It took a bit of leg work, but Radhika Holmstrom was asked to find out what has happened since eye health was incorporated into the Public Health Outcomes Framework two years ago. The findings might surprise you especially when a Government body doesn’t even know the indicator comes under its remit.
In April 2013 to much acclaim from the sight loss sector, Public Health England’s (PHE) Public Health Outcomes Framework – then just over a year old – started to include an ‘eye health indicator’. Two years in, what impact has the indicator had?
The data for the indicator is gathered from certificates of vision impairment (CVIs), and collated at Moorfields. The overall figure of CVIs is logged, and also three ‘sub-indicators’, which are the main preventable forms of blindness at the moment: diabetic eye disease, diabetes, age-related macular degeneration and glaucoma.
The resulting figures are incorporated into the overall Public Health Outcomes Framework which PHE publishes as an ‘interactive data tool’, with the aim of being able to ‘aid understanding of public health in a local population’.
Until recently, this data has been extracted from work funded partly by RNIB. “The voluntary sector has been funding epidemiological analysis of certificates of vision impairment since 2001,” explains Dr Philippa Simkiss, Head of Evidence and Service Impact. “Guide Dogs and RNIB have supported this work because we recognise how vital it is to know how many people are going blind each year and why. Only by understanding the trends can we act to do something about it.”
Getting vision health onto the wider health agenda in this way took considerable effort on the part of the sector – notably UK Vision Strategy. “It’s a major coup for ophthalmology – the recognition that ocular health matters,” says Mary Shaw, who is on the UK Vision Strategy Leadership Group and also chairs the Royal College of Nursing Ophthalmic Nursing Forum.
However, Shaw adds, the indicator “is not on everyone’s radar. Ideally, it’s a way to get health bodies tacking eye health as a part of overall health, but I do worry what knowledge and understanding the clinical commissioning groups (CCGs) have of vision matters and the impact of vision impairment as a health problem.”
“It hasn’t really had time to have any effect,” says Carrie MacEwan, president of the Royal College of Ophthalmologists. “It is an indicator and therefore reflects what is happening rather than the other way round.”
That is not always the case: some bodies have used it effectively, explains Russell Young, chief executive of the International Glaucoma Association. “We’ve been able to present the data to the public health department of one local authority, demonstrating the need for the at-risk groups to have their eyes tested. We’re also using it to feed into the commissioning guidelines we’re developing for clinical commissioning groups.”
However, several bodies, including Public Health England, had no contribution to make on the topic (PHE was bound by electoral rules at the time of writing, but initially did not know that it was part of its own remit) – and there is a tendency still to regard this as a Vision 2020 initiative rather than a PHE responsibility.
The indicator’s data also reveals another issue, which concerns several people. There are wide variations between different regions and Richard Wormald, consultant ophthalmologist at Moorfields, points out that this is almost certainly because there is a wide variation in certification rates. A study published in the BMJ even before the indicator went live (for which both Wormald was co-author) revealed the wide disparities in different areas.
“I’ve been doing workshops and roadshows in eye clinics around the country, trying to explain that a CVI is first and foremost important for the patient, but also important from a public health perspective – that these are people losing their sight to what are in theory preventable conditions,” says Wormald. “I hope that we can reinforce the importance of knowing the outcomes (or at least having some idea on a regular basis). There is still an awful lot to do, in terms of raising awareness within public health. And we do have to work hard to improve the reliability of the data, so that we can really make valid comments about differences or change in rates.”
“There was debate at the outset as to what the indicator for sight loss should be, but the CVI has a ready understanding to all,” adds Dr Catey Bunce, senior statistician at Moorfields. “This is the number of patients whose vision has fallen below a certain level, whose ophthalmologists has recognised it and who have accepted the offer of registration. Not everyone who is blind will have a CVI, though, and it is possible that the indicator is not being used to its full potential because people fail to understand what it is. We need to make certification positive for people so that we have accurate figures.”
Everyone is keen that the indicator should be retained, despite the patchiness of the certification process. “It does need reliable, long-term funding,” adds Cathy Yelf, Chief Executive of the Macular Disease Society. “That means that it has a better chance of someone thinking about how it is implemented and taken up.” Simkiss agrees wholeheartedly. “The indicator must be maintained and it’s time that government, not charities, took responsibility for funding this work.”
Yelf and others also suggest that there is potential for extending the indicator’s criteria – in particular to include inheritable retinal disease, which is overtaking diabetes as a main cause of blindness in people of working age (though it is not ‘preventable’ in the same way as the other conditions). The main issue, though, is to keep using this as a mechanism for putting eye health on the broader public health agenda.
“I suspect the commissioners have so many other figures that they're not focusing on this. It's only just got out there and I think it needs to be embedded,” Bunce concludes. “We need to demonstrate its value. If it is publicised and people are made aware of it, it will start to be used.”