Consultation on draft UK Vision Strategy
Comments from Jugnoo Rahi (November 2007)
I am very supportive of the idea of an inter-disciplinary national vision strategy for the UK, as this would be
critical to raising the profile of ophthalmic disease and vision impairment nationally and internationally. I had
rather expected that the draft strategy would ‘mirror’ National Service Frameworks and similar policy
documents - even though a formal NSF on Vision and Eye Disease is not being sought by DH. Indeed the
introductory paragraph of the draft sets out the purpose of the strategy as being to ‘establish a unified
framework for action on all issues relating to vision, across the UK and across all stakeholders’ (page 6).
I don’t think that the document, as it currently stands, delivers this.
Some specific thoughts are detailed below and I hope they will contribute positively to the re-drafting of the
document.
1. The document specifically focuses on Vision 2020 and thus on ‘avoidable’ visual impairment – which by
definition restricts its priorities to those diseases that are preventable or treatable with current knowledge.
Thus there is limited reference to the large number of people with diseases which are neither readily
preventable or treatable with current knowledge – which, for example, account for 75% of blind children
(Lancet 2003). Equally there is no reference to the very large number of people who have eye disease that
does not result in visual impairment - often because successful treatments exist. It is likely that these groups
represent the majority of people with ophthalmic conditions in the population using community and hospital
based ophthalmic, optometric and orthoptic services as well as relevant ‘non-health’ services and
resources. I wonder whether it is sensible to exclude certain groups of people with eye disease from a
document that sets universal standards of care and services.
I would suggest that the restricted scope of the strategy document is stated more explicitly at the outset
together with the intention to review ‘priorities’ every five years, in the light of emerging research, changing
population trends, and shifting resources and service provision. Or better still, in my view, would be to use
the consultation to establish whether a more broad-ranging strategy document is more appropriate and how
it could be achieved. I recognise this would be an even greater and equally under-resourced undertaking
but I am sure we all agree that the price of getting it wrong would be high and benefits of getting it right
could be great.
2. The document would be strengthened by more detailed reference to key extant policies and strategies.
For example, the National Service Framework for Children, Young People and Maternity Services and the
policies of relevant subgroups of the National Screening Committee (Fetal, Child and Maternal Health and
the Personal Child Health Record), set out national standards of care and services that children with
disabilities and specific diseases and their families should expect. Whilst they may not always specifically
mention visual problems it would be helpful to our cause to highlight key generic guidance.
3. I believe it is a serious strategic error to fail to separate out issues and priorities specific to children – to
simply ‘add on’ child-related priorities within other sections is rather counter to the prevailing approaches in
child health and adds to the impression that the strategy considers the needs of children with eye disease
have little in common with those of children with other disabilities.
4. I think it is inaccurate to suggest in the document that all relevant stakeholders were represented in its
preparation. For example in relation to priorities for children, I would have expected a community
paediatrician and a hospital paediatrician as well as an educationalist to have been consulted on each
‘paediatric’ priority. Perhaps if ‘children’s issues’ had been a separate chapter, wider ‘paediatric’
consultation would have been more easily achieved?
5. I think that the ophthalmic and vision sciences research community could have been usefully consulted
formally during the drafting of the document, avoiding:
a) firstly, the statement that the ‘during the consultation process priority areas of research will be identified
and incorporated as well as analysis of the financial investment required and the potential cost benefits of
the strategy.’ (page 7) This is puzzling. The starting point for a strategy document should be a systematic
review of the best quality research evidence on which recommendations are made - identifying gaps in
evidence should be the first step, not the last. Whilst it is not my area of expertise, robust economic
modelling is not a’ quick and easy’ task and it seems unlikely that it could be undertaken as part of a
consultation.
b) secondly, the several assertions in the document that are unsupported by evidence (of any quality) and
which therefore serve to undermine the authority of the whole document. I am very concerned that a
particularly strong theme throughout is the notion that universal and regular ‘sight tests’, referring mainly to
those conducted presently in the community by optometrists, would inevitably and universally improve early
diagnosis and thus lead to successful outcomes of treatment. This optimistic view (4 of the 7 case studies
describe the detection of relatively rare conditions by optometrists) would be strongly challenged by a
review of the most robust research evidence in relation to the detection of visually impairing or blinding eye
disease in children. Although I know the ‘adult literature’ less well, I think the same would be largely true.
6. I have concerns about the following specific recommendations about children:
a) Recommendation point 1.3.1.3 (page 12) regarding ‘eye health assessment’ at a number of key stages
during childhood contradicts the extant UK National Screening Committee policy on vision screening in
childhood. No evidence is presented in support of this recommendation. During March 2008, the National
Screening Committee will be re-examining the national programme of childhood vision screening and
surveillance, its implementation nationally and any new research evidence which informs policy. Mike
Clarke and I, amongst others will be contributing to this process.
In any case, about 75% of visually impairing or blinding eye disease in children in the UK is present from
birth or diagnosed by the first year of life (Lancet 2003). Thus the role of ‘sight’ tests during later childhood
is very limited. It would be important that the document clarified this.
Whilst ‘sight’ tests may be appropriate for detecting sub-optimal visual acuity due to refractive error and
amblyopia, there are limited robust data on the degree of refractive error that confers significant functional
disadvantage and the assumption that all refractive error in childhood, however mild, must be treated is
questionable.
For information:
i) we currently have a paper under review reporting on the prevalence (low) of undiagnosed refractive error
in working age adults in the UK and the functional correlates (surprisingly few).
ii) in relation to point 1.3.1.3, I have been discussing with the Personal Child Health Record Subgroup the
inclusion of detailed information on visual function and the best means of achieving this through electronic
data capture and record linkage – this is not a small or isolated undertaking, especially in the context of
implementation of Connecting for Health, but it is on their agenda.
b) Recommendations 2.3.1.8, 2.3.3.3, and 3.3.1.2
All the points made here are the subject of existing national guidance – it would probably be more powerful
to refer to these explicitly and in specific detail eg The National Screening Committee’s programme of
childhood screening and surveillance for eye disease, the National Service Framework for Children,
RCOphth and RCPCH joint party guidance on multi-disciplinary visual impairment teams, the Warnock
report on key workers etc.