Adopting a public health approach to eye care: how the Public Health Outcomes Framework is a tool for positive change.

Abstract

Sight loss is a significant issue for public health. It affects approximately two million people in the UK, and this number of people living with sight loss will increase over the coming decade. One in five people aged 75 and over and one in two people aged 90 and over live with impaired vision in the UK, yet over 50% of sight loss can be avoided.1The Public Health Outcomes Framework (PHOF), introduced by the Department of Health in April 2013, focuses on two high level outcomes: (1) increased healthy life expectancy and (2) reducing differences between life expectancy and healthy life expectancy between communities. In this new system in England, Directors of Public Health and their teams moved from the National Health Service (NHS) to local authorities, one of the most significant changes to the public health system since 1974.In addition to these changes, for the first time, there is a responsibility on commissioners of public health to tackle sight loss in their local communities. The PHOF includes an indicator directed at preventable sight loss, putting eye health alongside priority issues such as dementia and obesity. The indicator tracks the total number of people certified as blind or partially sighted and the numbers certified according to the three major causes of preventable sight loss (see Box 1).BENEFITS TO PUBLIC HEALTH AND SOCIAL SERVICESThe PHOF preventable sight loss indicator is a real opportunity to improve eye care services at a population level. It provides Clinical Commissioning Groups (CCGs) in England with an opportunity to identify unmet need and address inequalities in provision, to create a more seamless pathway for patients and to improve the early detection and treatment of eye disease, central to the prevention of sight loss and blindness.There are strong links between sight loss and many public health priorities (see Box 2). Significant savings may be possible by reducing the complications of concomitant conditions resulting from the poor management of avoidable sight loss. NHS commissioners in England spent on average £40,900 per 1,000 head of population on problems with vision in 2010-2011.9 Improving eye health can improve performance against at least ten other indicators in the PHOF.10CERTIFICATION AND REGISTRATION: THE IMPORTANCE OF KNOWING THE DATAEffective public health interventions need reliable epidemiological data, so it is important that the numbers certified with sight loss, and subsequently registered with social services, are accurate and reflect the need at a local level. Accurate data will mean services and support are better planned, commissioned and delivered to meet actual need.The PHOF preventable sight loss indicator is based on the numbers of Certificates of Vision Impairment (CVI) issued in the 12-month period, from April to March. A CVI is completed by an ophthalmologist in the hospital, and a copy is sent to the patient's General Practitioner, the Certifications Office at Moorfields Eye Hospital - for national monitoring purposes and inclusion in the PHOF - and the patient's social services department.When social services receive the CVI, they contact the patient to offer a needs assessment and to formally register the patient as severely sight impaired (blind) or sight impaired (partially sighted). The register of blind and partially sighted people is voluntary; however, it is a precondition of certain financial benefits. Registration is not a prerequisite for all social services concessions, and this factor means that the number of people registered may underrepresent the number of people eligible for registration. The registration figures are collected on a triennial basis and are managed by the Information Centre for Health and Social Care. Certification and registration are, therefore, suitably different processes in the same patient journey and result in two sets of data.Certification rates differ widely in English Primary Care Trusts (PCTs), and there is an 11-fold difference between the highest and lowest rate. …