All Party Parliamentary Group on Eye Health and Visual Impairment

All Party Parliamentary Group on Eye Health and Visual Impairment 22 October 2008, Committee Room 19

Children’s vision screening: Safeguarding sight and educational attainment

Observers: Michelle Acton (MA), Fight for Sight Shelagh Baynham (SB), British & Irish Orthoptic Society Mike Brace (MB), Vision 2020 UK Brenda Billington (BB), Royal College of Ophthalmologists Ellen Colquhoun (EC), College of Optometrists David Challinor (DC), Optometry Today John Dickinson-Lilley (JDL), RNIB Barry Duncan (BD), ABDO Kathy Evans (KE), Royal College of Ophthalmologists Tony Garrett (TG), ABDO Margaret Gilbert (MG), HOC Simon Grier (SG), General Optical Council Ian Humphreys (IH), College of Optometrists Vidan Hjandinl (VH), ITV Diversity Advisor Penny Jagger (PJ), Royal College of Ophthalmologists Anne Klepacz (AK), Keratoconus Support Group Sarah Lapham (SL), Eye Health Alliance Francesca Marchetti (FM), College of Optometrists Sanjay Patel (SP), College of Optometrists Geoff Roberson (GR) Association of Optometrists Sonal Rughani (SR), RNIB Nicolas Russell (NR), Guide Dogs Dan Scorer (DS), RNIB Jane Veys (JV), Vision Care Institute, Johnson & Johnson Vision Care Vibha Vora (VV), British & Irish Orthoptic Society Colin Whitebourn (GW), Action for Blind People Janna Wilkinson (JW), College of Optometrists Steve Winyard (SW), RNIB Cathy Yelf (CY), Macular Disease Society

MPs and Peers: Sandra Gidley MP (Chair) Doug Naysmith (MP Bristol & North West) David Heath (MP for Somerton & Frome) Simon Hall (for Edward Davy MP)

Speakers:

 Dr David Elliman, Consultant in Community Child Health, Islington PCT and Great Ormond Street Hospital and member of the UK National Screening Committee and  Dr Jugnoo Rahi, Ophthalmologist and Clinical Lecturer in Epidemiology, Great Ormond Street Hospital  Professor David Thomson, Department of Optometry and Vision Science, City University. 1. Introduction

The group’s Chair, Sandra Gidley MP, opened the meeting and introduced the speakers. SG said Dr David Elliman would set out the current screening recommendations and highlight the importance of screening both for the reduction of preventable sight loss among children and for safeguarding access and participation in education. Professor Thomson would present an alternative model that had been developed in collaboration with orthoptists in Barnet and successfully implemented by four Primary Care Trusts.

2. Dr David Elliman (DE) & Dr Jugnoo Rahi (JR) Gave the UK National Screening Committee’s (UKNSC) definition of screening and highlighted the importance of any screening programme having been approved by the UKNSC. He outlined the current provision and the criteria that need to be considered for any screening programme.

DE said there is a need to identify those at risk of having a problem without mislabelling those without a problem. He said this can be a fine balance and any tests require the cooperation/approval of the population.

DE explained that there is little point in identifying a problem where there is no appropriate management system in place for treatment. He said it is important to have evidence that the whole screening programme works, from the beginning to the end, and that it is appropriate and socially acceptable. He said any harm caused by screening must be outweighed by the benefits.

Current screening provisions: Newborn and infant physical examination takes place before 72 hours, and at 6-8 weeks and includes: - A full physical examination - 4 screening components – including checking if the eye is properly formed (routine physical examination)

This screening has been in place for 30+ years but is poorly maintained and run, there is a need to monitor quality and assurance in the future.

DE set out the current Vision Screening requirements for 2-5 year olds (Pre-school):

- All children should be screened for impairment of visual acuity by an orthoptic- led service at 4-5 years old - Agreed referral criteria - High population cover

DE highlighted the conclusion of a report by the Child Health Sub-Group evaluating vision screening against the NSC criteria. The report concludes that: "It is recommended that all children should be screened for visual impairment between four and five years of age. This should either be conducted by orthoptists or by professionals trained and supported by orthoptists. Once this programme is in place, the school entry vision screening programme should cease. No other preschool vision screening can be justified". DE said a survey of Orthoptic Services in UK had found - Response rate 72-90% - Screening by Orthoptists – 55% England, 67% Scotland

DE said that a letter was about to be sent to the Directors of Public Health at all Primary Care Trusts reminding them of the importance of visual screening at 4-5 years and suggesting an audit to develop a better understanding of the circumstances within their local area.

3. Professor David Thomson DT said his presentation would outline the process behind developing a cost effective new model of a computer based screening system that has been successfully trialled by Barnet Primary Care Trust.

DT considered the importance of vision screening, stating that learning is the acquisition of knowledge and skills through the senses therefore any sensory deficit will make learning more difficult. He said sensory deficits will impact on the learning process and he supported the case for vision screening, presenting evidence that eye problems among children are common (10-20%), usually remediable and have the potential to affect children’s social and educational progress. DT said parents tend to give their children’s eye care a low priority; they are more likely to take child to dentist.

DT said we should screen for the following conditions at the ages highlighted:

1. 4-5 years for amblyopia, refractive errors 2. 7 years – refractive errors, common BV anomalies 3. 11+ years – Self administered Visual Acuity and colour vision

He suggested the alternative screening model, developed in collaboration with orthoptists in Barnet provided an effective solution. The model makes good use of new technology, eliminating paperwork, transcription errors and saving time, the tests can be carried out by trained lay personnel. The model also provides an engaging format for children, using modern computer screens that create high quality visual stimuli, the screening is seen by children as a computer game. Crucially the model provides customised reports and is able to generate letters to parents, statistics and audit information.

DT went on to say the results of an evaluation of the software on 336 children aged 4-5 years in six Barnet schools showed that the screener had a sensitivity and specificity of 94% and 98% respectively when compared to a clinical evaluation.

DT argued that the recommendation that the screening should be carried out by orthoptists was unworkable, given that over 700,000 children require screening each year and there are approximately 1300 orthoptists in the UK, many of whom are unavailable to carry out screening. He pointed to the Barnet model which employed and trained assistants to screen 4-5 year olds, supervised by an Orthoptist. The data was collated by a central database and a customised report was produced, indicating if a follow up appointment with an optometrist was necessary. 4. Questions/Comments

Dr Jugnoo Rahi asked David Thomson to clarify the difference between those tested, failed and treated. DT said the system had identified some false positives and some borderline cases which were being monitored.

Steve Winyard said RNIB had recently issued a request to Primary Care Trusts to see how many are actually carrying out the recommended screening. 10% of PCTs are not funding anything. He asked if RNIB or other organisations should be encouraging Primary Care Trusts to adopt the Barnet model.

Dr Jugnoo Rahi said the question to ask PCTs not implementing the current recommendations should be why not? She said that we should not confuse the issue of how you test.

Francesca Marchetti said her local Primary Care Trust is not implementing the screening recommendations and this may be due to funding issues. She asked David Thomson if the model would provide a more cost effective solution. DT said that the business model was overwhelming. David Elliman said that as well as the issue of cost effectiveness it was important to factor in referral rates and ensure that referrals were accurate, reducing the burden on secondary services, of those who are recommended for further investigations.

Francesca Marchetti asked if any necessary secondary screening could be referred to High Street Optometrists. David Thomson said that this is not the only appropriate model, this system has been effective in Barnet but other models may be more appropriate elsewhere.

Brenda Billington said she was fascinated by the computer screening programme and asked if it had been trialled in rural areas. She suggested that perhaps the Department for Children Schools and Families could consider getting the programme into schools. Sandra Gidley MP clarified that the Child Health Promotion Programme was co-sponsored by the Department of Education.

David Elliman asked how Professor Thomson would feel about schools implementing this model independently; he asked if there were any training issues. David Thomson said that the model was simply a tool that had to be used appropriately and that must be supervised and continuously monitored. He clarified that in Barnet a two day course for screeners had been run by Orthoptists.

David Heath MP said he had observed that Primary Care Trusts are not good at providing services in institutions like schools and prisons. He said that generally it is essential to have agreed processes of treatment in place and it is important to understand treatment options in different parts of the world.

Sandra Gidley MP thanked the speakers and stakeholders for their attendance and closed the meeting.