Docstoc

Tackling health inequalities in relation to sight loss developing colour blindness

Document Sample
Tackling health inequalities in relation to sight loss developing  colour blindness Powered By Docstoc
					Tackling health inequalities in relation
to sight loss: developing effective
strategies for groups most at risk

A report based on a workshop held on 21st January 2009


Pritti Mehta




                                                         1
Contents
Acknowledgements…………………………………… 2
Executive summary…………………………………… 3
Background…………………………………………..... 3
Workshop highlights…………………………………... 4
Key findings and conclusions……………………....... 8
Full presentations……………………………………… 11
Panel discussion………………………………… …..... 28
Appendix 1 – List of attendees……………………….. 30

Acknowledgements
I would like to convey a huge thank you to the speakers, Ray
Earwicker, James Nazroo, Ian Murdoch, Andy Cassels-Brown,
James Woodhead and Alastair Kent, for their presentations and for
working together with me to develop the programme for the day.

I would also like to thank Lesley-Anne Alexander, Fazilet Hadi, and
Stephen King for their input into the programme and for chairing
the day. Thanks also go to RNIB's Service Development and
Research team for their support on the day, and particularly to
Stuart Duncan and Pam Dalton.

In terms of the report, I'd like to thank Alastair Kent for providing a
paper and to James Nazroo for support in writing up his
presentation. I'd also like to thank Sharon Haffenden and Sonal
Rughani for their comments on the full report.




                                                                          2
Executive summary
On 21 January, 2009, RNIB held a workshop to look at health
inequalities in the context of sight loss. The goals were to: build a
better understanding of health inequalities, both generally and in
relation to sight loss; identify innovative strategies and solutions to
towards targeting and tackling these inequalities; and to build
strategic partnerships with key stakeholders. The event was
attended by a wide range of organisations and professional
groups, including Department of Health (DH) and NHS, Equality
and Human Rights Commission, DH Regional Public Health
Groups, UK Vision Strategy (UKVS), Royal College of
Ophthalmologists, Association of Optometrists, Vision 2020UK,
and Thomas Pocklington Trust. The key themes debated at this
event will continue to influence RNIB's strategy development in the
period 2009-14 and inform further research.

Background
Reducing preventable sight loss is a key priority and objective for
the UK Vision Strategy and RNIB‟s own five-year strategy.
However, to achieve impact on this agenda, there needs to be a
deeper understanding and targeting of health inequalities. As with
other common conditions, such as diabetes and coronary heart
disease, preventable sight loss does not seem to affect all groups
equally. Socially disadvantaged and excluded groups, including
lower socio-economic and minority ethnic groups, are considered
to be at greater risk. If prevention strategies are going to be
effective, they will need to address these inequalities.

This workshop considered the following themes:
1. The broader health inequalities agenda
2. Understanding health inequalities in relation to sight loss
3. Tackling health inequalities in relation to sight loss – developing
   local solutions
4. Tackling health inequalities in relation to sight loss: what can we
   learn from other sectors and organisations?




                                                                      3
Workshop highlights

1. The broader health inequalities agenda

Ray Earwicker, Health Inequalities Unit, Department of Health, set
the context and spoke about the DH Strategy and Programme of
Action on tackling health inequalities. His presentation highlighted
the Acheson report, the independent inquiry into health
inequalities, published in 1998, which demonstrated the existence
of health inequalities and their relationship to social class. The
Acheson report had influenced the development of a national
health inequalities target (for 2010), and a programme for action.
Addressing the underlying determinants of health was fundamental
to the approach. More recently, the Health Inequalities: Progress
and Next Steps report, published in June 2008, outlined a cross-
government strategy for reducing health inequalities post-2010.
This had three key strands, namely that: 1) it is everyone‟s
business; 2) no-one should be left behind; and, 3) it is about
quality as well as length of life. Three key themes emerge around:
1) the influences on health; 2) the lives people lead; and 3) the
services people use. A clear objective of this future strategy is to
improve access to services and reach out to people. The
presentation concluded that inequalities in health are stubborn,
persistent and difficult to change but that political support, action
and evidence will provide the best prospect for meeting long-term
sustainable reduction in health inequalities.

In the discussions that followed, Ray Earwicker indicated that DH
thinking on health inequalities had been broadly shaped by life
expectancy, and that more needed to be done to address disability
and quality of life issues. However, advancing this agenda would
depend on evidence, particularly of the effectiveness and cost-
effectiveness of interventions.


2. Understanding health inequalities in relation to
sight loss

James Nazroo, Professor of Sociology, University of Manchester,
considered some of the evidence for socio-economic inequalities in


                                                                   4
the older population in relation to sight loss. His presentation
showed that there is a strong association between visual
impairment and social and economic inequalities, reflecting the
more general situation for inequalities in health. For almost all
outcomes (health, mobility and ability to care for oneself, social
participation, economic well-being and quality of life), those with a
visual impairment face considerable disadvantages. However, the
causal relationships in this are unknown. In the discussions that
followed, he indicated the need to continue evaluating and refining
policies: "for this we need evidence. A key question is how far do
general policies tackle inequalities in relation to sight loss?
Additionally, we need to understand how inequalities lead to
increased risk and how impairment leads to increased risk of
inequalities."

Ian Murdoch, Senior Lecturer and Consultant Ophthalmologist,
Institute of Ophthalmology, considered some of the links between
ethnicity and eye disease. His presentation showed that ethnicity is
complex, encompassing social as well as, lifestyle, cultural,
environmental, and genetic factors. These factors are likely to
impact on minority ethnic group access to services. Genetic
variation may also contribute towards differences in the gene pool.
Ian Murdoch noted that language could also be a significant barrier
to access and that services had to respond more appropriately to
these diverse needs.

The presentation showed, however, that there are gaps in the
evidence base. Evidence about ethnic health inequalities is limited
and the relationship between the different dimensions of health
inequalities – such as ethnicity and social class – is not always well
understood. Social and economic factors – known to be linked with
higher rates of disease, later presentation and poorer compliance
with treatment – may indeed play a greater role in ethnic health
inequalities than any perceived cultural or genetic or biological
difference.

In the discussions that followed, James Nazroo also highlighted
the need to challenge assumptions that high risk groups do not
prioritise health. Particular BME groups are, for example, more
likely to visit GPs. He emphasised the need to think about cultural
dynamics and structural inequalities. Ray Earwicker also
highlighted the need to amend services and engage with „at risk‟
populations and emphasised that it is the responsibility of Primary

                                                                      5
Care Trusts (PCTs) and Local Authorities (LAs) to reach out to
groups.


3. Tackling health inequalities in relation to sight loss
– developing local solutions

The second session highlighted local solutions towards tackling
eye health inequalities. James Woodhead, Strategic Partnership
Manager, Leeds PCT and Leeds City Council, talked about
developing local commissioning and service development
structures to target inequalities. His presentation highlighted that
the key to effective commissioning is in understanding local
population needs. He emphasised that the Joint Strategic Needs
Assessment (JSNA) is crucial, as is the need to know what
services are available. This requires a gap analysis. With this
information, it is possible to identify priorities and target resources
towards areas of most need ("super output" areas).

Commissioning for outcomes is also key and is part of World Class
Commissioning agenda. A number of other key principles and
policy hooks can also help to drive this agenda, including: health
and well-being, prevention – it is about creating the financial case;
the integrated health and local authority approach; and the „One
Council‟ approach.

Andy Cassels-Brown, Consultant in Community Eye Health,
Leeds PCT, also spoke about some of the innovative community-
based public health and prevention strategies being delivered by
Leeds PCT. His presentation provided striking evidence that
"super output" areas are also significantly under-served by GP
surgeries and Optometrists. One of the community-based
approaches he described was the 'Community Eye Champions'
model, where existing primary care and social care staff, would be
given extra training so that they could identify those at greatest risk
of eye disease and refer on to appropriate services.

Andy Cassels-Brown also highlighted the Leeds Glaucoma Equity
Profile. Glaucoma is a common cause of blinding eye disease, an
important public health cause and a consequence of inequalities.
As the first of its kind nationally, and as part of a broader Equity
Audit, the Leeds Glaucoma Equity Profile uses a wide range of


                                                                          6
mainly routinely collected data sources in order to inform and direct
local action to reduce health inequalities. The Equity Profile shows
that late presentation in glaucoma is linked with socioeconomic
status and older age, and it highlights that Leeds‟ private high
street optometrists are not well placed to provide primary eye care
services in communities at risk.


4. Tackling health inequalities in relation to sight loss:
what can we learn from other sectors and
organisations?

This part of the programme invited presentations from other
voluntary sector organisations. Alastair Kent, Director of the
Genetic Interest Group (GIG), an alliance of patient organisations
supporting people with genetic disorders, spoke about GIG's multi-
faceted and collaborative approach. The presentation showed that
in pursuant of equity in the NHS, for minority ethnic groups, GIG
has adopted an approach driven by partnership, in which all
stakeholders are involved. GIG has worked to establish
performance indicators, whilst at the same time promoting the
skills and confidence amongst professionals, by developing tools
and training. This has been complemented by the development of
information that is tried and tested by those who will use it in
earnest: the patients and families who will rely on it to make
decisions about their future genetic health and well-being. These
techniques are not unique to genetics – they are transferable
across health and social care into a range of different contexts.

There was significant panel discussion following each of the
sessions. Additionally, there were breakout sessions, where small
groups were asked to review priorities from RNIB‟s prevention
programme plan. The main themes from these discussions have
informed the conclusions below.




                                                                    7
Key findings and conclusions

1. Wider policy agenda
Health inequalities are linked to social determinants. They are
stubborn, persistent and difficult to change.

Political support, action and evidence and are all needed to make
any long-term sustainable impact.

2. Health inequalities and sight loss
There are health inequalities related to sight loss and these reflect
the more general picture for inequalities in health. Evidence
shows:
 visual impairment is strongly linked with social and economic
   inequalities;

 late presentation in glaucoma is linked with socioeconomic
  status and older age;

 significant gaps in the provision of primary eye care services
  (GP surgeries and Optometrists) in deprived areas.

Ethnicity is also a complex dimension of health inequalities,
encompassing social, lifestyle, cultural, environmental, and genetic
factors. These factors are likely to impact on minority ethnic group
access to services and their subsequent risk of eye disease.

3. Targeting health inequalities
Primary Care Trusts (PCTs) and Local Authorities (LAs) need to do
more to improve access to eye care services and engage with 'at
risk' groups. In targeting action, they should establish:

 areas of greatest need (based on local prevalence and
  incidence of key conditions, socio-economic and ethnic data,
  and language needs);

 levels of availability and access to eye care services,
  particularly for different social and ethnic groups (with tools
  such as the Leeds Glaucoma Equity Profile); and,


                                                                    8
 the overall percentage of the local population currently being
  reached by existing services, including early detection and
  treatment services.

This information should help target resources and shape local
commissioning decisions to address health inequalities related to
sight loss.

But, significant gaps in the provision of primary eye care services
indicate that new delivery models will also be needed to target
groups at risk. Examples include the Leeds based Community Eye
Champions model and a number of other community based
approaches are being piloted. However, further development work
is vital, not only to support the needs of the present population, but
also to plan for the future, when significant increases in the
prevalence and incidence of visual impairment are expected. To
note, Future sight loss UK, an RNIB funded study due to report
June 2009, will provide robust estimates of the future prevalence,
incidence and costs relating to the main eye conditions, for the UK,
and the devolved countries. The impact of improving access to
early detection and treatment services, on prevalence and costs,
will also be reported.

4. A strategy based on action and evidence
Along with action and development of new service models, we
need to regularly monitor and review progress, and evaluate what
works, particularly in terms of impact, effectiveness and cost-
effectiveness.

At the same time, we need to evaluate the impact of general
policies on tackling inequalities related to sight loss. How far do
they go?

Additionally, we need to continue building the evidence base on
the causes and consequences of health inequalities related to
sight loss. We also need to gain a better understanding of the
relationships between different dimensions of health inequalities,
such as ethnicity and social class, and how these impact on the
risk of eye disease.




                                                                      9
5. Promoting the agenda and sharing good practice
We need to identify tools and levers to promote the agenda of
tackling health inequalities related to sight loss, at local level.
Important to note are the Joint Strategic Needs Assessment
(JSNA) and World Class Commissioning, and both should be fully
utilised. Additionally, we need to learn the lessons from the
evidence and share good practice, particularly from local
developments, and use this evidence to shape national policy
decisions.

6. Working in partnership
Reducing the impact of health inequalities related to sight loss will
depend on partnership between all key stakeholders. DH, UK
Vision Strategy and RNIB are already working together and will
need to maintain collaboration in order to advance this agenda. It
will be important to take these key findings and conclusions and
develop a joint action plan towards addressing health inequalities
related to sight loss.




                                                                   10
Full presentations

Part 1: The broader health inequalities agenda

1.1 DH Strategy and Programme for Action in tackling health
inequalities

Dr Ray Earwicker, Health Inequalities Unit, Department of Health

Speaker bio:
Dr Ray Earwicker is a senior member of the Health Inequalities
Unit at the Department of Health. He has primary responsibility for
the infant mortality aspect of the national health inequalities target,
including work on the recent Review of the Health Inequalities
Infant Mortality PSA Target (2007). He was secretary to the
Independent Inquiry on Health Inequalities, known as the 'Acheson
report', published in 1998.

The Acheson report
The Acheson report demonstrated the existence of health
inequalities in the UK and their relationship to social class. It
highlighted, for example, that “in the early 1970s the mortality rate
among men of working age was almost twice as high for those in
Class V (Unskilled) as for those in Class I (Professional). By the
early 1990s, it was almost 3 times higher”.

National health inequalities target
The Acheson report influenced the development of a national
health inequalities target, which was first announced in 2001. The
aims of the target, which were to be achieved by 2010, were as
follows:
 Starting with local authorities: to reduce by at least 10 percent
    the gap between the fifth of areas with the worst health and
    deprivation indicators (the spearhead group) and the population
    as a whole
 Starting with children under one year: to reduce by at least 10
    percent the gap in mortality between the routine and manual
    group and the population as a whole.




                                                                    11
Programme of Action report
Tackling Health Inequalities: a Programme for Action report set out
key themes and principles to help deliver the target. It lay the
foundation for a long-term, sustainable reduction in health
inequalities. Key principles included: preventing inequalities
worsening; working through the mainstream; targeted
interventions; support from the centre; and delivering at a local
level. Key themes included: supporting families, mothers and
children; engaging communities and individuals; preventing illness
and providing effective treatment and care; and addressing the
underlying determinants of health principles. This action plan
included shorter-term (2003, 2010) and longer term (2030) targets.

Status report on the Programme for Action 2005
In 2005, a status report on the Programme for Action concluded
that "This country has shown leadership through its pioneering
approach of reviewing the evidence, setting targets, developing a
comprehensive strategy across government and monitoring
progress" (Sir Michael Marmot). However, the same report also
found that health inequalities had widened, despite the target
being set. The infant mortality (IM) gap widened from 13 per cent
in 1997-1999 to 19 per cent in 2001-2003. For life expectancy
(LE), the gap had increased by nearly 2 per cent for males and 5
per cent for females.

Why isn’t the gap narrowing?
 Life expectancy continues to improve year on year for all groups
 Infant mortality rates are at a historic low level. The reductions
  in infant deaths have been shared across different social groups
 Time lags. Given that health inequalities arise because of the
  nature of society, changes will take time
 Strategy and implementation – a seamless chain?

New approach
A new process for policy implementation now focuses on:
monitoring, audit and review.

Infant Mortality Review
Applying this approach to infant mortality, The Infant Mortality
Review found a number of identifiable actions to reduce the gap in
infant mortality by at least 10 per cent. It illustrated a set of


                                                                 12
interventions, which could make a significant contribution towards
narrowing the infant mortality gap by 10 per cent. The Review also
identified the need to commission research to improve the
evidence base on modelling interventions and outcomes and good
practice.

The Infant Mortality Review identified five key barriers to delivery,
which are: 1) no recognition of the target or widening gap; 2)
services not fully delivering to the target group; 3) lack of
leadership and systems to support delivery; 4) lack of knowledge
and understanding of the target; and 5) poor handling and use of
data and gaps in the evidence base.

Recommendations from the Review have informed the
Implementation Plan and the development of a national support
team for infant mortality. With this approach, future projections
suggest that “We will hit the infant mortality aspect of the
target…..”

Health Inequalities: Progress and Next Steps
However, there is more to do. Health Inequalities: Progress and
Next Steps, June 2008, highlights what more we can do to support
local areas meet the 2010 health inequalities targets. It also
outlines a cross-government strategy for reducing health
inequalities, post-2010. This has three key strands, that 1) it is
everyone‟s business; 2) no-one should be left behind; and 3) it is
about quality as well as length of life. Three key themes emerge
related to: 1) the influences on health; 2) the lives people lead; and
3) the services people use.

Strengthening the conditions for healthy lives
DH will continue to strengthen the conditions for healthy lives. It
will focus on: early years and families; work and health; key
behaviours and engaging people in healthy change. The latter
includes investing more in social marketing approaches that
support behaviour change as well as a major programme to
improve health literacy.

Improving access to services and reaching out to people
The DH will also ensure services work for those who need them
most by improving access to services and reaching out to people.
The latter includes: strengthening choice in primary care;


                                                                      13
enhancing incentives for primary care to diagnose earlier; the NHS
working in partnership with local government and the voluntary
sector; and ensuring the NHS makes best use of local partnerships
to deliver services relevant to people‟s needs.

Post-2010 Strategic Review
There will be an independent Post-2010 Strategic Review of
Health Inequalities (chair: Sir Michael Marmot) addressing the
wider social determinants of health. This will:
• review the latest global evidence and apply it to England
• identify possible objectives and metrics
• explore prospects for implementation and delivery
• publish a report – submitted end 2009

Conclusion
What the last 10 years show is that:
 inequalities in health are stubborn, persistent and difficult to
  change.
 political support ensures continuing focus on health and
  inequalities and it means actions can take place to address
  health inequalities.
 political support and policy development focused on
  implementation and delivery are the best prospect for meeting
  the target, as well as a long-term sustainable reduction in health
  inequalities.




                                                                 14
Part 2. Understanding health inequalities in relation to
sight loss

2.1 Sight loss and socioeconomic inequalities

James Nazroo, Professor of Sociology, School of Social Sciences,
University of Manchester

Speaker bio: James Nazroo is Professor of Sociology at the
University of Manchester. He trained at St. George's Hospital
Medical School, where he obtained a BSc (medical sociology) and
MBBS. He subsequently studied at Royal Holloway and Bedford
New College for an MSc in Sociology of Health and Illness and he
studied for his PhD in Sociology at UCL.

Issues of inequality, social justice and their relationship with health,
have been the primary focus of Professor Nazroo's research
activities, which have centred on gender, ethnicity, ageing, and the
intersections between these. His work on ethnic inequalities in
health has been concerned with developing an understanding of
the links between ethnicity, racism, class and inequality. His work
on social and health inequalities in ageing populations is
particularly focussed on the 'transmission' of inequalities across
the life-course, patterns of 'retirement', and formal and informal
social and civic participation. He is co-PI (Principal Investigator) of
the English Longitudinal Study of Ageing, a multi-disciplinary panel
study of those aged 50, and has used data from this study to
investigate visual impairment.

Background
An ageing population requires a thorough understanding of levels,
distribution and consequences of impairment and dependence.
Within the UK as a whole, around 190,000 people are registered
as blind and around 160,000 are registered as partially sighted. It
is estimated, however, that the true number of people with a sight
problem is closer to one million. However, the prevalence, causes
and consequences of visual impairment are under-researched. It is
likely that the prevalence of visual impairment will vary across the
population, and will reflect broader social and economic
inequalities. Visual impairment might also result in a poorer
economic position.

                                                                     15
Methods
This investigation involved analysis of the first wave of the English
Longitudinal Study of Ageing (ELSA), conducted 2002-2003. This
is a study of people aged 50 and older living in private households,
with interviews every two years. Wave 1 of ELSA included 11,392
respondents, with a response rate in the region of 70 per cent.

A weighting scheme is used to correct where there was no
response. Nevertheless, design factors mean that it is likely to
under-represent those with visual impairments.

Data are collected using face-to-face questionnaires, direct
measures (for example, lung function, blood samples), and
performance tests.

Questionnaire coverage
The questionnaire covers the following areas: demographics,
health and disability, social participation, housing, employment and
earnings, pensions and retirement, income and assets, cognitive
function, psychosocial well-being, expectations for the future,
measurements of function, biomedical assessment (four yearly).

Level of visual impairment is self reported using the following
question and categories:
Is your eyesight (using glasses or corrective lens as usual):
   1 excellent
   2 very good
   3 good
   4 fair
   5 poor
   6 spontaneous registered or legally blind

Prevalence of visual impairment by age and severity
The prevalence of visual impairment increases with age. 33 per
cent of those over 80 years old report a visual impairment (fair or
poor vision or are registered blind), compared with 12 per cent in
the 50 to 54 age group.




                                                                   16
Occupational class (NS-Sec) and visual impairment
Among those in semi-routine roles, twice as many people have a
visual impairment (21 per cent), compared with those in
managerial and professional occupations (10.6 per cent).

Economics and visual impairment
Among those who are not in paid work (and aged less than 60),
21.6 per cent report a visual impairment, compared with 10.1 per
cent of those that have a job.

More than one fifth of those in the bottom income quintile group
and more than one quarter of those in the bottom wealth quintile
groups report fair or worse vision, compared with less than 10 per
cent of those in the top quintiles.

Visual impairment and economic position
Looking at the data the other way around, by considering whether
visual impairment relates to socioeconomic circumstances, it
shows that employment, income and wealth are all strongly related
to visual impairment, with a graded relationship between
increasing visual impairment and poorer economic circumstances.

Visual impairment and housing conditions
There is also a graded relationship between visual impairment and
poor housing circumstances. Those who have poor vision or are
blind are more likely to have no central heating, cold
accommodation, a shortage of space and condensation than those
with fair vision. Those with fair vision are in turn more likely to have
these housing conditions than those with good or excellent vision.

Visual impairment and disability
Over 66 per cent of people with a serious visual impairment (poor
vision or blind) say they experience more than three mobility
difficulties, compared with just over 50 per cent who have fair
vision and 25 per cent with good or excellent vision.

50 per cent of people with a serious visual impairment (poor vision
or blind) say they have ADL difficulties, compared with 35 per cent
with fair vision and 18 per cent with good or excellent vision.

Almost 50 per cent of people with a serious visual impairment
(poor vision or blind) say they have experienced a fall in the last

                                                                      17
year, compared with just over 40 per cent with fair vision and
approximately 30 per cent with good or excellent vision.

Visual impairment and social well-being
48 per cent of people with a visual impairment (fair or poor vision
or blind) say they do not manage well financially, compared with 33
per cent with good or excellent vision.

Over 65 per cent of people with a serious visual impairment (poor
vision or blind) are not a member of an organisation, compared
with just over 50 per cent with fair vision and 35 per cent with good
or excellent vision.

Over 65 per cent of people with a serious visual impairment (poor
vision or blind) say they do not have a good quality of life,
compared with 58 per cent with fair vision and 35 per cent with
good or excellent vision.

Conclusions
Of those aged 50 and older, living in private households, just over
four per cent say they have poor vision or are registered blind, with
a further 12 per cent saying that their vision is fair, rather than
good or excellent.

This rate increases dramatically with age.

There is a strong association between visual impairment and social
and economic inequalities, reflecting the more general situation for
inequalities in health.

For almost all outcomes (health, mobility and ability to care for
oneself, social participation, economic well-being and quality of
life), those with a visual impairment face significant disadvantages.

The causal relationships between them are unknown.

Key questions
To what extent do socioeconomic inequalities lead to visual
impairment? Are those living in poorer circumstances more likely to
develop a visual impairment?




                                                                  18
How do socioeconomic circumstances change as visual
impairment occurs?

Is the impact of visual impairment on circumstances uniform, or are
some socioeconomic groups more likely to be disadvantaged as a
result of visual impairment than others?

How do circumstances change when vision improves (for example,
after cataract surgery)?

When is the best time to intervene?




                                                                19
2.2 Ethnicity and eye disease

Ian Murdoch, Senior Lecturer and Consultant Ophthalmologist
Institute of Ophthalmology

Speaker bio: Ian Murdoch is an ophthalmic surgeon and
researcher in epidemiology and public health. His sub-speciality is
glaucoma and his research group focuses on developing strategies
for prevention of blindness from glaucoma, primarily in the UK and
Africa, within the umbrella of Vision 2020.

Ethnicity is a complex concept encompassing social, lifestyle
cultural, environmental, and genetic factors. These factors are
likely to impact on minority ethnic group access to services and
may contribute towards differences in the gene pool. Ian noted that
language could also be a significant barrier to access and that
services had to respond appropriately to these needs.

The presentation indicated, however, that there are gaps in the
evidence base. Evidence about ethnic health inequalities is limited
and the relationship between the different dimensions of health
inequalities – such as ethnicity and social class – is not always well
understood. Social and economic factors, known to be linked with
higher rates of disease, later presentation and poorer compliance
with treatment, may indeed play a greater role in ethnic health
inequalities than any perceived cultural or genetic or biological
differences.

Minority ethnic populations are increasing, with almost one out of
10 people from a minority ethnic group. Although we don't have
good data on the prevalence and incidence of eye disease by
ethnic group, disease patterns do seem to vary by ethnic group.
For example, risk of primary open glaucoma is considered to be
greater for people of African and Caribbean origin. Diabetes is also
considered to be more prevalent in people of Asian, African and
Caribbean origin, and congenital cataract and buphthalmos in
people of Middle Eastern and Indian or Pakistani origin,
respectively.




                                                                   20
Part 3: Tackling health inequalities in relation to
sight loss – developing local solutions

3.1 Developing local commissioning and service development
structures to target inequalities

James Woodhead, Strategic Partnership Manager,
NHS Leeds and Leeds City Council

Speaker bio: James Woodhead works in strategic development
and service commissioning for NHS Leeds (Leeds PCT) and
Leeds City Council where, amongst other things, he leads on the
Leeds Vision Strategy. He is also currently seconded to the UKVS
team where is working on the England Implementation Plan.

This presentation considers how health inequalities might be
targeted locally through more effective commissioning of services.
The population of Leeds provides some challenging demographics,
as detailed below:
 population: 715,000
 8.2 per cent BME communities
 life expectancy: 73-83
 110,000 people over 65 (138,000 by 2030)
 5,276 people registered blind or partially sighted
 in the top 86 most deprived LAs.

The key to effective commissioning is to understand population
needs. A strategic assessment of these is crucial (as per JSNA).
Also crucial is to know what services are available (and what are
not). This requires a gap analysis. With these two key pieces of
evidence it is possible to identify priorities and target resources
towards areas of most need (super output areas). Commissioning
for outcomes is also key and is part of a World Class
Commissioning agenda.

A number of other key principles and policy hooks can also help to
drive this agenda, including health and well-being; prevention – it is
about creating the financial case; integrated health and local
authority approach; and the „One Council‟ approach.




                                                                   21
Good governance is also crucial and requires partnership
structures, programme management, implementation groups and
escalating issues.

A number of critical factors were identified, including:
 partnership (local Vision Strategy partnerships)
 eye care and sight loss on the agenda
 local Vision Strategy
 inequalities as a cross-cutting theme
 engagement of or with commissioners
 commissioners as facilitators
 business cases for change
 money in operational plans
 clinical and practitioner engagement
 involvement of people with sight loss
 whole person or whole system approach.




                                                           22
3.2 Targeting health inequalities through community-based
services

Andy Cassels-Brown, Consultant in Community Eye Health,
Leeds PCT

Speaker bio: Andy Cassels-Brown is a Consultant
Ophthalmologist at Leeds Teaching Hospitals Trust with a special
interest in Community Eye Health particularly in the developing
world. During his postgraduate training, he spent a year in Nigeria
researching the impact of ivermectin on river blindness. He started
his NHS consultant career as a subspecialist in Oculo-plastic,
lacrimal and Orbital surgery, but in 1999 studied for the Masters in
Community Eye Health at the International Centre for Eye Health
in London and subsequently supported their international Vision
2020 training programme. More recently, he has been a member
of the National Eye Care Services Working Group.

This presentation identified striking evidence to show that super
output areas (deprived areas where there are higher incidences of
eye disease), are also significantly underserved by GP surgeries
and Optometrists. It flagged the need to develop community-based
services and highlighted two approaches being developed in
Leeds.

'Community Eye Champions': These will be existing primary care
and social care staff who are given extra training and support so
that they can be a focal point for eye care and sight loss support in
the community in which they work. Their role will be to identify
those at greatest risk of eye disease and direct them towards
appropriate services. Initially, CECs will be based in super output
areas.

'Save your Sight Campaign': The Save Your Sight leaflet is part of
an existing public health programme, The Save Your Sight
Campaign, supported by Leeds PCT Public Health. The leaflet
uses a health promotion initiative as a vehicle for a case detection
tool designed to increase primary eye health care usage in the
over 60s. Present distribution includes Neighbourhood Network
Schemes: community groups for the over 60s, sheltered
accommodation and community eye centres.



                                                                   23
This presentation also highlighted the Leeds Glaucoma Equity
Profile. Glaucoma is a common cause of blinding eye disease and
important public health cause and consequence of inequalities. As
the first of its kind nationally, and as part of a broader Equity Audit,
the Leeds Glaucoma Equity Profile uses a wide range of mainly
routinely collected data sources in order to inform and direct local
action to reduce health inequalities. The Equity Profile shows that
late presentation in glaucoma is linked with socioeconomic status
and older age, and it highlights that Leeds‟ private high street
optometrists are not well placed to provide primary eye care
services in communities at risk. The findings have been used to
shape: 1) the PCT Service Specification for commissioning
Community Based Eye Care Services; 2) the UK Vision Strategy
and Leeds Vision Strategy Action Plans; 3) local health and social
care development; 4) awareness that local providers must develop
outreach, with free NHS sight tests, in areas of high need. This
methodology can be replicated throughout the UK.




                                                                     24
Part 4: Tackling health inequalities in relation to sight
loss: what can we learn from other sectors and
organisations?

4.1 Equity, access and inherited disorders

Alastair Kent, Director, Genetic Interest Group

Speaker bio: Alastair Kent is the Director of the Genetic Interest
Group (GIG), the UK alliance of charities and support groups for
people affected by genetic disorders. GIG's mission is to promote
the development of the scientific understanding of genetics and the
part that genetic factors play in health and disease, and to see the
speedy transfer of this new knowledge into improved services and
support for the treatment of currently incurable conditions. Prior to
joining GIG, Alastair worked for a number of voluntary
organisations on issues concerning policy, service development
and disabled people.

Alastair Kent kindly provided the commentary below.

Introduction
Families from ethnic minority communities are affected by or at risk
from genetic conditions just like those from the dominant ethnic
groups in this country. The pattern of genetic disease varies, and
cultural traditions such as consanguineous marriage may have an
impact on the prevalence of certain diseases, but members of
ethnic minorities need and should expect equal access to genetic
services on the same basis as any other citizen of this country. Yet
surveys by GIG have demonstrated that the referral rate to clinical
genetics centres does not reflect the prevalence of members of
ethnic minorities in the population as a whole, and that only a
minority of regional genetic centres (RGCs) systematically monitor
the ethnicity of patients and families referred to them, indicating an
access issue that needs to be addressed systematically if the
NHS's commitment to equity is to be more than just "fine words".

Why no monitoring?
When asked, RGCs offer a variety of reasons for not monitoring,
including the fact that, as a tertiary service they like all who are



                                                                       25
referred, they are "colour blind" and that there are too few to count
in their catchment area.

None of these are acceptable: unless you monitor, how can you
know if you are reaching all your community, and take steps that
might address imbalances where these may exist?

Ethnicity can also be important clinically, as the frequency of
mutations causing or predisposing to particular disorders can vary
between populations, so a standard set of mutation analyses may
not pick up those changes most likely to occur in ethnic minority
communities. Similarly, the prevalence of diseases themselves can
vary from community to community, so a knowledge of these two
aspects can influence the likelihood of a patient accessing a
speedy and accurate diagnosis and a culturally appropriate offer of
help and support.

Top down and bottom up
Anti-discrimination legislation requires ethnic monitoring, but it is
better to make people want to do this rather than feel they have to.
GIG worked with GenCAG (the Department of Health‟s Genetics
Commissioning Advisory Group) to make ethnic monitoring a
quality indicator in the data collected to ascertain performance. At
the same time GIG expanded the OPCS ethnicity categories in
ways that are clinically relevant but which can be "collapsed" back
into the OPCS categories for statutory reporting purposes, thereby
combining a carrot and a stick (albeit a small one) approach to
introducing monitoring.

One of the biggest barriers to ascertaining ethnicity is practitioner
reluctance. By demonstrating the clinical utility of the questions,
practitioners are able to ask with confidence as it has a reason that
is beyond the administrative requirement.

Providing information
Many attempts at providing health information in minority
languages have failed because clinicians are not sure about their
content and applicability. To address this, GIG devised a protocol
for translation and a process of community consultation that
ensured that the information was both relevant and
understandable. A key component of this was a glossary of genetic



                                                                   26
terms systematically translated into understandable equivalents in
the ethnic minority languages.

The format of information was standardised and presented with the
English text in parallel. Wherever technical terms are used in the
text their English equivalent appears alongside so both language
speakers know what is being understood. Language levels are
tested out with bi-lingual speakers and mother-tongue only
speakers, and metaphors checked for appropriateness and
relevance. In this way, it is possible to be confident in both the
content and the tone of the communication.

A multi-faceted approach
In its pursuance of equity in the NHS for patients and families for
all sectors of our multi-cultural society, GIG has adopted an
approach driven by partnership in which all stakeholders are
involved. We have worked to establish performance indicators,
whilst at the same time promoting the skills and confidence
amongst professionals by developing tools and training. This has
been complemented by the development of information that is tried
and tested by those who will use it in earnest, the patients and
families who will rely on it to make decisions about their future
genetic health and well-being.

These techniques are not unique to genetics – they are
transferable across health and social care into a range of different
contexts.




                                                                  27
Panel Discussion

This section provides summary of some of the key points arising
during the panel discussions.

On health inequalities faced by people with sensory
impairment
Inequalities faced by people with sensory impairment were well
expressed through the presentations. But how are these needs
being considered within the DH Health Inequalities strategy?

(Ray Earwicker): With statutory approach it is vital to look at
groups with specific needs. But it is not an either/or approach and
it can be advanced through the mainstream.

Health inequalities: is it about life/death or quality of life?
(Ray Earwicker): No doubt DH thinking and strategy is shaped by
mortality, not morbidity. Need to review – do more about morbidity.

But how can we influence DH to consider disability and social
care as part of the health inequalities agenda?
(Ray Earwicker): Health inequalities are stubborn, difficult to
change. We can begin to open up a dialogue, but will need to have
evidence, particularly on cost-effectiveness.

(James Nazroo): Need to continue evaluating and refining policies
and for this we need evidence. A key question is how far do
general policies tackle inequalities in relation to sight loss?
Additionally, we need to understand how inequalities lead to
increased risk and how impairment leads to increased risk of
inequalities.

However, a lack of knowledge should be no excuse for inaction.
We should not be detained due to lack of data.

How can we get messages across to DH and PCTs?
(Ray Earwicker): DH has had same problem with respect to
implementing wider health inequalities strategy. Recommend using
approach – monitoring, audit, review. Again, there is a need for
evidence-based approaches.



                                                                  28
Avoiding assumptions about culture
(James Nazroo): Need to challenge assumptions that high risk
groups do not prioritise health. Particular BME groups are for
example more likely to visit GPs. Need to think about cultural
dynamics and structural inequalities.

(Ray Earwicker): Need to amend service, and engage with at risk
populations. It is the responsibility of PCTs and LA to reach out to
groups.

When will there be more joined up thinking?
Dynamics of joint commissioning with LA: for prevention need
investment in health but the benefit is with social care. Incentives
are different.

There are many barriers as well as different, competing
professional groups. The key is commissioners. Can
commissioners get together and finding ways to share best
practice?

There are some places where budgets have merged – it will be
good to observe if things have changed.

What are the killer arguments? Why in Leeds?
(Andy Cassels Brown): Important to have enthusiastic
ophthalmologists, but to get PCTs engagement, need PCT
champions.

What are the key (policy) hooks towards achieving improved
outcomes?
(James Woodhead): World Class Commissioning, although
complicated by practice-based commissioning; targeting
inequalities, less sexy; 18 weeks; long-term care agenda; dignity or
care agenda; need public health data; and also need more data to
inform JSNA.




                                                                   29
Appendix 1
List of Attendees

Speakers

Andy Cassels-Brown, Consultant, Community Eye Health, Leeds
PCT

Ray Earwicker, Senior Policy Manager, Health Inequalities Unit
Department of Health

Alastair Kent, Director, Genetic Interest Group

Ian Murdoch, Senior Lecturer and Consultant, Ophthalmologist,
Institute of Ophthalmology

James Nazroo, Professor of Sociology, University of Manchester

James Woodhead, Strategic Partnership Manager, Leeds PCT and
Leeds City Council


Delegates

Lesley-Anne Alexander, CEO, RNIB

David Allen, Head of Regional Services, RNIB

Nick Astbury, Consultant Ophthalmologist, Chair Vision 2020UK,
Royal College of Ophthalmologists

Rosie Auld, Chair, British and Irish Orthoptic Society

Ian Bland, Regional Manager, RNIB

Carol Borowski, RNIB Trustee

Mike Brace, Chief Executive, Vision2020UK

Michael Brannan, Health Inequalities Policy Manager, Department
of Health, Regional Public Health Group, London

                                                                 30
Graham Brittain, Director of Health and Social Care, RNIB

Sarah Buchanan, R&D Manager, Thomas Pocklington Trust

Stuart Clayton, Head of Regional Services, Action for Blind People

R A Coates

Georgina English, Equality and Human Rights Commission

Jo Frazer, Project Manager, Sensory Services, Kent

Gus Gazzard, Consultant Ophthalmic Surgeon, King's College
Hospital

Nick Gradwell, Policy Manager, Health, Equality and Human
Rights Commission

Fazilet Hadi, Director, Policy and Advocacy, RNIB

Sharon Haffenden, Head of Service Development and Corporate
Research, RNIB

Tom Harrison, Head of Care and Support, Birmingham Focus for
Blind

Carol Norwell, Training and Practise Development Officer (ECLO)

Parin Hirji, Diversity and BME Development Officer, RNIB East
Midlands and East

Kate Hughes, Policy and Communication Team Leader, RNIB
Cymru

Sue Huyton, Regional Manager, RNIB West Midlands

Gozie Joe Adigwe, Membership Support Officer, RNIB, Edinburgh

Andrew Kaye, Policy Analysis Officer, RNIB

Nicky Kime, Research Officer, Leeds Metropolitan University



                                                                31
Stephen King, Group Director, Prevention & International Affairs,
RNIB Peterborough

Anita Lightstone, Project Director, UK Vision Strategy, RNIB

David Lye, Head of Dentistry and Eye Care Services, Department
of Health

Keith Marshall, Low Vision Programme Manager, Tower Hamlets
PCT

Barbara McLaughlan, Campaigns Manager (Eye Health and Social
Care) RNIB

Pritti Mehta , Senior Research Officer, RNIB

Rowena Morrell, Regional Manager - East Midlands and East,
RNIB

Kirstie Newson, Service Development Manager, RNIB

Ballu Patel, Black and Minority Ethnic Officer, RNIB

Vinod Patel, Associate Professor Clinical Skills, Warwick Medical
School

Terry Robinson, Trustee, RNIB and Proprietor, Describe on Line

Manjit Rooprah, Campaigns Officer, Eye Health, RNIB

Sonal Rughani, Senior Optometric Advisor, RNIB

Paula Spinks-Chamberlain, Director of Information and Advisory
Services, SeeAbility

Philippa Simkiss, Employment & Lifelong Learning Manager, RNIB
West Midlands

Martin Sissons, London Health and Social Care Manager, RNIB

Farhang Tahzib, Director of Public Health & Wellbeing, West
Sussex PCT and West Sussex Council



                                                                    32
Mike Thornicroft, Regional manager, RNIB North West

Bob Wilkes, Independent Optometrist, Association of Optometrists

Steve Winyard, Head of Public Policy, RNIB




                                                              33

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:59
posted:7/27/2010
language:English
pages:33
Description: Tackling health inequalities in relation to sight loss developing colour blindness