over 60s Team CIC, Buckinghamshire Waern M, Rubenowitz E, Runeson B, Skoog I, Wilhelmson K, Allebeck P (2002) Burden of illness and suicide in elderly people: case-control study. BMJ 324(7350): Walsall Council (2014) Eye Health Needs Assessment Walsall. (accessed 5 December 2014) Call for Reviewers The International Journal of Ophthalmic Practice is looking for experienced clinicians and academics to join its pool of dedicated volunteer peer-reviewers. If you would like to be considered, please contact the editor in the first instance with a brief CV and details of your particular areas of expertise or interest. Guidelines for reviewers are available. the editor: lee-mey.goh@markallengroup.com Website: International Journal of Ophthalmic Practice Vol 5 No 6 December 2014/January