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A revolution in Welsh low vision service provision
  1. T H Margrain,
  2. B Ryan,
  3. J M Wild
  1. School of Optometry and Vision Sciences, Cardiff University, Cardiff CF10 3NB, UK
  1. Correspondence to: Tom H Margrain School of Optometry and Vision Sciences, Cardiff University, Cardiff CF10 3NB, UK; margrainthcardiff.ac.uk

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Failure of the service in Wales was perhaps best reflected in the inadequate number of low vision assessments

People in Wales with impaired vision have recently benefited from the arrival of a new nationwide community based low vision service. Undoubtedly, this is a dramatic and welcome development for all those with untreatable sight loss, not just those registered blind or partially sighted. But what has motivated the Welsh Assembly to take this radical step?

One reason is that visual impairment in Wales, like the rest of the United Kingdom, is reaching epidemic proportions. Since 1982, the number of people in the United Kingdom registered blind and partially sighted1 has almost doubled and now stands at 359 000.2–4 However, the registers are known to underestimate the number with untreatable sight loss by a factor of twofold to threefold and so there may be more than 1 000 000 people in the United Kingdom with untreatable low vision.5,6 This estimate is supported by a recent Medical Research Council trial that has established that one in five people over the age of 75 have a binocular visual acuity below 6/12.7 In many parts of Wales, the combined prevalence of registerable visual impairment (that is, both blind and partial sight registrations) now exceeds 2%.8 The magnitude of the problem will undoubtedly increase because most sight threatening eye disease is age related and the number of people aged 60 and over is projected to increase by 57% over the next 30 years.9

Another reason for the Welsh Assembly’s decision is that the cost of failure to provide an effective low vision service is high. Without appropriate rehabilitation, visual loss can have a devastating impact on the individual and is associated with depression, falls, and loss of independence.10 The cost to society is no less significant. A recent review of the costs associated with blindness has highlighted the scale of the economic impact of visual impairment and suggests that the annual UK bill for residential care, just for those on the blind register, is approximately £715 million.10

Thankfully, the impact of visual impairment can be reduced by an effective low vision service. Low vision services have traditionally operated at the interface between healthcare and social care involving ophthalmologists, optometrists, social workers, and rehabilitation workers. The service helps people with visual impairment to remain independent by providing low vision aids such as magnifiers, which optimise residual vision, and by appropriate rehabilitation training.11 Although many studies have shown low vision service provision to be beneficial in terms of functional ability and patient satisfaction12–17 the effect on quality of life is less clear—that is, while low vision service provision appears to improve some aspects of vision related quality of life (in particular, those that relate to near vision and reading) it does not improve all aspects.15,17 Furthermore, it appears that more complex services, involving supplementary home based low vision rehabilitation, are no better at improving vision related quality of life than conventional (hospital based) low vision rehabilitation.18

Access to the new service has been optimised by ensuring that services are geographically spread throughout Wales

In reality, however, there has never been a “low vision service.” Instead, there is a patchwork of services, excellent in some areas and woefully inadequate in others—that is, a true postcode lottery. A survey of low vision service provision in the United Kingdom in 1998 highlighted the fragmented nature of the service with differences in availability and accessibility and a lack of communication between healthcare and social care professionals.8 A review of services in 2001 showed that one of the main problems in Wales was service access.19 Like many other parts of the United Kingdom, access to low vision services in Wales was restricted by a convoluted referral route typically involving referral from an optometrist to a general practitioner to an ophthalmologist and, eventually, on to a low vision service provider, and then to social services. A survey of waiting times showed that in some parts of Wales people with low vision had to wait up to 18 months to access a low vision service.19 Access in Wales has also been restricted by the poor geographical distribution of services. People with a visual impairment, many of whom are elderly and with multiple disabilities, were frequently required to make a round trip of 100 miles or more, often on routes not served by public transport, to reach the nearest service provider. Failure of the service in Wales was perhaps best reflected in the inadequate number of low vision assessments. In 2000, there were only 4500 low vision assessments serving a visually impaired population of at least 55 000—that is, a single assessment for every 12 people who might benefit.19

In recognition of these factors, the National Assembly in Wales has taken the radical step of introducing a nationwide low vision service. The new service, which opened its doors in the summer of 2004, is based on the conventional hospital eye service model but is located in community based optometric practices and exists alongside established services in secondary care. It is staffed by accredited optometrists and a limited number of dispensing opticians, who have successfully passed a theoretical and practical course in low vision administered by Cardiff University, working in close association with ophthalmologists, social services, education, and the voluntary sector. Waiting times are expected to be less than 2 weeks. Low vision aids are provided on a loan basis and home visits are made where necessary. A ”vision passport” has been introduced which, like the “personal child health record,” promotes individual empowerment, provides information, and facilitates inter-agency communication. Access to the new service has been optimised by ensuring that services are geographically spread throughout Wales. Currently, 95 optometrists, nine dispensing opticians, and one ophthalmic medical practitioner have been accredited (about one quarter of the optometrists in Wales) and a further 120 are undergoing training or have shown an interest (contact details can be obtained from the corresponding author). It is estimated that low vision services are provided at 121 sites across Wales. Referrals into the service are accepted from general practitioners, ophthalmologists, optometrists, social services, and from individual patients themselves. Indeed, anyone whose visual acuity is 6/12 or less, N6 or less, or whose field is significantly restricted, may access the service.

The arrival of the first national low vision service in Wales is a welcome and, some would say, long overdue development. In all, 1166 people were seen by Christmas 2004; 87% were seen within 2 weeks and 95% within a month. With improved access and universal coverage, the service should enable everyone living in the Principality with impaired sight to continue to make best use of their sight. Of course, the service is being audited and the impact on those that use it will be evaluated. Evaluation of the effectiveness of visual rehabilitation is essential and funding for this evaluation has been built into the service. Even if the service is found to be effective in Wales it may not be the most appropriate model for all parts of the United Kingdom. Indeed, in Northern Ireland, 10 new outreach clinics have been established in secondary care,20 and in England four pilot services have been funded under the new Eye Care Pathways project,21 and 66 local low vision service committees have been set up. However, half a decade on from the publication of recommendations for future low vision service delivery,22 endorsed by the then secretary of state for health, many people with low vision in the United Kingdom are still not receiving low vision care. We hope that it is not too long before everyone with low vision in the United Kingdom can benefit from assured investment in these important services.

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Failure of the service in Wales was perhaps best reflected in the inadequate number of low vision assessments

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