11 October 2019

Advancing our health: prevention in the 2020s

We have responded to a green paper on prevention public from the Department of Health and Social Care.

The College of Optometrists is the professional body for optometrists. It qualifies the profession and delivers the guidance, development and training to ensure optometrists provide the best possible care. We recognise excellence through the College’s affixes, by building the evidence base for optometry, and by raising awareness of the profession with the public, commissioners, and health care professionals. We also created a dedicated website for members of the public - lookafteryoureyes.org.  It includes extensive information about the eye examination, the main eye conditions and how to take care of our eyes.

General comment

The College welcomes the green paper on prevention. It rightly recognises the significant impact of sight loss on quality of life, but more still needs to be done by the Government and NHS England to reduce preventable sight loss. We would like to see increased visibility of and emphasis on interventions that encourage regular eye examinations with an optometrist as an important healthy lifestyle behaviour. Optometrists are in a good position to help deliver public health messages on lifestyle choices thanks to the frontline nature of the profession, and the high levels of patient coverage.

Q-Which health and social care policies should be reviewed to improve the health of people living in poorer communities, or excluded groups?

There are significant inequalities in the eye health of different UK populations, with people in deprived socioeconomic groups and certain ethnic groups more likely to lose their sight and less likely to access servicesi.

Deprived populations can be affected due to the perceived cost implications of needing spectacles, a lack of eye health awareness, and access issuesii. General Ophthalmic Services fees in England for a basic eye examination do not meet the actual cost of the examination, so certain areas will have a dearth of optometric businesses due to sustainability issues. The College of Optometrists’ report ‘See the gap’ summarises the evidence around inequalities associated with patient access in deprived areas. 

Minority ethnic communities are at higher risk of eye disease, yet are generally less aware of the conditions or their increased risk of contracting themiii.  They are a group who could potentially benefit the most from health education around improving eye health.

The sector lacks the population data needed to make the rigorous, evidence-based evaluations of existing services that would enable us to better understand why people in the UK are losing their sight due to eye diseases that are preventable, treatable or manageable. This same lack of data means that we don’t know how many people are living with visual impairment due to correctible refractive error. IF we had high quality, reliable and up to date population data we could properly evaluate the existing services and target new services to reduce preventable sight loss and uncorrected refractive errors. Since visual impairment is estimated to cost the UK £28 billion per year, there are important benefits to individuals and the nation to be achieved.

The College recommends that the messages to raise awareness of the importance of regular eye examination are championed by the Government and integrated into a funded public drive for eye health awareness, especially to the most vulnerable groups. This could easily be combined with the work to gather the population data noted above, which is vitally important to designing and delivering efficient and effective services in the future.

People with a learning disability are 10 times more likely to have serious sight problems, and they are often under-diagnosed and undertreatediv.  NHS England eye healthcare for people with learning disabilities must improve.

The College recommends that all people with a learning disability should be automatically eligible for an NHS-funded sight test.

Q-Do you have any ideas for how the NHS Health Checks programme could be improved?  

We would recommend adding an eye examination to the NHS Health Checks. When it comes to eye health, prevention is key. At least 50% of sight loss is avoidable. The complex links between eye health and the broader public health agenda are strong and often overlooked. Sight loss is a severe disability and can have a devastating and pervasive effect on all aspects of life.

We recommend that all people undergoing an NHS Health Check should be screened for visual impairment and those found to have a visual impairment should have a full eye examination by an optometrist, and all people should be encouraged to have regular eye examinations. 

Q -What ideas should the government consider to raise funds for helping people stop smoking?

The College of Optometrists welcomes the ambitious goal for a smoke-free society. There is good evidence of a causal relationship between smoking, sight loss and blindnessv. Smoking accelerates the likelihood of age-related macular degenerationvi (AMD), the leading cause of sight loss in the UK, and cataract. Yet, while most people know that smoking leads to health issues such as cancer, less than a fifth of people know that smoking affects eye health.

Optometrists have a major and influential role. For example, a Healthy Living Optician (HLO) initiative has been started in Dudley. This scheme allows optical practitioners to offer a range of health-related advice, including alcohol screening, weight management and smoking cessation, as well as NHS health checks. As part of the initiative, patients also receive lifestyle advice and, if necessary, referral into other support services.

Optometrists are well placed to offer smoking cessation advice to at risk groups, since they have a significant amount of contact with patients with established Age-Related Degeneration (AMD) and those at high risk of developing the disease. Furthermore, by utilising this professional group, an important public health message can be delivered to a large proportion of the population who generally have good health and therefore not in regular contact with other healthcare professionals.

The College recommends that this HLO scheme should be considered, encouraged and promoted across the country.

Q -How can we do more to support mothers to breastfeed?


Q -How can we better support families with children aged 0 to 5 years to eat well?

See our response above regarding the Healthy Living Opticians scheme.

Q -How else can we help people reach and stay at a healthier weight?

See our response above regarding the Healthy Living Opticians scheme.

Q -Have you got examples or ideas that would help people to do more strength and balance exercises?

Vision is fundamental to coordinating our movement –balance and postural stability are directly affected by vision. In addition, vision is fundamental to adapting gait to enable safe travel through the environment, avoiding obstacles and negotiating steps and stairsvii. However, emerging evidence shows that standard falls rehabilitation strategies may not be effective for people where vision was a factor.

We feel that vision should be a consideration in all aspects of a patient pathway through falls services – including prevention and rehabilitation programmes.

The message that generic falls rehabilitation exercise programmes may not be effective for people with sight loss should be highlighted to the relevant professionals. We would stress the importance of ensuring that physical activity programmes are tailored to people with sensory impairment. Research shows that older people with eye diseases are 3 times more likely than those with good vision, to limit activities due to fear of fallingviii.

Optometrists also have a role in identifying those adults with poor vision who have fallen or who have a fear of falling and signposting them to services and resources for crucial strength and balance exercise training to prevent falls. Joined up services should be in place. The College of Optometrists has developed a Falls Directory [no longer available] and is encouraging our members to make contact with their local Falls Team when they identify risk.

Q -Can you give any examples of any local schemes that help people to do more strength and balance exercises?


Q -There are many factors affecting people’s mental health. How can we support the things that are good for mental health and prevent the things that are bad for mental health, in addition to the mental health actions in the green paper?

Sight is the nation’s most precious sense by far; 10 times more people (78 per cent of people) said sight was the sense they fear losing most compared to the next most popular sense, smell (8 per cent), followed by hearing (7 per cent).

Visual issues can exacerbate co-morbidities with other long-term health conditions, such as depression. Sight loss can also cause social isolationix, increase a person’s risk of falling and create a fear of movement, which can then lead to poor muscle growth. This in turn increases frailty which leads to more social isolation - a vicious circle. 

A 2015 studyx found that the prevalence of depressive and anxiety disorders were significantly higher in visually impaired older adults compared to their normally sighted peers, with agoraphobia and social phobia being the most commonly found. In addition, a 2016 studyxi found that three quarters of low vision patients with clinically significant depression were not receiving any treatment. Alarmingly, the prevalence of clinically significant depressive symptoms was found in 43% of those seeking help for sight loss in Britain. This suggests that it is an unrecognised high-risk group.

We recommend that patients attending low vision services should be screened regularly for depression. 

Q -Have you got examples or ideas about using technology to prevent mental ill-health, and promote good mental health and wellbeing?


Q -We recognise that sleep deprivation (not getting enough sleep) is bad for your health in several ways. What would help people get 7 to 9 hours of sleep a night?

Increased public awareness of the impact of lighting on sleep cycles, in particular the impact of screen use (TV, smart phone, tablets, PCs) close to the time of going to sleep has been shown to have a significant effect on time taken to fall asleep and on subsequent quality of sleep.

Q -Have you got examples or ideas for services and or advice that could be delivered by community pharmacies to promote health?

Community optometrists – alongside community pharmacies – could play a critical role in delivering important public health messages to a large proportion of the population who are generally in good health and therefore, not in regular contact with other healthcare professionals. They should not be left out of planning at primary care or community level. Many patients may have undiagnosed health conditions or may be putting their health at risk due to their lifestyle choices. Optometrists can have a huge impact on the health and wellbeing of every patient they make contact with through advice, signposting and support.

Many lifestyle choices have an impact on eye health:

  • Smoking increases the risk of age-related macular degeneration (AMD) which can lead to blindness
  • A patient with undiagnosed or poorly controlled diabetes risks damage to their retina and conditions such as diabetic retinopathy, cataracts and glaucoma
  • Being overweight can put you at risk of health problems including high blood pressure, stroke and type 2 diabetes which can all have an adverse effect on the eyes.

Eye examinations can pick up high blood pressure, high cholesterol and patients that may have diabetes or be pre-diabetic. Optometrists, highlighting some of these risks, can start to identify and support patients with their eye health and general health.

Our public-facing website Lookafteryoureyes.org provides general information on eye health and includes information and advice on smoking, nutrition, obesity, diabetes, high blood pressure and high cholesterol.

Q -What should the role of water companies be in water fluoridation schemes?


Q –What would you like to see included in a call for evidence on musculoskeletal (MSK) health?


Q -What could the government do to help people live more healthily: in homes and neighbourhoods; when going somewhere; in workplaces; in communities?


Q -What is your priority for making England the best country in the world to grow old in, alongside the work of Public Health England and national partner organisations? 

We would like to see increased visibility of and emphasis on interventions that encourage regular eye examinations with an optometrist as an important healthy lifestyle behaviour. 

Optometrists are in a good position to identify people who are at an increased risk of falling due to vision problems and can help to reduce that risk by offering advice on prevention to patients and carers, and colleagues in other medical and care professions.

Awareness of Falls Services among relevant primary care clinicians is a fundamental factor. Methods of reciprocal referral between Optometry and falls services should be explored. The College has been working with Falls teams across the UK and developed a Falls Directory [no longer available].

850,000 people are living with dementia in the UK. The risks of visual impairment and dementia both increase with age, and the UK’s ageing population will lead to many more people living with both dementia and sight loss. The impact on quality of life of having both sight loss and dementia are much more severe than those resulting from either dementia or sight loss alonexii.

The Government-funded Prevalence of Visual Impairment in Dementia project led by The College of Optometrists found that the prevalence of visual impairment in those with dementia is generally higher than for the overall population, indicating that the lives of many people with dementia could be improved by regular eye examinations and taking appropriate action. Prevalence is up to 2.5 times higher in people with dementia living in residential care homes, suggesting that concurrent dementia and visual impairment may lead to increased need for residential care.

Awareness on how good vision will help people with dementia live better, and possibly slow their decline should be raised.

Q -What government policies (outside of health and social care) do you think have the biggest impact on people's mental and physical health? Please describe a top 3.


Q -How can we make better use of existing assets -across both the public and private sectors -to promote the prevention agenda?

Optical practices should be seen as health hubs where the public can access information, advice and support on any element of health. Optical professionals can offer brief advice and signpost to local services, which would have an impact on the health and wellbeing of their population.

An excellent example of optometry integrating with public health and social care can be found in Dudley, with their successful Healthy Living Opticians scheme.  In partnership with Public Health Dudley, the optometry practices who participate can offer the following services:

  • Alcohol Screening
  • NHS Health Checks such as glucose testing and cholesterol
  • Weight Management
  • Smoking Cessation Services

Initial results have proved to have a positive effect in deprived communities, and the service is slowly growing, with eight Healthy Living Opticians now operating across the area.

Q -What more can we do to help local authorities and NHS bodies work well together?


Q -What are the top 3 things you’d like to see covered in a future strategy on sexual and reproductive health?


Q -What other areas (in addition to those set out in this green paper) would you like future government policy on prevention to cover?

We would highlight the importance of how saving sight prevents other health issues and preserves quality of life. Almost two million people are living with significant sight loss in the UK and this figure is predicted to double to four million by 2050xiii. Improvements in eye health messaging, alongside planning, provisioning and commissioning of services are needed. It is vital for the public to understand the importance of eye examinations, which are crucial in detecting early signs of eye disease, as well as signs of other health problems - and for patients with eye conditions to be able to access timely follow-up treatment. 

Hospital eye departments are under ever-increasing strain due to the ageing population and the lack of capacity. This has led to up to 22 people per month experiencing unnecessary and irreversible sight loss because of delays to hospital appointmentsxiv. This is unacceptable, especially as a solution to ease some of the pressure on hospital eye departments already exists. Optometrists in community practice can provide NHS services to treat minor eye conditions and monitor patients with chronic-but-stable conditions like glaucoma. These services can free up capacity in hospitals, allowing them to focus on the most complex cases, and are also more convenient for patients. Many areas of England have commissioned these services from optical practices, but provision is patchy across Englandxv. In order to prevent avoidable sight loss, the NHS in England must make full use of optical practices.


i  Das BN, Thompson JR, Patel R et al. (1994) The prevalence of eye disease in Leicester: a comparison of adults of Asian and European descent. J R Soc Med 87, 219–22

Rauf A, Malik R, Bunce C et al. (2013) The British Asian community eye study: outline of results on the prevalence of eye disease in British Asians with origins from the Indian subcontinent. Ind J Ophthalmol 61, 53–8.

Cedrone C, Mancino R, Cerulli A et al. (2008) Epidemiology of primary glaucoma: prevalence, incidence, and blinding effects. Prog Brain Res 173, 3–14

Klein R, Klein BE (2013) The prevalence of age-related eye diseases and visual impairment in aging: current estimates. Invest Ophthalmol Vis Sci 54, ORSF5–13
Kapetanakis VV, Chan MPY, Foster PJ, et al Global variations and time trends in the prevalence of primary open angle glaucoma (POAG): a systematic review and meta-analysis British Journal of Ophthalmology Published Online First: 18 August 2015. doi: 10.1136/bjophthalmol-2015-307223 

Kosoko-Lasaki O, Gong G, Haynatzki G, Wilson MR. Race, ethnicity and prevalence of primary open-angle glaucoma. Journal of the National Medical Association. 2006;98(10):1626-1629

Zhang X, Cotch MF, Ryskulova A et al. (2012) Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys. Am J Ophthalmol 154 (suppl.), S53–62

Wormald RP, Basauri E, Wright LA, Evans JR. The African Caribbean eye survey: risk factors for glaucoma in a sample of African Caribbean people living in London. Eye (Lond) 1994;8(Pt 3):315–320. doi: 10.1038/eye.1994.64

Fraser S, Bunce C, Wormald R (1999) Retrospective analysis of risk factors for late presentation of chronic glaucoma. Br J Ophthalmol 83, 24–8

Chen PP (2003) Blindness in patients with treated open-angle glaucoma. Ophthalmology 110, 726–33

Brown K, Avis M, Hubbard M. Health beliefs of African–Caribbean people with type 2 diabetes: a qualitative study. The British Journal of General Practice. 2007;57(539):461-469.

Sivaprasad S, Gupta B, Gulliford MC et al. (2012a) Ethnic variations in the prevalence of diabetic retinopathy in people with diabetes attending screening in the United Kingdom (DRIVE UK). PLoS One 7, e32182

Sivaprasad S, Gupta B, Gulliford MC et al. (2012b) Ethnic variation in the prevalence of visual impairment in people attending diabetic retinopathy screening in the United Kingdom (DRIVE UK). PLoS One 7, e39608

Yau, J et al. 2012. Global Prevalence and Major Risk Factors of Diabetic Retinopathy. Diabetes Care 35:556–564, 2012

Pardhan S, Gilchrist J, Mahomed I (2004) Impact of age and duration on sight-threatening retinopathy in South Asians and Caucasians attending a diabetic clinic. Eye (Lond) 18, 233–40

Spanakis EK, Golden SH. Race/Ethnic Difference in Diabetes and Diabetic Complications. Current diabetes reports. 2013;13(6):10.1007/s11892-013-0421-9. doi:10.1007/s11892-013-0421-9

Varma R, Sun J, Torres M, Wu S, Hsu C, Azen SP, McKean-Cowdin R, for the Chinese American Eye Study Group. Investigative Ophthalmology & Visual Science. 2016 Dec; 57(15): 6692-6699

ii Shickle, D. & Farragher, T., (2014). Geographical inequalities in uptake of NHS-funded eye examinations: small area analysis of Leeds, UK. Journal of Public Health. 

College of Optometrists (2016): https://www.college-optometrists.org/the-college/policy/see-the-gap-health-inequalities.html

iii College of Optometrists (2011) Britain’s Eye Health in Focus: A Study of Consumer Attitudes and Behaviour Towards Eye Health.

iv SeeAbility

v Association of Optometrists (2017)

vi Cong, R, et al (2008). Smoking and the risk of age-related macular degeneration: a meta-analysis. Ann Epidemiol; 18:647-656.

vii Skelton DA, Bailey C, Howel D, et al Visually Impaired OLder people's Exercise programme for falls prevenTion (VIOLET): a feasibility study protocol BMJ Open 2016;6:e011996. doi: 10.1136/bmjopen-2016-011996 

Thomas Pocklington Trust’s report Falls in older people with sight loss: a review of emerging research and key action points published June 2013.

The College of Optometrists’ Focus On Falls report which looks specifically at the relationship between falls and vision, making several practical recommendations for falls services and the optometric sector.

The College of Optometrists and The British Geriatric Society. The importance of vision in preventing falls

viii Skelton DA, Bailey C, Howel D, et al, Visually Impaired OLder people's Exercise programme for falls prevenTion (VIOLET): a feasibility study protocol BMJ Open 2016;6:e011996. doi: 10.1136/bmjopen-2016-011996.

ix Thomas Pockington Trust. (2016). Loneliness and social isolation in the visually impaired.

x  Hilde P. A. van der Aa et al. (2015) Major Depressive and Anxiety Disorders in Visually Impaired Older Adults. Invest. Ophthalmol. Vis. Sci. 2015;56(2):849-854. doi: 10.1167/iovs.14-15848

xi Claire L. Nollett, et al. (2016). High Prevalence of Untreated Depression in Patients Accessing Low-Vision Services. Ophthalmology, Volume 123, Issue 2, 2016, Pages 440-441, ISSN 0161-6420

xii Bowen M, Edgar DF, Hancock B, Haque S, Shah R, Buchanan S, et al. (2016) The Prevalence of Visual Impairment in People with Dementia (the PrOVIDe study): a cross sectional study of 60-89 year old people with dementia and qualitative exploration of individual, carer and professional perspectives. Health Serv Deliv Res 2016;4(21)   

xiii Pezzullo L, Streatfield J, Simkiss P, and Shickle D (2018) The economic impact of sight loss and blindness in the UK adult population. BMC Health Services Research, 18:63.

Office for National Statistics (2015) 2014-based National Population Projections: Principle projections.

xiv The Royal College of Ophthalmologists (2017)

xv LOCSU Minor Eye Conditions Service  

Submitted: October 2019

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