Eye health (health and wellbeing needs in South Tyneside)

In South Tyneside, as across England as a whole, growing numbers of people are living with sight loss or impairment. And this is likely to increase further as people live longer, since a good deal of vision impairment is related to the ageing process.

In South Tyneside we estimate that by 2020, about 5,700 people in the borough will be living with sight loss, which will be severe in more than 700 people.

About half of this vision impairment is preventable. In addition, many people in the borough have risk factors for eye disease which also contribute to other strategic priorities - for example smoking causes about 10% of eye disease and is a major contributor to cancer and cardiovascular disease; obesity is a risk factor for diabetes which in turn contributes to eye disease and cardiovascular disease.

However, advancing age is the single biggest risk factor for eye disease and the biggest driver of demand on secondary, tertiary, and voluntary care services.

Eye health as a public health priority

Indicator 4.12 of the Dept of Health Public Health Outcomes Framework (PHOF) confirms a commitment to reduce avoidable blindness that mirrors the Vision 20:20 UK aim of avoiding preventable blindness by the year 2020.

Improvements in indicators 2.24 (falls), 4.14 (hip fractures), 2.23 (self-reported wellbeing) and 14.13 (health related quality of life for older people) may also be assisted by improvements in eye health. It has been shown that visual impairment is a risk factor for falls in older people. People with visual impairment are more likely to be depressed and self-care for other systemic conditions is likely to be affected resulting in poorer health outcomes for these patients.

NHS Outcomes Framework

Two of the five overarching indicators in the NHS outcomes framework can also be directly and positively influenced by efficient eye care services:

• Number 2: Enhancing quality of life for people with long term conditions
• Number 3: Ensuring that people have a positive experience of care

At-risk populations

• The growing elderly population are by far and away at greatest risk of eye disease. For example, age-related macular degeneration alone accounts for almost half of diagnosed eye disease in South Tyneside.
• Smokers (around 19% of the adult population) are at increased risk of eye disease.
• People with a learning disability are also five times more likely than the general population to have an eye condition.
• In general, people who have multiple risk factors for cardiovascular disease are also likely to be at higher risk of eye problems as a result of hypertension, vascular degeneration and higher incidence of diabetes.

Current provision versus need

• Demand on eye care services is already rising and will continue to do so with the ageing population. Although use of outpatient services reduced slightly between 10 / 11 and 14 / 15, admissions for eye care increased by 42% over the same period.
• In particular, the number of admissions for age-related macular degeneration increased by 62%
• Uptake of sight tests overall, and in those aged over 60 is significantly lower than both the North East and England. In the under-16 age range it is significantly lower than England, and lower than the North East, although the latter doesn't reach statistical significance. This is of concern since sight tests are an important part of both primary prevention and early diagnosis treatment and secondary prevention.
• Secondary care services are of high quality and are very highly rated by both patients and referring clinicians, but many South Tyneside patients experience significant difficulty accessing Sunderland Eye Infirmary.
• There is strong support from service users, GPs and optometrists for more local provision of services, including the commissioning of a community-based minor eye care service.
• There is evidence within the EHNA report of a demand for greater community-based low vision service for South Tyneside.
• Diabetic Eye Services appear to be highly regarded, in particular the provision of a "one-stop" clinic where all annual care is provided in one appointment. Uptake of Diabetic Eye Screening is above acceptable levels and among the highest in the region.
• Rehabilitation and re-ablement services currently provided by Eye Care Liaison Officers (ECLOs) and by Sight Service are highly regarded by service users. However, many people have indicated that they feel there should be greater provision.
• Given the local demographic trends, prevalence of risk factors and limited uptake of eye tests, there needs to be a strong focus on prevention in the borough.

How well are assets being used to meet current needs?

This area needs systematic evaluation.

Are population needs likely to be met in the future?

It is projected that there will be a substantial rise in the number of people with visual impairment in South Tyneside - see section 2 below. In addition, the availability of new treatment options is likely to increase pressure on services. The capacity of the system to meet this increased demand, given the current fiscal pressures, must be in doubt.

If there are many concerns, which are the most important to address?

• Prevention is the biggest priority
• Accessibility of services, particularly in secondary care
• Minor Eye Care service provision was identified as a priority in itself and a potential way of reducing pressure on secondary care
• Mental and emotional wellbeing of people with impaired vision and their relatives

• Monitoring changes in hospital activity to predict future demand
• Ensuring access to services
• Systematic approach to prevention

Prevention is an absolutely key priority

• Risk factors for eye disease to be included in all relevant health promotion work
• A concerted effort should be made to establish the reasons for low uptake of eye test, and then to promote greater uptake in the under 16 and over 60 age groups.
• The CCG should provide specific training for GPs on eye disease prevention
• All stakeholders should stress the benefits of seeking assistance as soon as visual problems occur.

Rehabilitation and Re-ablement

• A low vision service would improve access to the kind of aids which allow people to regain a degree of independence.
• If someone loses sight through trauma resulting in a long hospital stay, they should be provided with re-ablement support while still in hospital.
• Adjusting to life with a visual impairment often involves a period of bereavement and people who are sight-impaired are at an increased risk of common mental health conditions such as anxiety or depression.
• Commissioners should ensure that there is an opportunity for patients to be referral into counselling where appropriate, at different stages in the care pathway.
• Services should meet needs of family and carers too and link people into third sector organisations that can provide ongoing support.

Eye care pathway

• It is recommended that a stakeholder workshop be convened, with service users, GPs, Optometrists, and Secondary Care clinicians to review and optimise current referral pathways, and to consider whether communication between clinicians in all areas of care can be improved.

Those at risk

Impact of risk factors and lifestyle on eye health

The Eye Health Needs Assessment includes details of how modifiable and non-modifiable factors may impact on the risk of eye conditions in individuals. These include age, socio-economic status, ethnicity, smoking, alcohol, and various conditions including learning disability, dementia, obesity, diabetes, stroke, and hypertension. Visual loss also increases the risk of falls, and depression (6).

Association of Eye Health with Other Co Morbidities

• 60% of stroke survivors have some residual visual dysfunction following a stroke.
• Uncontrolled high blood pressure can cause retinal damage
• Around 2.5% of people over the age of 75 will have dementia and significant sight loss
• Older people with sight loss are almost three times more likely to experience depression than people with good vision.
• Adults with learning disabilities are ten times more likely to be visually impaired than the general population. treatment, and to have developed visual impairment
• People with hearing loss are at increased risk of having undiagnosed eye conditions which lead to visual impairment
• People with visual loss are 1.7 times more likely to have a fall and 1.9 times more likely to have multiple falls. Of the total cost of treating all accidental falls in the UK, around 21% is spent on the population with visual impairment

Local Risk Factor Prevalence

Population

The population included in this HNA is the resident population of South Tyneside. ONS data population estimates and projections have been used to consider current and future trends in risk factor prevalence, epidemiology and demand for eye care services. South Tyneside, in 2014, had an estimated total population of 148,700, of which 28,800 were 65 years and over and 3,900 were 85 years and over. The total population of South Tyneside is forecast to grow at a much slower rate than the England population as a whole (a 4% projected increase between 2015 and 2030 compared to a 10% rise across England), but the population of older people will continue to grow at a much faster rate. The risk of experiencing eye health conditions increases with age and so it is the change in the size of the older population that will determine demand on eye health care services. Between 2015 and 2020 there it is forecast that there will be an 8% increase in the population 65 years and over in South Tyneside, and a 15% increase among those 85 years and over. Between 2015 and 2030 the equivalent growth will be 34% and 43% respectively.

Deprivation

There is a substantial amount of evidence which shows that people living in the most deprived areas have worse health and health indicators than those in the most affluent areas. People in deprived areas are likely to have a higher exposure to negative influences on health, and to lack resources to avoid their effects.

The 2015 Indices of Multiple Deprivation (IMD) list South Tyneside as the 23^rd most deprived local authority in England out of 326 local authorities. The borough has 102 small area geographies, 22 of which are ranked within the 10% most deprived in England. Moreover, 40% of the South Tyneside population lives within the most deprived fifth of all areas across England. The rankings are a compilation of indicators from 7 domains shown in the figure below.

Smoking

The proportion of adults that smoke in South Tyneside fell between 2012 and 2015 from 21.8% to 17.4%, whilst in routine and manual group smoking prevalence has fallen from 28.4% to 27.1% over the same period.

Diabetes, Physical Activity and Obesity in Adults

• In South Tyneside, 26% of adults were classed as obese and a further 42% were classed as overweight; this is higher than the England prevalence of 23% obese and 41% overweight (source: Active People Survey, 2012).
• Obesity is associated with a range of health problems including Type 2 Diabetes, which in turn increases risk of a range of eye conditions
• Recorded prevalence of diabetes in South Tyneside is 6.9% (around 8,780 persons aged 17 and over) compared to a prevalence of 6.2% in England

In 2014 there were 380 people registered as blind among the South Tyneside population[1] (0.51% of the total population compared to 0.49% in the North East and 0.53% across England). There were also 435 people registered as visually impaired (0.58% of the total population compared to 0.64% in the North East and 0.54% across England). However the total number experiencing some degree of sight loss is higher and is estimated by the RNIB to be 5,240 in South Tyneside in 2015, increasing by 10% to 5,740 in 2020 and by 32% to 6,900 by 2030[2]. This represents 3.5% of the population currently, rising to 4.5% in 2030. It is estimated that there are 56 children 0-16 years and 35 young people 17 - 25 years either blind or partially sighted[3]. In 2015 there were 28 pupils in South Tyneside schools with Special Educational Needs where the primary need was a visual impairment[4].

Table 1 below estimates the total number of people in the South Tyneside population living with more common long-term eye conditions and risk factors and projects the same numbers forward to the year 2020

Table 1. Estimated numbers living with specific eye conditions in South Tyneside (source: RNIB Sight Loss Data Tool v2.2, 2015)

Key data from the RNIB sight loss data tool estimate that in South Tyneside:

• There are 1,026 people of working age living with some degree of sight loss.
• 240 people of working age are registered blind or partially sighted.
• 220 blind and partially sighted people claimed Disability Living Allowance in 2013/14
• Since 2012 / 13, the number of people with a visual impairment that received adult social care went down by 41% . This compares to a 6% reduction across England
• 550 people over the age of 65 are registered blind or partially sighted.
• 344 people have dementia and significant sight loss
• 979 people are living with a degree of dual sensory loss, in 323 of whom it is severe
• 626 people with sight loss who are aged over 65 experience a fall each year. 49 of these cases result in a hospital admission.
• National data estimate that only one in four blind and partially sighted people of working age are in employment
• Given the projected rise in the prevalence of these conditions, and also the emergence of new treatment options, there is likely to be significant pressure on services by 2020.

The primary unmet needs that were identified by the South Tyneside Eye Health Needs Assessment were:

• Emotional wellbeing and mental health support
• Low vision service

See table 1.

Community assets were not mapped as part of the EHNA. Mapping of community assets in relation to eye health should be considered.

Clinical eye health care in South Tyneside is commissioned and provided in accordance with NICE guidance.

The CCG recently commissioned an evaluation of the case for providing minor eye care service in South Tyneside, which recommended the provision of such a service on both effectiveness and cost-effectiveness grounds.

A stakeholder workshop was held before the project started to consider what some of the issues might be. During the course of the EHNA, four surveys were carried out, both online and on paper, to gain the views of, respectively, service users, GPs, Optometrists and Opthalmologists. Sight Services also provided both one-to-one support and facilitated workshops to maximise engagement of people with sight loss in the needs assessment. The results are summarised below:

Service User Views

• Care at the Sunderland Eye Infirmary is rated as very good or excellent.
• Users value the provision of the voluntary sector very highly, and when asked, these are the services that are most important to them.
• The need for improved access to low vision services for South Tyneside was clearly expressed in the stakeholder forum, survey returns and focus groups. Gateshead seen as a good model
• Many service users and professionals in primary care cite the journey from South Tyneside to Sunderland as a serious problem for accessing care
• Loss of sight is a bereavement and there is not enough recognition of this, nor is there appropriate emotional wellbeing support
• There were mixed views amongst service users about how well services worked together, support for more local services and for more service integration was a common theme.

Professional Views

• GPs were able to identify the more medical risk factors, but there was a significant deficit in knowledge of lifestyle risk factors. GPs felt there was a need for more local provision of services.
• Optometrists also felt that more local provision of services were available, and that better information could be exchanged by health professionals.

Trends and patterns in Eye Care A&E attendances among the South Tyneside population. In particular, this work should seek to identify the number and proportion of attendances that it is considered could be treated within primary care, and how this proportion has changed over time in recent years.

The views of minority ethnic communities were not specifically sought in this EHNA. Given the likely high prevalence of diabetes in the minority ethnic communities within South Tyneside, this is an area where further assessment is needed.

[1] Health and Social Care Information Centre (2015) "Registered blind and partially sighted people, year ended 31 March 2014" available at NHS Digital: Registered Blind and Partially Sighted People (last accessed 28 October 2015)

[2] Royal National Institute for the Blind (2015) "RNIB Sight Loss Data Tool - Local Authority Report, South Tyneside" available at RNIB: Sight Loss Data Tool (last accessed 28 October 2015)

[3] Ibid.

[4] Department for Education (2015) GOV.UK: Special educational needs in England, January 2015 (last accessed 28 October 2015)

Last updated: December 2016