RNIB supporting blind and partially sighted people
Research briefing
Low Vision Service Model Evaluation
(LOVSME) Project
February 2011
Introduction
Research indicates that there are currently significant problems of
poor co-ordination between eye clinics, low vision services and
rehabilitation services, inadequacies in the assessment of people
with recent sight loss and failure to address the emotional impact
of visual impairment. Due to fragmentation in service delivery there
has been an emphasis in recent years on development of new and
existing services which prioritise multi-disciplinary working.
However there remains a problem over definition of such services
– some services may be termed ‘integrated’ simply by virtue of
locating clinical and social services on the same site, while others
take a much more holistic and person-centred understanding of the
term.
This research, carried out by researchers from the universities of
Cardiff, Manchester, Aston and Bangor with Moorfields, Royal
Victoria Eye and Manchester Royal Eye Hospitals plus Fife Society
for the Blind, on behalf of RNIB, aimed to investigate the benefits
for people with visual impairment of an integrated low vision and
rehabilitation pathway, and to determine whether this integrated
approach has additional benefits for users, when compared to
standard low vision and rehabilitation care.
Method
a. A systematic Review of the evidence of both integrated and
standard low vision and rehabilitation services on patient
outcomes
This included a review of existing literature on models of low vision
and rehabilitation in sight loss and the impact on patient outcomes
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of integrated low vision and rehabilitation services, published in
peer reviewed journals in the UK and internationally.
b. Identification and review of examples of standard
and integrated low vision and rehabilitation services
in order to identify optimum models - profiling low
vision services
The LOVSME group selected seven low vision services to take
part in a service profiling exercise. The models evaluated were
chosen for their diversity: included were two “integrated” or “one
stop shop” services; two hospital services staffed by optometrists;
a hospital service staffed by orthoptists and nurses; a commercial
provider; and a Social Services provider. The services were all
based in England, although they were well-spread geographically
and varied in the nature of their catchment areas. Information
about the services was gathered in advance using questionnaires.
A comprehensive list was compiled of all the descriptors required
to profile the service, based on criteria that were developed to
respond to the needs of people with a visual impairment (Low
Vision Service Consensus Group, 1999; NHS Recommended
Standards for Low Vision Services, 2007). These included
methods of access, catchment areas, waiting times, the
professionals involved and staffing levels, intensity and duration of
service, level of integration, referral pathways to other agencies,
pathways for special populations and the audit tools/outcome
measures in use.
Two members of the LOVSME team visited each of the
participating services, met with the “lead provider” and as many as
possible of the individuals who had completed questionnaires.
Providers also identified areas of best practice within their service,
and described any challenges which they faced.
c. Development of a research protocol for an
evaluation of an integrated low vision and
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rehabilitation service - Low Vision Assessment
Framework
The LOVESME group reviewed the recommendations of Low
Vision Services Consensus Group (1999), the recommendations of
the Low Vision Working Group (2007), and drew lessons from the
review of the peer reviewed literature and visits to a wide variety of
contemporary low vision services as part of this research to
develop a framework to help service providers evaluate different
aspects of their service, identify any ‘gaps’ in existing service
provision and act as a starting point for future service
development.
Key messages from the systematic review of
low vision services outcomes
There is a lack of high quality evidence to support the
effectiveness of low vision service provision. The majority of
studies use a relatively weak ‘before and after’ comparison
design, many do not provide a full description of the intervention
studied and results are not always reported in full. There has
been little agreement about how best to measure outcomes and
this frustrates study comparisons.
Low vision aids improve reading ability and are valued by
service users.
Well resourced rehabilitation programmes (e.g. Veterans
Affairs programmes in USA) can produce large improvements in
‘functional ability’ but there is no evidence that they improve
‘generic health related quality-of-life’.
There is contradictory evidence about the ability of services to
improve ‘vision related quality-of-life’.
Despite several reports of small improvements in mood
following low vision rehabilitation there is no evidence that even
the well resourced Veterans Affairs programme can reduce
depressive symptoms in its client group. However, other types of
programme such as “Independent Living Programmes” and
“Adaptive Skills Training” may help people ‘adjust’ to vision loss.
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There is no evidence that ‘enhanced’ services are better at
improving ‘vision related quality of life’ than ‘standard’ hospital
based services in the UK.
There is no evidence that ‘multidisciplinary services’ are better
at improving vision related quality of life than ‘optometric
services’ in Holland, however there is evidence that a ‘group
based health education programme’ is more effective than an
‘individual intervention’.
There is some evidence that rehabilitation outcomes peak at
around 2-3 months and decline thereafter but this is not a
universal finding.
There is some evidence that rehabilitation outcomes are better
following more intense rehabilitation programmes but, the
optimum ‘dose’ has not yet been established.
There is very little information about rehabilitation outcomes in
children and none about outcomes in those of ‘working age’ and
in minority groups.
Only 2 studies are directly relevant to the cost of low vision
rehabilitation but it is not possible to conclude that the
programmes studied were cost effective.
Key messages from the profiling of low vision
services
 Although guidelines have been published detailing the desirable
characteristics of a comprehensive service, there is currently no
standard model of delivery in the UK. Low vision rehabilitation is
delivered by a wide variety of providers using different
strategies to operate at the interface between the health, social
care and the voluntary sectors.
 Typical staffing requirements to carry out low vision
assessments appears to be 1 full time equivalent (FTE) staff
member per 1200 appointments; typical Social Services
provision is 1 FTE per 100 new service users (SU) per year.
Additional services such as counselling obviously require extra
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staff, and there is also a requirement for administrative and
clerical assistance.
 The key cost drivers across all types of low vision service
model provision are in staffing and in equipment for people
with low vision. The report gives estimates of the costs of the
service models currently operating in the UK and estimates
the cost per service user consultation, noting that the annual
number of service users seen ranged from 450 in an
integrated service to 1600 in a hospital service. Further
research is required to ascertain the cost effectiveness of the
different types of service model to deliver the best outcome
for people with low vision. The sustainability of funding
remains a key concern for all providers.
 Although auditing procedures are in place in all services, this
consists of a simple internal audit of service user numbers,
sometimes broken down by category. All providers obtained
some form of feedback from service user groups, and
several had evidence of having used it to change their
procedures. In terms of clinical audit of effectiveness, only
one service routinely collected quality of life data, but these
had not been published and it was unclear how they was
used.
Of the services profiled, none fulfilled all the desirable criteria of a
comprehensive service, although the significance of these
apparent weaknesses is unknown because objective assessments
of the effectiveness of different service delivery models are not
currently available. Two features which have been considered
important in setting up new services (the ability of patients to refer
themselves back to the service at any time; and the location of a
service at a single site) are seen to have disadvantages as well as
advantages. Several services which use a multi-agency approach
appear to have risen to the challenge of working together in
imaginative ways to provide continuity of care.
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Key messages about the Low Vision
Assessment Framework
This Low Vision Services Assessment Framework tool was
developed to support service providers to evaluate their service
and assess the quality of care offered. There are 15 sets of
questions that cover key aspects of low vision service provision.
Each question can be completed with a simple ‘yes’ or ‘no’ but
service providers are encouraged to expand on the answer under
the comments banner provided. There is no ‘pass mark’ for the
Framework and it is assumed that all individual questions are
equally important. The aim is simply to promote discussion about
whether and where there are areas for improvement and how this
might be achieved.
It could be used to demonstrate the value and worth of a service to
relevant commissioners or funding bodies, and to promote
discussion about whether and where there are areas for
improvement and how this might be achieved.
Conclusion
Robust research methods and high quality reporting are
necessary to advance our understanding of how rehabilitation
services can best help people with a visual impairment.
Copies of the full reports and the framework may be obtained
from RNIB at:
http://www.rnib.org.uk/aboutus/Research/reports/earlyreach/Pages
/LOVESME.aspx
RNIB has since undertaken further work to pilot and refine the
tool and we are publicising this framework as the Low Vision
Services Self Assessment tool, encouraging services to use it
promote good practice. This is available at:
http://www.rnib.org.uk/professionals/healthsocialcare/Pages/low_vi
sion_assessment_framework.aspx
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For more information visit rnib.org.uk/research
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