Effective low vision services

What key things are needed to make a low vision service successful?  

Preeti Singla (PS): The key is integration between all the different services involved in low vision care. It’s not just the low vision service as a standalone, it’s how that fits in with social care, with rehabilitation, and with the medical side of things. To make sure that that is all integrated, and everyone is communicating well together, so the care is joined up.  

Accessing the service should be as easy as possible. Referrals should be made into services as soon as it’s highlighted that a patient has a need. It shouldn’t be a complicated way in: people shouldn’t have to jump through hoops to get that referral. It should be embedded into the journey. 

Louise Gow (LG): It’s a network, not just a referral into a low vision service and job done. It’s looking at that patient holistically.  

One of the biggest problems that we have with low vision is that people find it accidentally, too late on in their sight loss journey. The pathway needs to start at the point at which that patient needs the help. That may, for some people, be at the point at which they lose their driving licence, or it might be much later, when a spouse dies, and suddenly they’re having to do everything for themselves.  

It needs to be person-centred. Every practitioner who is involved in the care of that individual in the ophthalmology pathway should be double checking whether they need any support, and whether they are aware that there is support out there.  

It’s making sure that patients, at the earliest possible opportunity, get access, and that it’s not limited to patients who have a certain level of central acuity or are registered as severely sight impaired. Central to a good low vision pathway is that the patient doesn’t find it accidentally when they’re in crisis, which is unfortunately all too often the case. 

Nick Black (NB): Herefordshire has a multitude of local enhanced services, of which low vision was the first, 30 years ago. It’s well established, but there are still holes in the net. There’s a push away from hospital-centric services to the community, but low vision is a service that has been left behind and can still be quite hospital-centric, depending on your postcode. 

Because community low vision services in Herefordshire have been running for a long time, there is a very mature relationship locally with the optical community. There is a handful of practices around the county that that are providers of the low vision service. Practices will identify people who have need, and inter-refer, and there will be communication back.  

There’s an open, honest and mature relationship that allows for patient-centric care among potential competitors. It’s done with the understanding that, ‘we’re going to offer this person the level of care they need, but we’ll copy you into the communication, so you know what’s going on.’ That may involve the rehabilitation officer, and the local eye clinic liaison officer (ECLO). They may be under a clinic at the hospital. That co-joined, patient-centric care is really important. 

Sid Maher (SM): The pathway needs to be user-friendly. It needs to be a streamlined service, that offers low vision resources close to home. That will reduce patient waiting times and mobility issues, and increase access to hospital services, especially if they live in a rural area. 

I’m a low vision practitioner in Gloucestershire, and part of the local optical committee (LOC). A couple of years ago, we put a business case together for an adult low vision pathway.  

Gloucestershire is semi-rural, especially if you go towards the Forest of Dean and Wales. A lot of older people live that way, and we found that people really struggled, from that area, to get to Stroud, Cirencester or Gloucester. We included a domiciliary home visiting service. Now, if there’s a patient who can’t make it to the hospital, I can go and visit them in their own house with the kit.  

The pilot has worked really well. For the integrated care board (ICB), it’s a very low-cost service. But it is high impact, in terms of the difference it makes to it individuals’ lives. 

NB: Fundamentally, it is local knowledge about what is available. Different areas will have different pathways, which are more established or less established. Familiarity with what is on your own doorstep is crucial: whether it’s hospital-centric, or community-centric. 

Central to a good pathway is that the patient doesn’t find it accidentally when they’re in crisis, which is unfortunately all too often the case

What are the benefits of a low vision service for older patients? 

NB: Consider the access points. Different locations may have better or poorer access to public transport. Being able to see someone locally can be important. There is often a familiarity, and you build relationships with your patients. Also, it reduces the barriers for entry to low vision services, for example, self-referral. 

SM: When it comes to older patients, the Local Optical Committee Support Unit (LOCSU) low vision pathway encourages collaborative working, with multi-disciplinary teams, such as the falls team and the sensory support team. That is really valuable when we’re talking about the older generation. Because of that collaborative working, there’s a lot of information sharing and sign-posting following a low vision appointment. 

PS: Primary care is often the first place a patient will go if they are having trouble. A lot of these patients are not under secondary care at all, or they may be on a long recall in the hospital, being seen every year.  

They also don’t have much time to ask questions when they go into secondary care appointments. Consultants don’t have a lot of time, and they’re not always linked up with the ECLO or the low vision service in the hospital. Patients can’t ask all the questions they have. It will be their primary care optometrist that they turn to for this advice. 

LG: Patients get to know their optometrist much better than most of the eye care professionals that look after them, even if they’re under the care of the hospital. It’s potentially the optometrist who first spotted the condition, and has maybe been looking after them and their family for years. Patients may feel more comfortable talking to people within the practice that they already go to. 

As a practitioner, you can see a change in a patient if they’re struggling. I think that general practice approach is really reassuring for the patient. If they know the people that they’re talking to, they’re much more likely to open up when they are having difficulties. 

For a lot of patients, community-based low vision is brilliant. Having an optometrist who even understands the basics, like talking books, bigger, brighter, bolder strategies, and talks to them about the use of a task light, or maybe provides a range of glare shields for the light-sensitive patients – these are really simple things that you can do without even having to refer a patient.  

This is what I would refer to as low vision first aid, enabling patients to access visual strategies, whilst potentially waiting for a low vision appointment within a hospital setting. It’s when they start to need more intervention and support that the low vision service becomes essential.  

Having low vision services in the community is not a panacea and is not going to solve everything. But at the minimum, a community practitioner needs to understand the basic principles of low vision and how you optimise vision and contrast. That’s the start of the journey. Having a community-based low vision service is the icing on the cake, because it means patients are going somewhere familiar. 

PS: There’s a hugely recognised link between low vision and depression. Being able to have every practitioner that a patient sees ask the right questions could set patients up on a better journey of living well with their sight loss, being able to manage independently, being able to go out and about, and keep the interests that they have. Having it early in the journey is the most important thing.  

LG: Reduction of falls, reduction of social isolation, talking to patients about the possible chance that they might develop Charles Bonnet Syndrome – all these things improve quality of life.  

The last thing you need is for an older person to have a nasty fall or a burn in the kitchen. Low vision services can make such a big difference to all aspects of someone’s health and wellbeing. You connect low vision with handing someone a magnifier, but there is so much more to it. These services can prevent people from falling, from becoming isolated, and from losing their independence. 

NB: A low vision service can make a huge difference. It gives people confidence. It gives them self-belief. I see low vision as enabling people to be independent and happy in their world. When it’s done with empathy, it’s an enabling service, and that creates a huge amount of loyalty.  

For family members, it can be a real practice-builder, because they see that their parent or person who is going through a challenging time is being treated with respect and empathy. It’s not a direct sales relationship. It’s a much more holistic exposure than in almost all other areas of practice, because you’re asking them about their home environment, and you might be referring them to social services via a rehabilitation officer. All these factors make people really appreciative of what you do, even if sometimes it doesn’t seem to you like you’re doing that much. 

I see low vision as enabling people to be independent and happy. When it’s done with empathy, it’s an enabling service, and that creates a huge amount of loyalty

Encouraging practitioners to take up low vision work  

NB: Engage with your LOC. They are your local framework. There will be a potential relationship with the hospital, with the ICB, with LOCSU if you’re in England, or if in Wales, Scotland or Northern Ireland you will have your respective local framework. Engage with what is there locally, so that you can know what is in place. LOCSU have low vision pathways, which can be adapted for local considerations. 

Also, don’t do it alone. Realistically, if you’re going to do something as a community, you need the community. If you’re only one practice offering it, it’s not that different to a hospital. You can offer a private service, but success will be harder to come by. If you can set up a funded service, you’re more likely to get other stakeholders involved and engaged.  

If you’ve got a new service, part of being effective is how you communicate. The ICB will have networks and patient groups that can help to disseminate and expand that local knowledge.  

You get multi-disciplinary teams on some of these groups. They can help to raise the profile for something that’s a newer service. It is education, and it's something that will need to be repeated, because people will only remember it when they need it, or someone they know needs it. 30 years into providing a low vision service, we still get people saying, ‘I didn’t know about this.’ There’s that repetition, making sure stakeholders and other parties know what is available. 

Also, we’ve got optometrists who are upskilling and doing different services. This doesn’t necessarily need to be an optometry-led service. It can be led by dispensing opticians. We’re all qualified to do low vision. It’s things like, if you’ve got a low vision patient presenting at the front desk, how do you take them to a chair? Do you guide them? These skills can make a huge difference to those people, but also to the relationship that the front of house team develops with them. 

PS: I’m not sure all practices would want to run a full low vision service, but even if they could give advice and screening for patients that might need more support, and set them up with some tools in the meantime until they can access a full low vision service, that would be great. 

What we really want is for all practitioners to be able to support patients with sight loss to a certain degree, so that every contact matters and that if somebody goes in for their regular eye test, they can get basic advice and guidance. It may be a referral into a low vision service, but that takes time. Support around that information, for example, signposting to local organisations, advice on lighting, and those other things that you can do in the meantime, is what we aim for. 

Practitioners who would be interested in running a full low vision service can look into what the process is in their area, if they can get it commissioned under the NHS, or whether they want to provide a private service. 

What we really want is for all practitioners to be able to support patients with sight loss to a certain degree, so that every contact matters

LG: We have support to help people learn how to make their services accessible, and how to develop low vision services. If someone is interested in doing that, make sure you get the right training, advice and support to do it. 

SM: Low vision is such a high impact service, which both optometrists and dispensing opticians can offer and can carry out. I have spent years seeing firsthand the difference it makes to people being able to live more independently. 

In Wales, it’s an established way of working. Every practice offers low vision. I hope that, in England, we can start on that route. 

I’m really passionate about low vision. As a practitioner, it has given me personal reward like no other part of my job. If anyone reading wants to talk about anything that is going on in their area, or opportunities, they can contact me directly.