“A generation of children have missed out” 

Uncertainty over service specification and fees is causing concern amongst those delivering the Special Schools Eye Care Service

A small boy in a black and white striped t-shirt is trying on glasses and smiling
Contractors facilitating the Special Schools Eye Care Service (SSECS) are voicing concerns over a lack of progress in confirming the programme’s long-term service specification.

Learning disability charity, SeeAbility, told OT that contractors and performers currently delivering the SSECS are feeling uncertain about the future of the service without a stronger commitment to its quality or confirmation on what the long-term fee will be.

The charity holds a contract to provide services for 3000 children across 25 special schools.

A potential ‘unpicking’ of the current contract in order to create a new service specification could mean a lower quality service in the future, SeeAbility said.

“This is a really good quality service,” Donna O’Brien, policy, public affairs and research manager at the charity, emphasised, adding: “The worry is the suggestion of commissioning something completely different and more fragmented, and that at the same time, we’ll lose all the data that was collected with the proof of concept.”

She added: “The proof-of-concept is proven as a really successful service, with huge patient satisfaction. The one-stop shop, the dispensing, the spare pair of glasses and the dedicated training – this all went down really well. And now, if NHS England isn’t going to take on board all the comments to its consultation exercise, including from its Expert Working Group, you’re going to have something different. We do hope they have listened.”

There are questions over whether hospitals will feel comfortable discharging patients to the service if it is not as high a quality as it was previously, O'Brien said, as well as whether schools will continue to trust the service if the goal posts change.

“It has been announced that it could reach up to 165,000 children. If you do commission something different, you may have nervousness from the schools about who to allow in,” O'Brien said.

There is concern about the service becoming more commercial than the one that was so positively evaluated, which was based on a not-for-profit model for glasses dispensing that valued the dispensing optician’s clinical time.

O'Brien emphasised that children served by the SSECS are “heavy users of paediatric clinics,” and that decision makers should engage with secondary care if they want further evidence of the value of the service or their support in providing it.

“The current SSECS contract names clinicians for each of the schools so that they cannot be swapped for locums who the child does not know,” Lisa Donaldson, head of eye care and vision at SeeAbility, explained. There is also a fear that, if the contract changes, this provision might not continue.

An ongoing conversation

The SSECS has existed in a ‘proof-of-concept’ form since 2021. Doubt was cast over its future in August 2022, when contractors were told that the service in its current form would cease at the end of March 2023.

The SSECS in its proof-of-concept form was later extended to August 2023.

In June 2023, then minister for primary care, Neil O’Brien, said that, following the positive evaluation, the service would be expanded to 165,000 children from 2024–2025, in a £10 million funding commitment.  

In the same month, a parliamentary debate focused on the issue, with Siobhain McDonagh, MP for Mitcham and Morden in south London, emphasising that SSECS was developed because children with special needs are 28 times more likely to have a sight problem than other children, but that 55% of children with special needs miss the hospital eye clinic appointments that they have booked.

The proof-of-concept evaluation data also found that half of children seen had no eye care history.

A consultation on the future of the service was carried out in autumn 2023, before contractors were told that the service would be handed over to Integrated Care Boards (ICBs) from April 2024.

Contractors in London received an email from the dentistry, optometry and pharmacy commissioning hub at North East London ICB on 12 April, confirming that the ICB had been handed contracts for the SSECS and would now be the main point of contact.

North East London ICB works on behalf of all London ICBs with regards to General Ophthalmic Services (GOS) contracts.

OT understands that ICBs will be in touch with those delivering the service from June 2024 as the new commissioners for the service, based on an updated commissioning standard and service specification.

Donaldson also expressed concern that the service specification may end up classifying the SSECS as opt-in rather than opt-out, which would mean a failure to capture all the children that need it.

An opt-in system is “not going to solve the problem of the 50% of children who have never had any eye care,” Donaldson said.

The proof-of-concept model also includes specific training for special schools, which SeeAbility believes may be at risk if a new service specification is drawn up.

The question of fees

There are fears that the long-term fee offered to contractors and performers may be lower than that offered through the current contract.

“We’re just about breaking even. It’s very hard to see how, in lowering the fee, you could make it sustainable without lowering the standard of care,” Donaldson added.

Donaldson also shared that, as of 1 April, contractors and performers have been required to log their SSECS work using a GOS-style Microsoft Word form, after the system that had been used previously closed down.

A form is now required for every sight test performed as part of the SSECS, she said.

The change was communicated to contractors in a Primary Care Support England webinar on 20 March.

Forms are at risk of being rejected and returned in the same way that GOS forms sometimes are, leading to further frustration from practitioners, Donaldson said.

She added that the previous system also allowed contractors and performers to track clinical data.

Aside from questions over fees and the service specification, SeeAbility raised the direct impact of delays in administration of the SSECS on children in special schools, 35–40% of whom need glasses.

Donaldson noted that only 9% of special schools currently benefit from the SSECS, and that it is close to a decade since the initial research that made the case for it – meaning “a generation of children have missed out.”

In 2016, a paper entitled Framework for provision of eye care in special schools in England was developed by SeeAbility, alongside a number of sector bodies, including the Royal College of Ophthalmologists. This was endorsed by Public Health England as part of its child vision screening guidelines.  

Donaldson shared: “We get emails from schools all the time. They contact me and say, ‘I thought we were going to hear, because you said it was going to be rolled out in April.’ For us, it feels like we’re being dishonourable, because we keep saying this, and then it doesn’t happen.”

Donaldson emphasised that there is strong consensus that the SSECS works, and that the proof-of-concept model was developed and commissioned based on work done in 2016.

“It's a generation of children, since Maggie Woodhouse’s first bit of research, and Rachel Pilling’s in Bradford,” she said.

Donaldson added: “Since those studies that evidenced this huge level of unmet need in this population, we’ve had numerous stops-starts, and we’re still in a position where, typically, 50% of children [in special schools] aren’t getting any eye care. That is the bigger thing.”

“Kids are getting older,” Donaldson emphasised. “They’re missing out on their education all the time, because they haven’t had eye care.”

O’Brien emphasised the benefits of the service, outside of the immediate positive effect on the children it services.

“If there’s one argument you can make, it’s that there is huge potential for this service to reduce that immediate pressure in secondary care – but only if people feel able to trust to discharge to the service,” she said.

O’Brien said: “We have made lots of representations about the concerns above, alongside others in the eye care sector and learning disability charities, and we really hope that these concerns will be addressed in any final service specification or announcements made.”

NHS England confirmed to OT that the SSECS would continue into the 2024–2025 academic year, and that work confirming a service specification and new contracts has now transferred to ICBs.

A spokesperson said: “In London, this is a significant piece of work, given the large number of special schools. We are currently scoping out the task, so in the meantime the current service will remain in place until we have arrived at a position where new arrangements can be confirmed.”

Work required to establish a long-term fee for the SSECS will be taking place in the final two quarters of 2024, NHS England said.