Seeing the future Boots Opticians Green Paper on children’s eye health

1 Seeing the future Boots Opticians Green Paper on children’s eye health

1. Foreword Contents

2. 3. Executive Children’s summary eye health in numbers

4. Introduction

5. Children’s eye health 5.1 Children’s eye conditions 5.2 Risk factors 5.3 Service provision 5.4 Commissioning of services 6. The opportunity to make a difference now 3.1 Literacy, educational attainment and employability 3.2 Wider health and wellbeing 3.3 Sport, 7 . fitness and How to physical achieve activity our full potential

8. 9. Conclusion References and next steps

1 Seeing the future Boots Opticians Green Paper on children’s eye health

1.

Foreword Ben Fletcher, Managing Director, Boots Opticians

It is estimated that there are over one and a half million school-aged children in England who have an undiagnosed issue with their vision. It is a situation that is both unseen, and rarely discussed. Those children with impaired vision do not know any different, and often there are no obvious symptoms for parents, carers or teachers to notice. The impact of this is wide- I am particularly proud of our research and our existing ranging and long-lasting, affecting role in developing Zookeeper Zoe knowledge, including some that children’s ability to read, learn, in partnership with the National will affect our own practice, and are participate in sport, and, ultimately Literacy Trust. The book gives keen to work with parliamentarians, their ability to get a decent job, power to the people who know policy-makers, commissioners have a decent home, develop children best – their parents – professional bodies and colleagues strong relationships, and look and enables them to understand to implement them. By thinking after their own health. This is an whether their child might have an about what children, young people issue of social mobility. issue with their vision. We have and parents need, we can begin to already given away half a million develop a system that will deliver Boots has a long heritage copies of the book and it has significantly better outcomes for of taking a broader view of been accessed over 100,000 all of them as individuals and for people’s health, and we have times online. us as a society. always understood that wellbeing means more than just being Although we carry out around I believe that by working in healthy. In the early part of the 2.5 million eye examinations a partnership we can make a 20th century, Boots lending year, Boots Opticians cannot significant impact on the long- libraries ensured easy access fix this problem alone. We are term life chances and health to books for over one million working with a system that relies and wellbeing of children and subscribers. Today, we are again heavily on parents understanding young people across the country, providing space in our practices the importance of regular eye now and in the future. That is the for libraries, giving away books examinations without providing goal we are working towards and for free, and working with local them with the information they investing in; this Green Paper is sports organisations to promote need to protect their children's a step towards achieving it. reading among boys. Every one eyes. Emerging technology will of our 6,000 colleagues has two make it ever easier to assess Because children’s days of literacy volunteering even very young children’s vision vision matters. time in schools as part of their and eye health but the whole employment contracts, because system has to work to make children’s vision matters. sure children have access to the services they need.

Because children’s vision matters we have developed this Green Paper as part of our commitment to improving children’s eye health. We have made a range of recommendations, based on

2 Foreword

3 Seeing the future Boots Opticians Green Paper on children’s eye health

2. Executive summary

4 5 Seeing the future Boots Opticians Green Paper on children’s eye health

2. Executive summary It is estimated that over one and a half million school-aged children have an undiagnosed issue with their vision in England and there are clear indications that the number of children affected by poor vision and eye health will increase. As with other major public health challenges, such as looking after children’s teeth, promoting healthy eating and increasing exercise, starting good eye health habits early can stand children and young people in good stead for the rest of their lives. Yet there are few planned interventions in the system which provide opportunities to check children's vision and eye health.

The recommendations in this There are few planned Poor vision impacts on a child's Green Paper focus on the system interventions in the system ability to engage in sport and in England where the issues are which provide opportunities to fitness activities. The importance particularly acute. However, Boots check children's vision and eye of improving eye health and Opticians is active in improving health. Those that do exist can making sure children and young children’s eye health across the be patchy across the country, people can access the options UK and is committed to taking the with concerns being expressed that are appropriate for their visual principles from this Green Paper about the implementation of the needs should not be overlooked, into our on-going discussions with current screening programme particularly at a time of rising stakeholders in Scotland, Wales in schools. In addition, despite obesity rates and increasing and Northern Ireland. the importance of children and concerns about physical inactivity young people having regular eye among children and young Research is increasingly examinations, research has found people. Enabling young people demonstrating that the risk factors that a quarter of parents said their to participate in a wider variety that can affect children’s eye child had never had an eye test2. of sporting, cultural and artistic health include not only UV light activities is not only good for their but also genetics, demographics, Good eye health is key to physical health but can also have 1 ethnicity and lifestyle . We need supporting children’s wider life benefits for their mental health to take into account the expected chances. Research has shown and wellbeing. increase in the prevalence that sight problems can have a of conditions such as short- negative impact on a child’s literacy NHS England’s Five Year Forward sightedness (myopia)‎1 to ensure and educational attainment3, both View has stated that ‘the future that services are in place in the of which are associated with a health of millions of children, future to meet children’s needs. higher likelihood of people being the sustainability of the NHS, unemployed or with lower paid and the economic prosperity of At present, the system relies too employment in later life4. This is Britain all now depend on a radical heavily on parents understanding increasingly important given the upgrade in prevention and public the importance of regular eye wider implications of research health’6. The potential wider, examinations and taking their such as the Marmot Review, long-lasting impact of poor eye children to have their eyes tested. Fair Society, Healthy Lives, which health in childhood means that we In turn, this relies on parents found inequalities in life expectancy must take action now; children’s overcoming a range of different and quality of life associated eye health must be given the same barriers to accessing services, with levels of socioeconomic priority as all of the other major including a lack of information on deprivation5. public health challenges. We must the importance of good eye health create more, and better signposted from a young age, as well as local Additionally, low literacy can affect opportunities for children and variations in commissioning of a person’s ability to manage their young people to access eye health services for children health and wellbeing, with poor appropriate eye health services. and young people in England. educational attainment linked to It is critical that action is taken to negative health behaviours and, ensure parents feel more informed in some instances, a reduced about how they can protect their ability to manage treatments children’s eye health. for other health conditions4.

6 Executive Summary

Our recommendations

A. Education and information D. School governors must for parents and carers must ensure schools maximise improve through a national the resources available to awareness campaign and support the eye health of their updated resources. These pupils, such as free vision should include the Personal check tools and staff time Child Health Record (Red from external organisations Book) and NHS Choices, which should highlight the E. Consideration should be We hope that through importance of children's eye given to how the current implementation of health, as well as potential voucher system can enable these recommendations risk factors for children's children and young people we will see: eye health, the importance to access the full range of of screening at school entry, vision correction solutions, • More children with a vision regular eye examinations such as additional pairs problem diagnosed earlier and as a minimum a first eye of glasses where clinically and able to access an option examination to take place no necessary, contact lenses to correct their vision that later than the age of six as and sports eyewear enables them to be involved in the activities they want to be well as information about the F. NHS England should work services available with the Clinical Council for • More children achieving their B. Mandatory commissioning Eye Health Commissioning full potential at school, in sport of a fully funded screening (CCEHC) to develop national and throughout the many programme for all children service specifications and mile-stones in their lives aged four to five, to be pathways to move more updated to maximise the services currently delivered opportunities of community in secondary care into the provision, including catch- community, so that only those up provision, alongside children with the most complex better data collection on needs are referred to secondary the coverage and impact care, speeding up diagnosis of the programme and treatment for all children and young people C. Better training on the . importance of eye health G Consideration should be • More parents feeling is needed for all health, given to how providers can informed about how ensure that their services education and social care they can protect their professionals working are accessible to children with parents, children and and young people, including children’s eye health young people, to maximise through investment in opportunities for providing technology, staff and training and reinforcing information and the design of services about eye health 7 Seeing the future Boots Opticians Green Paper on children’s eye health

3. Children’s eye health in numbers

8 9 Seeing the future Boots Opticians Green Paper on children’s eye health

Children’s eye health

An estimated one in Short-sightedness 30 to one in 50 children (myopia) is a relatively will develop lazy eye common condition, with (amblyopia)8 an estimated one in three people affected9

It is estimated that over one and a half million school-aged children have an undiagnosed vision problem in England7 The prevalence of short- sightedness today is already twice that of Children who have the 1960s1 one parent with short- sightedness are three times more likely to be affected by short- sightedness than those whose parents do not have the condition. Those with two parents affected Around 40 minutes a have a seven-fold day spent outside over greater risk1 three years can reduce Children are three times both the incidence and more likely to develop the progression of short- short-sightedness in sightedness1 primary school than after primary school1 Service provision

The UK National Screening Committee recommends all children aged four to five years old should be included in the national screening programme10

Funding for free eye examinations and In the six months from April access to free glasses to September 2015, the for children and young NHS invested an estimated people is provided by But only just over 50 per £30 million in community the NHS cent of local authorities eye services for children in England commission up to the age of 1611 the screening programme; consequently there will be a large number of children 10 who are missing out Children’s eye health in numbers

The impact of poor eye health

Around 80 per cent of People with functional what children learn is literacy skills earn on through sight average 16 per cent more than those with People with low literacy are up to lower literacy skills4 18 times less likely to be able to identify their medicines than those with adequate literacy4

We have had feedback through our School Vision Screening Programme In 2011, 24 per cent of People with sight loss are that, for some children, people not in work had more likely to suffer from correcting their vision has entry level literacy skills13 social isolation14 had an impact on both learning and behaviour12

Boots Opticians in numbers

We operate 637 practices In 2009, Boots Opticians merged with Dollond & Aitchison to create the second largest optical chain in the UK

We employ approximately 1,500 optometrists

Half a million copies In August 2013, Boots Opticians of Zookeeper Zoe became the first multiple optician have been given in the UK to include digital retinal away for free photography as a standard element of its eye test for customers of all ages. We conduct around This provides a permanent health 2.5 million eye record which can be shared with examinations a year other healthcare providers 11

Seeing the future Boots Opticians Green Paper on children’s eye health

4. Introduction Boots Opticians is a health-led optician yet we care about a whole lot more. We operate 637 practices, employ approximately 1,500 optometrists and conduct around 2.5 million eye examinations a year. This means that, every day, up and down the country, our colleagues see children and young people with vision and eye health problems and help them to take action to improve their sight. However, we know that, in England, it is estimated that over one and a half million school-aged children have an undiagnosed vision problem and are not currently getting the help they We recommend: need. We understand the impact that poor eye health can have A. Education and information D. School governors must on children not only in their daily for parents and carers must ensure schools maximise lives, but also on their life chances. improve through a national the resources available to Research indicates a awareness campaign and support the eye health of their link between eye health, and updated resources. These pupils, such as free vision attainment and achievement3. should include the Personal check tools and staff time We are committed to improving Child Health Record (Red from external organisations children’s eye health and a key Book) and NHS Choices, which should highlight the E. Consideration should be part of this is highlighting where given to how the current we believe there are barriers in importance of children's eye health, as well as potential voucher system can enable the health, care and education children and young people systems that could be overcome. risk factors for children's eye health, the importance to access the full range of of screening at school entry, vision correction solutions, This Green Paper sets out: regular eye examinations such as additional pairs • The current eye health services and as a minimum a first eye of glasses where clinically for children and young people examination to take place no necessary, contact lenses later than the age of six as and sports eyewear • An overview of the wider well as information about the impact of poor eye health F. NHS England should work services available with the Clinical Council for • Recommendations for B. Mandatory commissioning Eye Health Commissioning improvements in service of a fully funded screening (CCEHC) to develop national provision to make the most programme for all children service specifications and of every child’s potential aged four to five, to be pathways to move more updated to maximise the services currently delivered The recommendations in this opportunities of community in secondary care into the Green Paper focus on the provision, including catch- community, so that only those system in England. However, up provision, alongside children with the most complex Boots Opticians is active in better data collection on needs are referred to secondary improving children’s eye health the coverage and impact care, speeding up diagnosis across the UK and is committed of the programme and treatment for all children to taking the principles from and young people this Green Paper into our C. Better training on the on-going discussions with importance of eye health G. Consideration should be stakeholders in Scotland, is needed for all health, given to how providers can Wales and Northern Ireland. education and social care ensure that their services professionals working are accessible to children with parents, children and and young people, including young people, to maximise through investment in opportunities for providing technology, staff and training and reinforcing information and the design of services about eye health

12 Introduction

13 Seeing the future Boots Opticians Green Paper on children’s eye health

We have not produced this Green Paper in Based on our expertise in, and commitment to, isolation. Because children’s vision matters, children’s eye health, this Green Paper is our view we are taking action on children’s eye health of how the system should improve to ensure that which is raising the bar across our sector and every child has the opportunity to achieve their full setting the pace for change: potential. We are keen to hear views from partners • In September 2015, we launched the Boots and stakeholders on the recommendations we have Opticians Schools Vision Screening Programme put forward and the action we can all take together to support schools to quickly and easily check the to make a difference today, for future generations. vision of their pupils. Aimed mainly at children Because children’s vision matters. aged 4–7, it can be used with all children of primary school age. The programme allows schools to “The National Literacy Trust are take action to improve the eye health of their pupils, providing web-based resources to carry working with Boots Opticians to out vision checks as well as enabling them to, raise awareness of eye health and at the touch of a button, provide a letter to advise the importance of reading for parents if a further referral is recommended and remind them of the importance of regular enjoyment in communities across the eye examinations UK. Reading is the key that unlocks

• We have a strong partnership with the National every child’s potential, and yet almost Literacy Trust and are working together to raise a quarter of children in the UK leave awareness of the importance of reading for primary school unable to read well. enjoyment and eye health. As part of the partnership, we launched the Boots Opticians In the poorest communities this Schools Challenge in September 2015, which can rise to 40%. involves colleagues volunteering in local primary schools to promote reading for enjoyment and By promoting good eye health we can good eye health. By highlighting the link between ensure that children’s reading is not eye health and literacy, the partnership aims to held back by an undiagnosed vision help improve the literacy outcomes of the UK’s most disadvantaged children problem which affects their ability to learn. Healthier, more literate children • We have also worked with the National Literacy Trust to develop Zookeeper Zoe, an interactive will secure a stronger, more equal and story containing a range of eye check activities for successful society for all of us.” parents to read with their children and help them identify whether a full eye examination with an Jonathan Douglas optometrist is required. We have produced half a Director, National Literacy Trust million copies of the book which have been given away for free in schools, in our practices and in Boots stores across the country. The book is also available digitally as an App

• As signatories to the National Literacy Forum’s Vision for Literacy Business Pledge 2016, we are committed to taking action to reduce the impact of both poor eye health and low levels of literacy on children's attainment. This includes providing two volunteering days a year for each of our colleagues to support the work of the National Literacy Trust

14 Introduction

15 Seeing the future Boots Opticians Green Paper on children’s eye health

5. Children’s eye health 5.1 Children’s eye conditions 5.2 Risk factors 5.3 Service provision 5.4 Commissioning of services

16 Children’s eye health

17 Seeing the future Boots Opticians Green Paper on children’s eye health

5.1 Children’s eye conditions Maintaining good eye health from • Refractive error Hyperopia (long-sightedness) an early age is vital and needs to •  – children with long-sightedness may be able to see distant be seen as part of the wider efforts objects more clearly than near ones33 to improve children’s health and • Myopia (short-sightedness) – children with wellbeing. As with other major public short-sightedness see near objects more clearly health challenges such as looking but distant objects are blurred. Short-sightedness after children’s teeth, promoting is a relatively common condition, with an estimated one in three people affected, and it is thought to healthy eating and increasing 1,9 exercise, starting good eye health be becoming more common habits early can stand children and • Astigmatism – children with astigmatism may experience distorted or blurred vision young people in good stead for the at all distances34 rest of their lives. A child’s visual system continues to develop until • Childhood cataracts – cataracts occur when changes in the lens of the eye cause it to become they are at least eight years old less transparent, which results in cloudy or misty meaning that, if early opportunities vision. Cataracts can be present when a baby is to identify problems are missed, born, or shortly afterwards, or can be diagnosed the impact can be lifelong. in older babies and children. Cataracts in babies and children are rare; it is estimated that they There are a range of conditions that can affect affect between three and four in every 10,000 children’s eyes, some of which are rare but serious children in the UK16 and others which are more common and can be corrected with technology, such as glasses. An estimated five in every 10,000 children up to the age of 16 are severely sight impaired or blind17. Some of the conditions more commonly We are aware that many children with sight loss or identified in children include: severe visual impairment may be reliant on community • Amblyopia (lazy eye) – in lazy eye the vision in optometry services to provide continuity of care. one eye does not develop properly which usually However, many of them are likely to have specific means the child can see less well out of one eye needs which should be met by health, social care and relies on their ‘good’ eye. An estimated one and education services. We have not included in 30 to one in 50 children will develop lazy eye8 recommendations on specific additional services for these children and young people but they should • Strabismus (squint) – squint is a condition be able to benefit from enhanced community eye where the eyes point in different directions. health provision if our recommendations This is relatively common and can affect around are implemented. one in 20 children, usually appearing before the age of five although it can appear later15

18 Children’s eye health

If early opportunities to identify problems are missed, the impact can be lifelong

19 Seeing the future Boots Opticians Green Paper on children’s eye health

5.2 Risk factors There are clear indications that the number of children affected by poor vision and eye health will increase – the prevalence of short-sightedness today is already twice that of the 1960s1. Research published in early 2016 has suggested that future changes could be significant as it identified a number of risk factors that will affect the prevalence of short-sightedness – just one condition – in children and young people in the future1. We need to take account of these increases to short-sightedness and other conditions now to ensure that services are in place in the future to meet children’s needs, helping to keep more children out of secondary care services and to deliver care closer to their homes.

The key risk factors for short-sightedness were identified as:

Genetics1 Ethnicity1 • Children who have one parent with short-sightedness • The prevalence of short-sightedness is are three times more likely to be affected than those higher in different ethnic minority groups whose parents do not have the condition. Those with two parents affected have a seven-fold greater risk • Internationally, the prevalence of short- sightedness in 19 year olds in South Korea is thought to be as high • As the prevalence of as 95 per cent35 short-sightedness increases so will the genetic risk to • Children from certain ethnic minority groups can be more vulnerable to short-sightedness. For example, future generations in Birmingham, the prevalence of short-sightedness in white European children aged 12-13 years was found • However, the speed of the increase in prevalence to be 18.6 per cent but was 27.5 per cent in young cannot be explained by genetics alone; short- people from Black African or Caribbean backgrounds sightedness can also develop because of and 36.8 per cent in young people from South 36 other factors Asian backgrounds • Research suggests that people from certain ethnic groups are less likely to access eye health services, Lifestyles1 even if they are readily available • There is a clear link in the research between the • Parents from ethnic minority groups are also more development of short-sightedness and the amount likely to be disproportionately affected by the barriers of time that children spent playing outside to accessing eye health services, such as a lack of time, distance to travel and cost, as well as other issues such • Around 40 minutes a day spent outside over three as language barriers18 years reduced both the incidence and the progression of short-sightedness • This would suggest that, as the population in the UK changes, the prevalence of short-sightedness will lead to greater need for services in some areas

20 Children’s eye health

Disability19 • Children with learning disabilities are at a much higher risk of sight problems and eye health disorders. There is evidence that the more profound the learning disability, the greater the likelihood of visual impairment

• For children with learning disabilities, additional barriers exist to accessing The World Health eye care, such as a lack of specialist Organization estimates training among optometrists, and a that 80 per cent of a lack of school screening initiatives person’s lifetime UV light exposure occurs before • Research from Wales has shown that a high the age of 1822 proportion of pupils attending special schools had uncorrected refractive errors and some had previously unrecognised vision impairment. Over 40 per cent of pupils reported no previous eye examination and 53 per cent needed glasses. It also identified that entry year vision screening was only available in 53 per cent of special schools

Demographics20 • There are significant inequalities in the eye health of Another key risk factor for children’s eye health is people from lower socioeconomic groups, who are more ultraviolet light (UV). Both UVA and UVB rays have likely to lose their sight and less likely to access services, been shown to cause long-term damage to the eyes even if they are readily available and the World Health Organization estimates that 80 per cent of a person’s lifetime UV light exposure occurs • Area studies in Norfolk and Leeds found higher levels before the age of 1821. Many adults routinely wear of low vision amongst financially disadvantaged groups 37 sunglasses but children tend to spend more time due to undiagnosed refractive error . Additionally, outside without sunglasses than adults. evidence from an area study conducted in South Wales found that people who live in deprived socioeconomic Diet and nutrition is a vital factor in eye health but populations have a higher incidence of undiagnosed awareness about the link between diet and good eye refractive error, yet do not access optometry services health is low. Studies have shown that a diet rich in to have it corrected38 colourful fruit and vegetables, nuts, whole grains and cold water fish can have an important role to play in • People from lower socioeconomic groups can be maintaining eye health. disproportionately affected by barriers such as a lack of education or isolation from the local community. Additionally, a lack of information available to This can contribute to a lack of awareness of the parents and carers on the importance of protecting importance of eye health across families, and further and promoting eye health throughout childhood barriers to accessing eye care services can mean that some children do not receive regular eye examinations. • This suggests that further consideration should be given to how to make eye health services more accessible in areas of greater deprivation, particularly given the inequalities in life expectancy and quality of life associated with levels of socio-economic deprivation identified in research such as the Marmot Review, Fair Society, Healthy Lives5 21 Seeing the future Boots Opticians Green Paper on children’s eye health

5.3 Service provision The system for delivering children’s eye health services, including screening, varies in each country across the UK. This Green Paper focuses on the system in England but we are committed to working with partners across the UK to improve eye services for all children and young people. This section sets out the existing screening programmes and approach to eye testing in the community in England, highlighting where there are current gaps in provision. Screening programmes If left untreated it can result in A Children’s Vision Community permanent, lifelong vision defects Service Pathway has been developed Currently, there are few planned and so the screening programme is by the Local Optical Committee interventions in the system timed to identify children at an age Support Unit (LOCSU) as a model which provide opportunities to when treatment has the potential for community optometrists to check children's vision and eye to improve vision. provide management and treatment health. Instead the system relies to children with suspected amblyopia heavily on parents understanding All children aged four to five years following school-based screening. the importance of regular eye old should be offered the screening. If this pathway were implemented examinations and taking their However, the latest information more widely across the country children to have their eyes tested. provided to the CCEHC has shown it would provide significant that just over 50 per cent of local opportunities for improving access authorities in England commission 23 New-born screening and service provision . It could the screening programme so there also offer greater opportunities for All babies should have a reliable will be a large number of children catch up provision for children who eye check at birth and again at about who are missing out. We have found miss the usual screening age of six weeks of age. These checks are that around 18 per cent of children four to five. usually carried out by a GP or health screened through our School Vision visitor, and are designed to look at Screening Programme have been Increasing provision of these both the appearance and movement identified as having a potential vision services in the community would of the baby’s eyes. The checks also correction need12. In addition, when mean that care could be provided look for signs of cataracts but do school-based screening does take closer to children’s homes in line not check the baby’s vision. Two to place, it is as a one-off event. This with the Five Year Forward View6. three babies in every 10,000 will be means that children who are absent This would speed up access to identified as having a problem with on that particular day due to illness services for the children identified by their eyes that needs to be treated, or because they later move to the the screening programme. It would and will be referred to a hospital school from another area may miss also release capacity in secondary eye service22. out on the screening altogether. care services, which are already Catch-up opportunities are not under pressure, ensuring those School-aged screening currently delivered in all schools. children and young people who really need secondary care services can Children should be screened for The current approach to the access them more quickly, speeding vision problems in their first year of screening programme is led by up diagnosis and treatment for all school. There is a national screening orthoptists, although the programme children and young people. programme recommended by the may sometimes be carried out by UK National Screening Committee other health professionals, such as and it should be offered to all children school nurses or health visitors. aged four to five years10. The primary The screening usually results in aim of the screening programme children with a potential problem is to identify children with a specific being referred into secondary care condition: lazy eye (amblyopia). services where ophthalmology Lazy eye results in decreased accounts for the second highest vision in one eye which can appear rate of outpatient attendances. It is unaffected and so it can often possible for more of these services go unnoticed in children. to be delivered in the community.

22 Children’s eye health

All children aged four to five years old should be offered the screening. However, the latest information provided to CCEHC has shown that only just over 50% of local authorities in England commission the screening programme and so there will be a large number of children who are missing out

These screening programmes, while important, • The current programmes do not offer any opportunities miss wider opportunities for assessing and for providing parents with information about how to improving children’s eye health: maintain their child’s eye health. For example, parents should be made aware of the beneficial effects of • The screening programme offered to four and five exposure to daylight on children’s eye health, provided year olds has a clear focus on lazy eye and is not an they are adequately protected from UV such as eye examination. This means other vision defects with sunglasses such as refractive error may not be picked up • By screening for a single condition there is no opportunity for consideration of the health of the child’s whole eye, particularly the inside of the eye. This could mean that serious problems are going undetected until it is too late • The one-off nature of screening does not allow for We recommend: catching later vision deterioration Mandatory commissioning of a fully funded • Parents are often not aware that the screening screening programme for all children aged four to programme is focused primarily on one condition five, to be updated to maximise the opportunities and do not have enough information about the of community provision, including catch-up provision, differences between the screening test and an alongside better data collection on the coverage eye examination. Many parents may wrongly and impact of the programme assume that their child’s eyes have been tested at school and so there is no cause for concern if they were not alerted to a problem. This can result in parents having a false sense of reassurance as their child progresses through their school life

23 Seeing the future Boots Opticians Green Paper on children’s eye health

Eye tests for children Eye examinations can be carried The research demonstrated that out even with young children, children are three times more likely and young people as they do not need to be able to to develop short-sightedness in read; they can be asked age- primary school than after primary appropriate questions to assess school1. The study also showed their vision and new technology that the fastest progression of is making testing more fun short-sightedness is in the pre- and engaging for children. The teenage years. technology for testing children’s Research has shown that eyes is developing so that results Children will rarely uncorrected long-sightedness will become ever more reliable, (hyperopia) was associated with complain about their eye even for very young children. Eye problems in developing early tests for children under 16 are free sight, as they may not literacy skills, which can be and continue to be free for young be aware of what they associated with future problems people up to the age of 18 if they learning to read and write25. should be able to see. remain in full-time education.

This makes it all the more important that parents are aware that children should have regular eye examinations, at least every two years, as problems can occur This means that the at any age. The Five Year Forward current approach to View has stated that ‘the future health of millions of children, the checking children’s sustainability of the NHS, and the eye health is likely economic prosperity of Britain all to be inadequate, now depend on a radical upgrade in prevention and public health’6. The most recent statistics show leaving children While many of these efforts will be that in the financial year 2015/16, struggling unnecessarily focused on the other big public between April and September with unidentified health challenges such as obesity, 2015, more than 572,000 sight smoking and physical inactivity, eye tests were carried out in the eye problems and examinations must be recognised community for children and young the associated 11 as an important preventative public people under 16 across England . social and economic health intervention which provide This does not include eye care an opportunity to consider a delivered for children and young consequences. child’s eye health and visual status people in secondary care services. and take early action to address While this may appear to be a Research has also found it is potential problems. significant number, there are an possible to identify children at estimated 11 million children and higher risk of short-sightedness Eye examinations assess whether young people aged 16 or under when they are six to seven years 1 children and young people have a in England24, so these sight tests old . This would suggest that problem with their vision and if they represent only 5.2 per cent of regular eye examinations during need to wear glasses, or if their children and young people, which primary school are critical for current glasses need changing. would suggest there are still many identifying those children at greater This would also include talking to young people not receiving the risk, and at the very least parents children and their parents about care they need. must be made aware of the need which vision correction options will for all children to have an eye suit them best and enable them to Research published in early 2016 examination by the age of six. be involved in the activities they has challenged current clinical This would allow earlier want to be. opinion by suggesting that while interventions to support children short-sightedness is being picked with short-sightedness and up in teenagers, this is actually minimise the longer term impact an indication of unmet need with on their learning. In addition, it is children experiencing short- critical that more information is sightedness for some time before provided to parents to help them 1 being identified . understand and, where possible, mitigate the known risk factors for short-sightedness.

24 Children’s eye health

25 Seeing the future Boots Opticians Green Paper on children’s eye health

Despite the importance of Information on eye The current system misses children and young people health examinations having regular eye examinations, opportunities provided by a quarter of parents report that Parents do not receive enough the Red Book and the regular their child had never had an eye information about children’s contact health professionals test and one in ten could not eye health and the importance have with young children remember when their child last of regular eye examinations. to offer and reinforce had an eye test2. Many parents For many parents, the main information for parents are unaware of the need for source of information about about how to protect their regular eye examinations or think their children’s health is the children’s eye health. This that professionals working with personal child health record, would include encouraging their children will highlight any more commonly known as the time outdoors to reduce the issues and recommend an eye ‘Red Book’, which all children risk of short-sightedness, examination if this is necessary. receive when they are born. the importance of monitoring Primarily this is a record of and managing screen time The current approach to their health and development, on digital devices, awareness children’s eye examinations including their weight and of the effects of UV and the does not reflect recent research vaccinations. However, it also need for sunglasses. suggesting children are being serves as a source of information diagnosed with eye problems on health and wellbeing issues later than necessary. There is including safe sleeping for babies, a lack of education for parents breast-feeding and childcare. about the importance of regular eye examinations, from the age The information on eye health We recommend: of six at the latest, which risks within the Red Book is limited, vision defects going unidentified, stating that while there is no • Education and information preventing action being taken easy way to test a young baby’s for parents and carers must as early as possible. eyes accurately, parents can improve through a national help check there is no serious awareness campaign and problem by watching how their updated resources. These baby uses their eyes. Parents should include the Personal are encouraged to notify a health Child Health Record (Red visitor or GP as soon as possible Book) and NHS Choices, if babies, toddlers or young which should highlight the children appear to have any importance of children's eye problems with their eyes or sight, health, as well as potential including if they have a squint; risk factors for children's Parents do not if they have any difficulty in eye health, the importance receive enough seeing small objects or if there is of screening at school entry, any family history of serious eye regular eye examinations information about disease that started in childhood. and as a minimum a first eye children’s eye health Parents are also informed that examination to take place no and the importance their child should be offered a later than the age of six as vision test as part of their routine well as information about the of regular eye school entry physical examination, services available examinations between the age of four and five years old, but it is not clear that • Better training on the the screening is primarily for lazy importance of eye health eye (amblyopia) and is not an is needed for all health, eye examination. education and social care professionals working In addition, parents are not with parents, children and provided with information young people, to maximise about the risk factors for vision opportunities for providing defects and poor eye health, and reinforcing information such as the risks associated about eye health with unprotected UV exposure to children of all ages.

26 Children’s eye health

5.4 Commissioning of services The system for commissioning eye health services for children and young people described below is specific to England, different arrangements are in place in Scotland, Wales and Northern Ireland. Commissioning of services for children and young people, including the screening programmes highlighted above, is fragmented in England.

Following the transfer of In the six months from April to national service specification responsibility for children’s public September 2015, the NHS invested was developed and implemented, health services to local authorities an estimated £30 million in these providing significant opportunities from 2015 (under the Health and community eye services for for improving service provision. Social Care Act 2012), the universal children up to the age of 1611. screening checks for children aged up to five years old are now the Clinical commissioning groups The current approach to responsibility of local councils. (CCGs) have responsibility for commissioning creates a This includes the new baby review commissioning enhanced local risk that children and young and the six to eight week check eye services and can discuss people fall through the gaps when a baby’s eyes are screened local eye care services with in service provision and does as previously described. Although both NHS England and Local not take sufficient account of the delivery of these services will Eye Health Networks. Currently, opportunities for community continue to be through GPs and many of these services are not provision, not only to move health visitors, responsibility for the commissioned against a national services closer to children’s funding has moved and could be protocol, meaning standards homes but also to reduce affected by the current cuts and pathways can vary across duplication and therefore to public health budgets26. the country. As has been noted offer better value for earlier, a Children’s Vision the NHS. In addition, responsibility Community Service Pathway has for school-based screening been developed by LOCSU to programmes sits with local enhance the current screening authorities in England as part of programme. In this pathway the Healthy Child Programme. community optometry provides Again, taken from the public early intervention for children We recommend: health budget but delivered by following school screening with a health services, the arrangements maximum lead time of two weeks. NHS England should work for this programme vary across This provides increased access with the Clinical Council for the country. and choice for patients as well as Eye Health Commissioning increased capacity and reduced (CCEHC) to develop national Access to free eye examinations waiting times in secondary care service specifications and and glasses for children and to treat those children who have pathways to move more young people is provided by complex issues. Given that an services currently delivered the NHS through the General outpatient appointment in hospital in secondary care into the Ophthalmic Services Contract. costs around £120, this could community, so that only those These arrangements include be more cost efficient than the children with the most complex reimbursement rates for children acute care model. needs are referred to secondary and young people's eye care, speeding up diagnosis examinations and vouchers There will be other services and treatment for all children for glasses and repairs currently delivered in secondary and young people or replacements. care that could be moved into the community if a similar

27 Seeing the future Boots Opticians Green Paper on children’s eye health

The opportunity to make a difference now Good eye health can have an impact on children and young people’s wider life chances. Improved access to eye health services could affect:

6.1 Literacy, educational attainment and employability 6.2 Wider health and wellbeing 6.3 Sport, fitness and physical activity

28 29 Seeing the future Boots Opticians Green Paper on children’s eye health

6.1 Literacy, educational attainment and employability

Children do not necessarily complain about their vision but their behaviour may change as a result of not being able to see properly. One area where this could have a major effect is in school. It is possible that children who are no longer able to see properly may become disengaged or disruptive in lessons, they may also fall behind in their work or avoid activities they find difficult. We have had feedback through our School Vision Screening Programme that, for some children, correcting their vision has had an impact on both learning and behaviour12. Around 80 per cent of Recent research has shown a Low literacy is also associated link between lower visual acuity at with a higher likelihood of people what children learn is school entry and reduced literacy being unemployed. In 2011, 24 through sight, and so at four to five years old3. Similarly, per cent of people not in work 13 the impact of problems uncorrected long-sightedness had entry level literacy skills . has been shown to be linked to The National Literacy Trust has with children’s eye sight difficulty with early literacy skills highlighted low levels of literacy as on literacy and education that affect later ability to learn to a driver of inequality in the UK with 25 attainment could be read and write . a clear link between low literacy and poverty: low literacy has a significant. The impact of poor literacy can negative impact on household be lifelong. A review by the earnings, and low earnings have National Literacy Trust has shown an impact on literacy through lack that literacy is related to people’s of access to resources13. earnings: people with functional literacy skills earn on average 16 The wider implications of socio- per cent more than those with economic deprivation have been lower literacy skills4. Similarly a demonstrated through research Skills for Life survey in 2011 such as the Marmot Review Fair found that more than one in four Society, Healthy Lives, into the of those earning less than £10,000 impact of health inequalities, had entry level literacy skills, which found inequalities in life compared to only four per cent expectancy and quality of life5. of those who earned more Health outcomes are positively than £30,00013. affected when people have a decent job, a decent home and decent human relationships all of which are improved with greater literacy skills; and we know that poor vision is a barrier to literacy.

30 The opportunity to make a difference now

The impact of poor literacy can The virtuous circle of good eye health, improved attainment, be lifelong improved life chances and wider social wellbeing must not be ignored. People’s We recommend: abilities to get a good job, live It is critical that changes are in a decent home and have School governors must made to ensure all parents, healthy relationships could all ensure schools maximise the children and young people are be affected by issues with their resources available to support aware of, and can access, eye eye health such as uncorrected the eye health of their pupils, health services. Taking action vision problems. such as free vision check tools for example through checking and staff time from external whether school screening organisations is in place and regular eye examinations, can identify and address problems quickly before they have a wider impact. This is not only preferable for the individual but could be more effective and cost-effective for society as a whole. Enabling children and young people to achieve their full potential, could help to bridge the current skills and productivity gaps in the UK economy.

31 Seeing the future Boots Opticians Green Paper on children’s eye health

32 The opportunity to make a difference now

6.2 Wider health and wellbeing Low literacy, which could be driven by poor vision, can also have an impact on a person’s ability to manage their health and wellbeing in an optimal way.

The National Literacy Trust The wider impact on lifelong health and wellbeing cannot be overlooked when has found that ‘low literacy considering the importance of investment in can limit an individual’s ability children’s eye health services. Taking action to obtain, process and earlier to ensure children have good eye health, and therefore good literacy, can support them understand information to look after their own health and avoid a about health’4 catalogue of issues later in life, which can also lead to increased costs for the health service. If we do not take action now, the impact for the current generation of children and young people will be significant and long-lasting.

We recommend: Better training on the importance of eye health is needed for all health, education and social care For example, people with low literacy levels find professionals working with parents, children and it more difficult to manage medication for existing young people, to maximise opportunities for health conditions: people with low literacy are up providing and reinforcing information about to 18 times less likely to be able to identify their eye health medicines than those with adequate literacy. They are also less likely to be able to demonstrate how to take their prescription medication properly4. Failure to take medicines properly is a major cause of attendances at accident and emergency departments and, in the case of medicines such as antibiotics, can have serious wider implications for public health28.

More broadly, poor literacy and low educational attainment are associated with negative health behaviours. Studies have found that people with non-functional literacy skills are nearly three times more likely to smoke than people with functional literacy. It is difficult to demonstrate a direct causal link to the impact of other related socioeconomic factors but it is clear that the relationship between literacy and health choices needs to be explored further4.

33 Seeing the future Boots Opticians Green Paper on children’s eye health

6.3 Sport, fitness and physical activity The importance of physical activity for children and young people’s health and wellbeing is widely documented. can also be less willing to take Indeed, children part in sport for fear of their glasses being knocked off or the reactions who spend more of others which could involve being time outside are asked to remove them for the We recommend: found to be at activity. The current arrangements need to be considered to enable lower risk of short- Consideration needs to be children and young people to given to how the current sightedness (myopia) receive contact lenses and other voucher system can enable than those who lead technologies such as prescription children and young people to swimming goggles free of charge access the vision correction more sedentary through the NHS as this could 1 solutions appropriate to lifestyles affect their ability to stay fit support them to participate and healthy. fully in sport and cultural Beyond the immediate health activities such as additional benefits of being able to engage pairs of glasses where clinically Current government guidelines in physical activity, it is important necessary, contact lenses and recommend that children aged to recognise the wider benefits sports eyewear 5 to 18 should engage in moderate young people may also experience to vigorous intensity physical in increased confidence and activity for at least 60 minutes a social inclusion through better eye day. In 2011, only 32 per cent of A combined effect health. People with sight loss are boys and 24 per cent of girls more likely to suffer from social All three of these factors are linked aged 2 to 15 in England achieved isolation14. Access to different and can compound the effects of the recommended levels of technologies can mean children one another. Children who are more physical activity29. It is therefore and young people are more willing active and engaged are more likely critical that we seize every to put themselves forward to to be able to concentrate in school. opportunity to increase children take part in activities than if they This is more likely to lead to greater and young people’s participation were wearing glasses. Beyond levels of literacy and educational in physical activity. sport, this could include drama, attainment which improves not only The impact of poor vision on singing or opportunities such their employability but also their children and young people’s ability as debating societies all of which health literacy and the ability of to engage in physical activity can have significant health and young people to live the lives should not be overlooked. It is social benefits. they want. important that children can access Enabling young people to fully It is clear that strong foundations the most appropriate option for grasp such opportunities supports of good eye health in childhood them to correct their vision, given their health and wellbeing and will have a significant long term the activities they are, or want to allows them to develop skills that impact for individual children and be, involved in. For example, a they will need throughout their lives, for society as a whole. We need variety of sports including rugby, such as team working, negotiation to take action now to deliver this. swimming, dancing and even and assertiveness. At a time when Because children’s vision matters. running can be negatively affected the mental health and wellbeing by wearing glasses. Children and of children and young people is young people who wear glasses rightly of concern, the impact of interventions such as improving eye health must not be overlooked. 34 The opportunity to make a difference now

35 Seeing the future Boots Opticians Green Paper on children’s eye health

How to achieve our full potential

36 37 Seeing the future Boots Opticians Green Paper on children’s eye health

Summary It is time that children’s eye health is given the same priority as conditions such as obesity and tooth decay, which are seen Our recommendations as major public health challenges. A. Education and information for parents The potential wider, long-lasting and carers must improve through a national impact of poor eye health in awareness campaign and updated resources. childhood means that we must These should include the Personal Child Health take action now. We must create Record (Red Book) and NHS Choices, which should highlight the importance of children's more, and better signposted, eye health, as well as potential risk factors for opportunities for children children's eye health, the importance of screening and young people to access at school entry, regular eye examinations and as appropriate eye health services. a minimum a first eye examination to take place no later than the age of six as well as information The following recommendations are based about the services available on Boots Opticians expertise in delivering eye health services for children and young people B. Mandatory commissioning of a fully funded combined with the research outlined in the previous screening programme for all children aged four to sections. We have included more detail on how five, to be updated to maximise the opportunities these recommendations should be implemented of community provision, including catch-up below (from page 44 onwards). provision, alongside better data collection on the coverage and impact of the programme While our recommendations in this Green Paper focus on the system in England, we are C. Better training on the importance of eye committed to working in partnership with health is needed for all health, education and stakeholders across all four nations of the social care professionals working with parents, UK to implement the principles underpinning children and young people, to maximise improvements in eye health services for all opportunities for providing and reinforcing children and young people. information about eye health D. School governors must ensure schools maximise the resources available to support the eye health of their pupils, such as free vision check tools and staff time from external organisations

E. Consideration should be given to how the current voucher system can enable children and young people to access the full range of vision correction solutions, such as additional pairs of glasses where clinically necessary, contact lenses and sports eyewear

F. NHS England should work with the Clinical Council for Eye Health Commissioning to develop national service specifications to move more services currently delivered in secondary care into the community, so that only those children with the most complex needs are referred to secondary care, speeding up diagnosis and treatment for all children and young people

G. Consideration should be given to how providers can ensure that their services are accessible to children and young people, including through investment in technology, staff and training and the design of services 38 How to achieve our full potential

It is clear that not all children and young people are able to access the eye health services they need. Much of this is a result of poor information and education for their parents at critical points in the early years. The importance of the good foundations for eye health is currently overlooked. If these recommendations were implemented in full, a new pathway for children’s eye health would be delivered, as set out on the following page

39 Seeing the future Boots Opticians Green Paper on children’s eye health

Figure 1: Model children’s eye health pathway

The new-born Vaccinations Start of physical examination primary school and 6–8 week check

• Expectant parents should have • Through the regular • Teachers use the excitement the importance of their child’s vaccination schedule, of starting school to remind eye health highlighted during healthcare professionals parents of key eye health pregnancy discuss eye health as part messages including: of a wider conversation • The Red Book provides with parents about health − The need for regular eye information for parents about and wellbeing examinations and notification eye health, including: if a school screening • Good habits are established programme is in place − Why looking after children's early as parents are reminded eye health is important on a regular basis that even − The importance of time spent outdoors to reduce − The importance of vision very young children can have their eyes tested the risk of short-sightedness screening at school entry and (myopia) an eye examination if screening is not provided − How to protect from UV

− Children and young people’s − How to monitor and entitlements to free eye tests manage screen time on and corrective technologies digital devices including glasses and contact lenses under the NHS

− How to protect children’s eyes from the start, including the impact of good nutrition on eye health

• This is reinforced for parents 40 at the 6–8 week check How to achieve our full potential

Age four–five Age six–seven Start of amblyopia screening secondary school programme

• The four-five year old • All parents receive a • Parents receive tailored screening programme is reminder that children information about the universally available, should have a full eye importance of continuing to supported by community examination no later than maintain their children’s eye providers, including good the age of six, if they have health as they grow and their catch up opportunities not had one already, and learning changes regular eye examinations • Parents receive high quality after that • The importance of encouraging information about how the time outdoors and managing screening programme is • The information also screen time screen time on different from a full eye reinforces the importance digital devices are highlighted examination and the of protecting children from along with information about importance of taking their UV, the benefits of time young people’s entitlements children for regular eye spent outdoors and how to glasses and contact lenses examinations even when to manage screen time on through the NHS they have received the digital devices screening30

41 Seeing the future Boots Opticians Green Paper on children’s eye health

Figure 1: How we are currently working to deliver these recommendations

Because children’s vision matters, at Boots Opticians we have already taken significant action to improve the services we provide for children and young people:

We have worked with the National Literacy Trust to develop Zookeeper Zoe, an interactive story containing a range of eye check activities for parents to read with their children and help them identify whether a full eye examination with an optometrist is required

“Boots Opticians have been working with the L.E.A.D. Academy Trust in Nottingham. Teams As well as the book being available digitally as an App, half a million copies have been given of volunteers have been lined up to provide away for free in schools, in our practices and reading support at four of the academies in in Boots UK stores across the country, which the Trust (Edna G Olds, St Ann’s Well, Jubilee demonstrates the unmet need among parents and Radford) where many of the pupils speak for information about their children’s eye health. English as a second language. This support We have launched the Boots Schools Vision is being provided every week on an on-going Screening Programme to support schools to quickly basis. Volunteers have also led whole-school and easily check the vision of their pupils. Aimed assemblies at both Edna G Olds and Radford mainly at children aged 4–7, it can be used with and taken the Boots Opticians Schools all children of primary school age. The programme Challenge bus to entertain and inform parents allows schools to take action to improve the eye health of their pupils, providing web-based resources and pupils on the importance of eye health and to carry out vision checks as well as enabling them reading for enjoyment. They’ve also launched to, at the touch of a button, provide a letter to advise the Vision Screening application, which has led parents if a further referral is recommended and to teachers sitting pupils in different places in reminding them of the importance of regular the classroom to support their learning.” eye examinations. L.E.A.D Academy Trust

42 How to achieve our full potential

However, no single organisation can make all of the changes that are needed to deliver for children and young people. Boots Opticians is keen to work in partnership with policy-makers, parliamentarians, commissioners and other partners to deliver improved access to high quality eye health services for all children and young people

Through our partnership with the National Literacy We have recently upgraded our Peterborough and Trust we have developed our Schools Challenge, Wimbledon practices specifically to appeal to children which provides two days of colleagues’ time a year and young people. We will be adapting further stores to engage with schools through activities such as where this is appropriate to local community needs reading with children and providing special assemblies and expect this to become an important part of our and classroom sessions to help children learn more property portfolio in the future. about their eye health. The programme uses games Working with external stakeholders we are gathering and fun activities to support children not only to protect information which will be valuable for future research their eyes but also to enjoy reading and learning. on children’s eye health and how services will need We are using television advertising to raise awareness to change to meet their needs. among parents of the services available and also the We are evaluating technology to enable an importance of regular eye examinations to protect their increased level of participation by very young children's eye health. children in eye examinations and are supporting We are training our own colleagues to ensure that work in local areas such as the 'Test around Two' they have the skills and confidence to increase the initiative in Essex. accessibility of our services for children and young people, and are investigating new technologies which “We have had six children out of our forty increase the accuracy of eye examinations for two that are now going to make appointments even very young children. for a full eye test due to not being able to see the smaller lines of symbols. We have had We are providing feedback from parents about how pleased information and they are that this is being offered”. support to teachers, “One child in early years foundation stage school nurses and other was identified through the screening and is professionals to ensure now wearing glasses – she has caught up quickly with her peers and her confidence that they understand and enjoyment at school has flourished.” the importance of eye “Three children have been referred for health and regular eye specialist support in school; with one found examinations and are to have a visual difficulty and another a able to communicate visual impairment" this to parents, children Feedback from teachers involved and young people. in our Schools Challenge

43 Seeing the future Boots Opticians Green Paper on children’s eye health

Figure 2: Implementing our recommendations

The following table sets out a proposed plan for implementing our recommendations, detailing what action is required, who needs to be involved and a proposed timeline for delivery:

44 How to achieve our full potential

Recommendation A: Education and information for parents and carers must improve through a national awareness campaign and updated resources. These should include the Personal Child Health Record (Red Book) and NHS Choices, which should highlight the importance of children's eye health, as well as potential risk factors for children's eye health, the importance of screening at school entry, regular eye examinations and as a minimum a first eye examination to take place no later than the age of six as well as information about the services available

Action required Responsible Timeline organisations

A national awareness campaign Public Health England Development work should should be developed and run for begin immediately with a parents and carers through TV, campaign delivered from radio and social media, to highlight early 2017 onwards the importance of regular eye examinations from the age of six, if not before, and to provide information on how to protect children’s eye health

Resources such as the Personal Department of Health, the Royal Development work should Child Health Record (Red Book) College of Paediatrics and Child begin immediately with a new and NHS Choices must be updated Health and local authorities Red Book rolled out nationally to include information for parents as soon as possible and carers on:

• Why looking after children's eye health is important

• The importance of vision screening at school entry and an eye examination if screening is not provided

• The risk factors for common eye conditions

• How to protect children’s eyes, including from UV

• The eye health benefits of spending time outdoors in reducing the risk of short- sightedness (myopia)

• How to manage and monitor screen time on digital devices

This will also be an opportunity to provide parents with information about the skills that their children develop, even from a young age, and the importance of reading to children and talking to them about what they can see

45 Seeing the future Boots Opticians Green Paper on children’s eye health

Recommendation B: Mandatory commissioning of a fully funded screening programme for all children aged four to five, to be updated to maximise the opportunities of community provision, including catch-up provision, alongside better data collection on the coverage and impact of the programme

Action required Responsible Timeline organisations

All children must receive this National Screening Committee Immediately, with universal screening regardless of which coverage from the school year school they attend and where CCEHC starting in September 2017 they live. Sufficient funding must Local authorities be provided by local authorities to reach all children, including Clinical Commissioning ensuring that children with Groups special educational needs have full eye examinations beyond the standard screening

In addition, the screening programme needs to be supported by commissioning of community optometry and optics to increase capacity and choice and ensure the children who need care most are seen in secondary care sooner

The National Screening Committee National Screening Committee As part of their current review should review the role of community of the programme providers in delivering the screening Public Health England programme and catch up services. This will ensure that the follow up to screening is provided as close to children’s homes as possible. This could be modelled on the Children’s Vision Community Service Pathway

Data on the coverage and uptake Public Health England Immediately, with the data of the screening programmes, included in the next iteration one of the VISION 2020 indicators CCEHC of the profiles 31 of eye and health care 2015 , LEHNs should be included in the Child Health Profiles published by Public Health England. This will help to improve data collection and analysis to identify areas where investment in the screening programme is required and to improve understanding of the long-term implications for health and wellbeing of missing eye health problems early on32 46 How to achieve our full potential

Recommendation C: Better training on the importance of eye health is needed for all health, education and social care professionals working with parents, children and young people, to maximise opportunities for providing and reinforcing information about eye health

Action required Responsible Timeline organisations

Training providers must Training providers As soon as possible ahead of update the training curricula the start of the academic year for teachers, social workers, Optometry Schools starting in September 2017 health professionals and youth workers to provide up-to-date information on children and young people’s eye health and how to engage parents at every opportunity

Boots Opticians are prepared to develop and make available a training module for providers

Optometry teaching institutions should review the exposure students receive to children as undergraduates

The wide-ranging nature of NHS England, Clinical As soon as possible in the the professionals who engage Commissioning Groups financial year 2017/18 with parents, children and young and local authorities people provides an opportunity for reinforcing critical eye health messages. These professionals must have up-to-date information on which to base these conversations

47 Seeing the future Boots Opticians Green Paper on children’s eye health

Recommendation D: School governors must ensure schools maximise the resources available to support the eye health of their pupils, such as free vision check tools and staff time from external organisations

Action required Responsible Timeline organisations

Children’s eye health should National Governors Association Immediately be a priority for schools, given the potential impact on their ability to learn, play sport and socialise. Alongside the current screening programme, or in place of it where there is no provision, schools have a number of resources available to them to check children’s vision. It is vital that schools maximise these opportunities, including free resources such as the Boots Opticians School Vision Screening Programme, developed and launched in partnership with the National Literacy Trust www.bootsvisionscreen.co.uk

Schools must also take up opportunities provided by companies for external support such as the information sessions and volunteering days that are available through Boots Opticians colleagues as part of the Schools Challenge

Schools must highlight to parents the importance of children's eye health, school entry screening and regular eye examinations with community optometrists

Schools are in an excellent position to inform parents about the importance of eye health for key skills development and to reinforce messages that an undiagnosed eye problem could affect their child’s ability to learn to read and to achieve their full potential

48 How to achieve our full potential

Recommendation E: Consideration needs to be given to how the current voucher system can enable children and young people to access the full range of vision correction solutions, such as additional pairs where clinically necessary, contact lenses or sports eyewear

Action required Responsible Timeline organisations

NHS England should work with NHS England Discussions should begin the CCEHC, the Optometric Fees immediately with a view to Negotiating Committee (OFNC) CCEHC implementing arrangements and community providers to OFNC in the financial year 2017–18 consider how the voucher system can enable children and young Community providers people to access appropriate vision correction solutions to support them to participate fully in sport and cultural activities

49 Seeing the future Boots Opticians Green Paper on children’s eye health

Recommendation F: NHS England should work with the Clinical Council for Eye Health Commissioning (CCEHC) to develop national service specifications and pathways to move more services currently delivered in secondary care into the community, so that only those children with the most complex needs are referred to secondary care, speeding up diagnosis and treatment for all young people

Action required Responsible Timeline organisations

NHS England needs to engage NHS England Immediately with the CCEHC to identify those elements of eye care which are CCEHC currently delivered for children and young people in secondary care but could be delivered in the community and ensure only those children with the most complex needs are referred to secondary care services

Once the areas of care that can NHS England As soon as possible and not move into the community have later than early 2017 to enable been identified, NHS England CCEHC specifications to be used in should work with the CCEHC on Local Eye Health Networks (LEHN) the financial year 2017–18 a programme to develop a series of national specifications and Local Optical Committee Support pathways, potentially modelled on Unit (LOCSU) the Children’s Vision Community Service Pathway. This would enable commissioners to adopt new models of care for children and young people to meet local need without risk of duplication or variations in standards

Following the development National and local From the start of the of the national specifications, commissioners 2017-18 financial year commissioners should work with local communities to LEHNs identify and prioritise those areas of local need where community provision is required and commission services for children and young people accordingly

50 How to achieve our full potential

Recommendation G: Consideration should be given to how providers can ensure that their services are accessible to children and young people, including through investment in technology, staff and training and the design of services

Action required Responsible Timeline organisations

Providers need to invest in up Providers Immediately, and on an to date technology to deliver ongoing basis accurate eye examinations for even very young children. Boots Opticians is already exploring and investing in the new technology which is likely to revolutionise how we deliver services

Providers should consider Providers Immediately, and on an their local demographics and ongoing basis ensure that their services are designed to meet the needs of children and young people. Boots Opticians has already started this process by completely redesigning some of our services for children and young people. This is part of our ongoing development programme

Providers should ensure that Providers Immediately, and on an their colleagues have the ongoing basis appropriate training not only to use new technology for checking children’s eyes, but also to have the skills and confidence to communicate with parents, children and young people. Boots Opticians is already developing training for our colleagues to make sure all children and young people feel welcome in our practices

Providers should ensure appropriate clinical training and regular exposure is available to ensure optometrists are confident and skilled in performing eye examinations on younger children

51 Seeing the future Boots Opticians Green Paper on children’s eye health

8. Conclusion and next steps As a health-led optician, we at Boots Opticians see the impact of eye health and vision problems for children and young people every day. We have put this knowledge and expertise into this Green Paper and its recommendations. If we fail to take action now the consequences for children and young people will be significant Beyond our ongoing and long-lasting. The effects of poor eye health activities to improve are evident in children’s attainment and employability and, as demonstrated by the eye health services Marmot Review, could have a much wider impact on health and social inequalities. for children and

We intend to work in partnership with policy-makers, young people, parliamentarians, commissioners, professional we will now be bodies and other partners to support them to implement our recommendations and take action taking further now for children and young people. This will have an effect not just today but for years to come. action to:

For more information about Boots Opticians, • Meet individual parliamentarians and and the recommendations in this Green Paper, policy-makers to help us implement the please email [email protected] recommendations in the Green Paper

• Explore the economic benefit of the recommendations we have made to demonstrate the impact on the NHS of improving children’s eye health

• Work with partner organisations to identify areas of common activity that can support children’s eye health

• Consider how we can change our services and pilot a new approach in a local area

• Engage in specific research and activity around how vision correction solutions, such as contact lenses, could be made more widely available to children and young people

Because children’s vision matters.

52 Conclusion and next steps

53 Seeing the future Boots Opticians Green Paper on children’s eye health

9. References

54 References

1 McCullough, S et al, ʻSix- 9 NHS Choices, Short-sightedness 18 Page, J et al, Department for year refractive change among (myopia), September 2015. children, families and schools, white children and young adults: Available at: http://www.nhs.uk/ Engaging effectively with black evidence for significant increase Conditions/Short-sightedness/ and minority ethnic parents in in myopia among white UK Pages/Introduction.aspx children’s and parental childrenʼ, PLOS ONE, services, 2007 10 January 2016 UK National Screening Committee, Recommendation 19 Welsh Government, Proposal: 2 The College of Optometrists, on vision defects screening in School Pupil Eye Care Service for Britain’s eye health in focus, children, December 2013 Wales (SPECS), February 2016 2013 11 Health and Social Care 20 The College of Optometrists, 3 Bruce A et al, ‘Impact of visual Information Centre, General See the Gap, June 2016 acuity on developing literacy at ophthalmic services, selected 21 age 4–5 years: a cohort-nested activity statistics for England – World Health Organization, cross-sectional study’, April 2015 to September 2015, Protecting children from BMJ Open, 2016 January 2016 ultraviolet radiation, July 2001. Available at: http://www.who. 4 Joe Morrisroe, National Literacy 12 Boots Opticians survey int/uv/resources/fact/en/ Trust, Literacy changes lives responses from School Vision fs261protectchild.pdf 2014: a new perspective on Screening participants, 22 health, employment and crime, available on request NHS Choices, New-born physical September 2014 examination. Available at: 13 Department for Business, http://www.nhs.uk/Conditions/ 5 Professor Michael Marmot, Innovation and Skills, The 2011 pregnancy-and-baby/Pages/ Fair society, healthy lives: skills for life survey: a survey of newborn-physical-exam.aspx strategic review of health literacy, numeracy and ICT levels 23 inequalities in England post- in England, 2012 Local Optical Committee Support 2010, February 2012 Unit, Children’s vision community 14 NHS England, Improving eye service pathway, November 2013 6 NHS England, Five Year health and reducing sight loss – 24 Forward View, October 2014 a call to action, June 2014 Office for National Statistics, Population estimates for 7 Estimated using 2016 DfE 15 NHS Choices, Squint, January England and Wales mid-2012, School Census data and school 2015. Available at: http://www. 26 June 2013 vision survey conducted by nhs.uk/conditions/Squint/Pages/ 25 Professor D Thomson, City Introduction2.aspx Kulp M T et al, Uncorrected University. Median estimates hyperopia and preschool early 16 used for purpose of this NHS Choices, Childhood literacy, Ophthalmology, 2016 cataracts, January 2016. calculation 26 Available at: http://www.nhs.uk/ Local Government Association, 8 NHS Choices, Lazy eye Conditions/Cataracts-childhood/ Children’s public health transfer, (amblyopia), June 2016. Pages/Introduction.aspx September 2015 Available at: http://www.nhs. 17 27 uk/conditions/Lazy-eye/Pages/ Rahi J et al, ʻSevere visual Statistics taken from the Eyecare Introduction.aspx impairment and blindness in Trust based on the Department children in the UKʼ The Lancet, for Children, Schools and Vol 362, 25 October 2003 Families 2009 School Census 0–12 year olds

55 Seeing the future Boots Opticians Green Paper on children’s eye health

28 McDowell, A. ʻHow improved 36 Logan, N. S. et al, ‘Childhood medication adherence can ethnic differences in ametropia prevent costly medicine wasteʼ, and ocular biometry: the Aston HSJ, February 2012 Eye Studyʼ, Ophthalmic & Physiological Optics, July 2011 29 UK Departments of Health, Start active, stay active: a report 37 Yip, J. et al, ‘Area deprivation, on physical activity for health individual socioeconomic status from the four home countries’ and low vision in the EPIC- Chief Medical Officers, Norfolk Eye Studyʼ, Journal of 11 July 2011 Epidemiological & Community Health, August 2013 30 Hall, D. and Elliman, D., Health for all Children, 38 Biddyr, S. & Jones, A., September 2006 ‘Preventing sight loss in older people. A qualitative study 31 VISION 2020 UK Ophthalmic exploring barriers to the uptake Public Health Committee, of regular sight tests of older Portfolio of Indicators for people living in socially deprived Eye Health and Care, communities in South Walesʼ, October 2015 Public Health, February 2015

32 The College of Optometrists, Better Care, Better Data. Ophthalmic public health data report, 2013

33 NHS Choices, Long-sightedness, August 2016. Available at: http://www.nhs.uk/conditions/ Long-sightedness/Pages/ Introduction.aspx

34 NHS Choices, Astigmatism, October 2014. Available at: http://www.nhs.uk/conditions/ Astigmatism/Pages/ Introduction.aspx

35 Jung, S et al, August 2012, ‘Prevalence of Myopia and its Association with Body Stature and Educational Level in 19-Year- Old Male Conscripts in Seoul, South Koreaʼ, Investigative Ophthalmology & Visual Science

56 57 About Boots Opticians Boots Opticians is one of the leading opticians in the UK with 637* practices, of which 177* operate on a franchise basis. Around 30 per cent of practices are located in Boots stores with the majority being standalone optical practices. We employ approximately 1,500 optometrists.

In 2009, Boots Opticians merged with Dollond & Aitchison to create the second largest optical chain in the UK. Both businesses had a strong heritage and an excellent reputation for quality care, harnessing over 250 years of optical experience. This has included launching our own brand of frames and being the first UK chain to launch daily disposable contact lenses. In August 2013, Boots Opticians became the first multiple optician in the UK to include digital retinal photography as a standard element of its eye test for customers of all ages.

In 2013–14, Boots Opticians conducted over 2.5 million eye examinations across the UK.

* As at 31 August 2015 excluding equity method investments

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