For low vision specialists and those who consult them
Opinion piece: Low vision care in a state-funded health system
August 25, 2009Posted by on
I have been watching the debate over US health care with interest. I thought it may be interesting to discuss my experiences of working in a state-funded health system, and to provide my honest opinions of its strengths and weaknesses. This is based on my experience of working in a specialist centre in London, and I appreciate that things may not be the same elsewhere in the country.
Low vision care in the state-funded system is free at the point of delivery: this means the cost of the appointment is covered by the government through tax revenue. Every person with visual impairment is entitled to be referred into a low vision clinic either by their family doctor (general practitioner) or by their ophthalmologist. (This may not happen in every area because of knowledge of our services, but that is a different problem). A new appointment would typically be given within 8-12 weeks of referral.
The standard of care is a one-hour low vision consultation with an optometrist during which a full history would be taken, the spectacle refraction checked, magnification needs assessed and magnifiers prescribed. Optical magnifiers are issued on a permanent loan system: they are loaned to the patient for as long as they are useful. Follow-up appointments are made at the discretion of the clinic – if someone is prescribed complex aids, has rapidly changing vision or significant occupational demands, for example, they will be reviewed after a few months.
Lighting, electronic aids and training are not covered by the NHS. Non-optical devices are supplied by the local sensory impairment team, who will make a home visit. Electronic magnifiers such as CCTVs are paid for by the education authority for schoolchildren; by the university disability fund for students; and by a government scheme called “Access to Work” for those in employment (where the employer is legally obliged half of the cost of the devices and the government contribute the rest of the cost).
Visual training (such as eccentric viewing training) is not offered by many NHS clinics because of the time and staff costs involved. However, some charities and local groups provide this training. Orientation and mobility training is provided by the local sensory impairment team.
I will give a hypothetical case to illustrate how the NHS works at its best.
Mrs A is an architect with albinism. Her vision has been stable for many years but its been some time since she had a low vision consultation. She attends her family doctor to ask for a review. The hospital receive the referral, and contact her to discuss a convenient time for an appointment. Mrs A attends an hour long consultation with me, although the clinic is quiet and I spend a little longer with her. I refract her and find a changed prescription, which gives an extra line of distance vision. I prescribe her a large bright field stand magnifier to help with blueprints and drawings, an illuminated hand magnifier to help read menus in dimly lit restaurants and some hyperocular spectacles to read the newspaper at home. I also give her a 4x distance vision monocular telescope to look at airport departure boards. She takes all of these devices away with her. I show her a portable CCTV system and give her information about local agencies who provide grants to assist with the cost of them if needed, but she feels that she would not use one. We also chat about screen magnification and screen reading software – I give her information about the Access to Work scheme, she has a workplace assessment and ends up with a 30″ screen and Zoomtext, paid for by the state and her employer. I make an appointment to see her in a year. Mrs A leaves the clinic with several hundred pounds worth of devices, much more understanding about where to seek further help from, and a script for new spectacles, all at no cost to her.
However, it doesn’t always work like this. There is only limited time for each person seen in the clinic: if someone really needs extended training in device handling or eccentric viewing training they are unlikely to receive this. If they need a CCTV but are unemployed and can’t afford one then they are at the mercy of charities to provide grants for these expensive devices. One of the elements of the clinic is that you don’t see a named person: for review appointments there is no guarantee that you will see the same clinician who assessed you at the first visit, nor can you request to see the most senior or experienced member of staff present rather than a (supervised) member of junior staff. Appointments will only be offered during office hours, Monday to Friday. You may have to wait for half an hour before being seen. The clinic probably won’t look as nice as an American hospital, although it will be clean.
There are centres in the USA that would provide far better low vision care – particularly for people who need extended device training – as long as they have good insurance, are a military veteran and could be seen in a Veterans Administration clinic, or if they are wealthy. My understanding is that Medicare does not cover low vision devices.
The ethos of a publically funded system is that it provides a certain standard of care for everybody, regardless of age, income, insurer or employment status, without direct cost to the patient. National Health Service low vision clinics are not perfect but they are open to every British citizen.
It is frustrating to me that I am able to offer better care to the private patients I see – they know that they will see me rather than another member of staff, they will have less time to wait and they can see me as often as they (or their insurer, or government) can afford.
Neither the UK nor the US system works perfectly, and I can’t see how we can get an equitable service with gold-standard care without very high taxation. However I fundamentally believe in the aims of the National Health Service: it seem fairer to me that there is a system where everyone gets standard care (everyone will receive magnifiers and spectacles if appropriate) than a system where one person gets the world’s best care whilst their uninsured neighbour doesn’t even get an illuminated hand magnifier supplied to them.