wales eye clinic liaison service impact report · liaison services are included in the welsh...

Wales Eye Clinic Liaison Service Impact Report

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Contents1.0 Introduction 5

1.1 Thechallenge 5

1.2 TheWaleseyeclinicliaisonservice 5

1.3 Thepolicycontext 6

1.4 Summary:benefitsoftheeyeclinicliaisonservice totheNHSinWales 6

2.0 TheroleoftheEyeClinicLiaisonOfficer(ECLO) 8

3.0 Thebenefitsoftheeyeclinicliaisonservicetothe NHSinWales 11

3.1 Ophthalmology 11

3.2 Fallsprevention 12

3.3 Mentalillhealth 12

3.4 Poverty,unemploymentandimpactonphysical andmentalhealth 13

4.0 Conclusion 15

Appendix1 Eyeclinicliaisonservicepartners 16

Appendix2 Waleseyeclinicliaisonserviceandfunders 17

References 18

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1.0 Introduction

1.1 The challengeWiththenumberofpeopleintheUKwithsightlosspredictedtodoubleby2050(1),findingwaystoreducetheeconomicimpactandrelievepressureonhospitaleyeclinicsisanurgentpriority.

•AlmosttwomillionpeopleintheUKarelivingwithsightloss(2).

•HealthcareexpenditurelinkedtoeyehealthinWalesisnearly£120millionayear(3),buttheindirectcosttotheeconomyismorethandoublethisamount(4).

1.2 The Wales eye clinic liaison serviceTheWaleseyeclinicliaisonservice,developedbyRNIBandpartnerorganisations(seeAppendix1forpartnerinformation),aimstoreducerisktothepatients’physicalandmentalhealth,andincreasetheirabilitytolivesafelyandindependently.Theserviceprovidesessentialemotionalsupportandpracticaladviceatthepointofdiagnosisofsightloss,providinganeffectivelinkbetweenhealth,socialandcommunitysupportservices.

TheeyeclinicliaisonserviceinWalessupported6,730patientsin2012/13.

Thecriticalroleoftheeyeclinicliaisonserviceiswidelyrecognised.EyeclinicliaisonservicesareincludedintheWelshGovernmenteyecarepathwaysforAgeRelatedMacularDegenerationandGlaucoma.TheRoyalCollegeofOphthalmologyrecommendsthatEyeClinicLiaisonOfficers(ECLOs)arepartofaminimumserviceteam(5).

EyeclinicliaisonservicesinWalesarefundedbyBetsiCadwaladrHealthBoard,theBIGLottery,RNIBCymru,CardiffInstitutefortheBlind,andSightCymru(seeAppendix2forserviceandfundingdetails).ThethirdsectorhasprovidedsignificantinvestmentandpumpprimingtoensureservicesareavailabletopatientsacrossWales.Thisfundingistimelimitedandserviceswillbeatriskinthenext18months.

Thefutureprovisionofthiscriticalserviceisatrisk.

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1.3 The policy context TogetherforHealth,theWelshGovernment’sfive-yearvisionfortheNHS,focusesonreducedhealthinequalities,improvedaccesstoservices,animprovedpatientexperience,andprovidinghighqualitycare.

TheWelshGovernment’sdraftEyeHealthCarePlanforWalessetsoutfiveobjectivesinrelationtoeyehealth:

•Preventingpooreyehealthandvisualimpairment.

•Improvingeyehealthoutcomes.

•Ensuringearlyidentificationandintervention.

•Providinghighquality,efficientservices.

•Ensuringpatientfocuseddeliveryofintegratedservices.

TheeyeclinicliaisonservicesupportsdeliveryofWelshGovernmentobjectives.Byprovidinginformation,advice,emotionalandpracticalsupporttopatientsinatimelyfashion,theserviceimpactspositivelyonpatients’healthandwellbeing.ECLOsareanefficientandeffectivelinkbetweentheeyeclinicandthewidersupportandserviceswhichpeopleneedtolivewellwithsightloss.

1.4 Summary: benefits of the eye clinic liaison service to the NHS in WalesWhenpeoplemanagetheirconditionsthemselvestheyimprovetheirqualityoflifeandthisreduceshealthcarespendinginthelonger-term.Theeyeclinicliaisonservicecanmeettheneedsofthoselivingwithlong-termconditionsbyofferingsupportforself-careandencouragingindependence.

Theserviceincreasestheefficiencyofclinicalstaffthroughenablingthemtofocustheirtimemostappropriately.Thisisachievedthroughreducingthetimeclinicalstaffneedtospendwithdistressedpatients,providingemotionalsupport,assistingwiththeadministrationofCertificatesofVisualImpairmentandprovidinginformationonpatients’eyeconditions.Patientthroughputismaximisedandthestressfeltinclinicscanbereduced.

“FallsareamajorcauseofdisabilityanddeathinolderpeopleintheUK,andresultinsignificanthumancostsintermsofpain,lossofconfidenceandindependence”(6).ECLOsprovideinformationonfallpreventionandsupportpatients’timelyaccesstolowvisionandrehabilitationservices.Thereisasignificantfinancialcosttohealthand

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socialcareservicesassociatedwithdealingwiththeresultsoffalls(7).Helpingreducepatients’riskoffuturefallscanreducetheconsequentcosttotheNHSandSocialServices.

TheAllWalesMentalHeathNetwork’s2010reportestimatedthecostofpoormentalhealthinWalestobemorethan£7.2billionperyear.Olderpeoplewithsightlosswholivealonearethreetimesmorelikelytoexperiencedepressionthanthosewithnormalsight(8).Theeyeclinicliaisonserviceprovidesessentialemotionalsupportatthepointofdiagnosisandsignpoststosocialandcommunitysupportservices,helpingthepatientadjusttolivingwithsightloss.

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2.0 The role of the Eye Clinic Liaison Officer (ECLO)

TheserviceprovidedbytheECLOisperson-centredemotionalandpracticalsupporttailoredtotheneedsofthepatient.Thisisprovidedatanoftentraumaticandvulnerabletime.

Supportcaninclude:

•providinginformationonthepatient’seyeconditionandongoodeyehealth

•referraltotheLowVisionServicetoenablepatientstomakebetteruseofexistingsight

•referraltostatutoryservicesincludingsocialservicesandrehabilitationservices

•adviceonfallspreventionandsafetyinthehome

•adviceoncertificationandregistrationandsupportincompletingtheCertificationofVisualImpairment

•referraltospecialistservicessuchasRNIBCymru’swelfarerightsadviceservice,employmentservice,oreducationandtransitionsservicesforchildrenandyoungpeople

•referralstolocalandnationalvoluntaryservices,includinglocalsupportgroups

•informationonproductsandequipmenttosupportindependentlivingandpersonalsafety

•supportandinformationforfriends,familyandcarers.

Whenpeoplemanagetheirconditionsthemselvestheyimprovetheirqualityoflifeandthisreduceshealthcarespendinginthelongerterm(9).ECLOsmeettheneedsofthoselivingwithlong-termconditionsbyofferinginformation,adviceandsupportforself-care,andencouragingindependence.

PatientfeedbackontheRNIBCymrueyeclinicliaisonservice:

•98percentfelttheircontactwiththeECLOhelpedthemtounderstandwhatothersupportandinformationisavailabletothemoutsideofthehospital.

•88percentthoughttheyhadabetterunderstandingoftheireyecondition.

•67percentsaidtheyhadabetterunderstandingofwhatthingstheycoulddotocareforandtreattheireyecondition.

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Case studyMrDhasage-relatedmaculardegeneration(AMD)andrestrictedmobility.AftermeetingwiththeECLOanumberofissueswereidentifiedthatimpacteduponhishealthandabilitytomaintainindependentliving.Referralsweremadetothefollowingservices:

•RehabilitationOfficerfortheVisuallyImpaired.

•Occupationaltherapy.

•SocialWorkerfortheHardofHearing.

•ITProjectOfficer.

•WelfareRightsOfficer.

ThroughtheworkoftheECLOandthroughcontactwiththeseservicesmanyofMrD’sissueswereresolved.Hewasprovidedwithsmallitemsofequipmenttoenablehimtomanagemoresafelyathome.Avolunteerdriverwasfoundtoassistwithshoppingandattendingappointments.Grabrailsandhandrailswereinstalledindoorsandoutdoorstoreducetheriskoffallingandanoccupationaltherapyassessmentwasspeededup.

TheRNIBCymruwelfarerightsservicesecuredHigherRateAttendanceAllowanceof£74perweek,whichalsogaveentitlementtoPensionCreditandCouncilTaxBenefit.

ByseeingtheECLOattheeyeclinicwhenhedid,MrDreceivedthesupportandfinancialassistanceatthebestpossibletimeandnotatatimeofcrisiswhenhisabilitytomanagemayhavedeteriorated.

Thispatient’sexperienceisinsharpcontrasttothemanypatientswhodonotreceiveaservicefromanECLO.Thepatientstoryonpage9isfromtheRNIBreport“LostandFound”(2009)describesavisittotheeyeclinic.

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Judith’s experience“[Afterthefirstappointment]theysaidtheywouldphoneontheMonday

ortheTuesday,andtheydidn’t.Theysaidtheyhadtakenmyphonenumberdownwrongly...thenexttimeIwentinforanappointmentmyrighteyehad‘gone’.”

Judithwasn’tofferedanyinformationonhereyeconditionorwhatitmeanttoloseone’ssight.Shewouldhavelikedtohavebeenabletotakeinformationawaywithhersosheandherhusbandcouldreferbacktoitintheirowntime.NooneintheeyeclinicspoketoJudithaboutherfeelingsorofferedanypracticaladviceonwhattodonowhersightlosswaspermanent.

“Asfarasthemedicalprofessiongoes,therewasnothing.WhenIwentbacktothewaitingroom,theygavemeacupofteaandleftmewithmyhusband.Iwasleftforawhileonmyown.

“Thereneedstobesomethingineyehospitalssoonafterdiagnosis.Thathastochange.”

Call to RNIB Cymru office – May 2013Aladycalledtheofficesayingthatshehaslostthesightinoneofhereyes.Shewasverydistressedandworriedaboutcompletelossofsight.Shehadreceivednoinformationoradvicefromthehospitalsthatshehasbeenattending,norhadshebeenreferredontotheECLObytheclinic.

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3.0 The benefits of the eye clinic liaison service to the NHS in Wales

Thenumberofpeoplewithsightlossisexpectedtodoubleoverthenext25years(10).ThecostofsightlossinWalesisalreadyestimatedat£370m(11)andhospitaleyeclinicsarestrugglingtocopewithcurrentdemand.Innovativeservicesthatcanhelprelievethepressureonclinicstaffandmitigatetheimpactofsightlossareurgentlyneeded.Theeyeclinicliaisonservicecandothisinanumberofwaysforarelativelylowcost.

3.1 Ophthalmology Inasurveyof15ophthalmologistsallagreedthattheeyeclinicliaisonservicecanincreaseclinicalstaff’sefficiencybyreducingtimespentwithdistressedpatients(12).ThisiscorroboratedbystudiesofeyeclinicliaisonservicesinotherpartsoftheUK(13).

ThesestudieshavealsofoundeyeclinicstaffvaluedtheECLOrolein:

•increasingpatientthroughput/management

•reducingstressintheclinic

•improvingpatients’accesstosocialservices

•assistingwiththeadministrationandprocessingofCertificatesofVisualImpairment

•increasingclinicalstaffefficiencybyreducingthetimespentwithnon-compliantglaucomapatients.

OfpatientsseenbytheRNIBCymruandBetsiCadwaladrECLOs:

•70percentof1,378patientsweregiveninformationandsupportaroundregisteringasblindorpartiallysighted.

•79percentof2,093patientswereprovidedwithinformationontheireyecondition.

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3.2 Falls preventionFallsarecommonlyassociatedwiththeneedforhealthandcommunitycareservices,aswellasadmissiontoresidentialornursingcare.Olderpeoplewithsightlosshave90percenthigheroddsofmultiplefallsthanapersonwithnormalsight(14).Afallcanhaveseriousphysicalandpsychologicalconsequences,aswellassignificantresourceimplicationsforpublicservices.

•Visualimpairmentisdirectlyattributableto47percentofthecostoffallsinthepopulationwithvisualimpairmentand10percentofthecostofallfallsintheUK(15).

•5percentofallfallsleadtoafractureandalmostallhipfractures(92percent)arearesultofafall(16).

•Thecostoftreatinghipfracturesin2005wasestimatedtobe£12,000perpatient(17).

•Whenadmittedforanyphysicalcondition,blindandpartiallysightedpeoplehaveanaveragelengthofstayinhospitaltwodayslongerthanpatientswithnormalsight(18).


•25percentof1,007patientssaidthattheyhadhadafall.

•26percentof3,105ofthoseover70saidtheyhadhadafall.

•47percentof1,242saidthattheyfearedafall.

“Byprovidinginformationonfallspreventionandsupportingpatients’timelyaccesstorehabilitationservicestheECLOservicecanhelpreduceapatient’sriskoffuturefalls,andtheconsequentcosttotheNHSandSocialServices.IfadvicefromanECLOpreventedjustoneortwofallsassociatedwithvisualimpairmentthatresultedinafracturedfemur,theECLOservicewouldbecostneutral.”(19)

3.3 Mental ill healthOlderpeoplewithsightlosswholivealonearethreetimesmorelikelytoexperiencedepressionthanthosewithnormalsight(20).Eyeclinicliaisonservicesworkpredominantlywitholderpeople,with90percentofpatientsseenbyRNIBCymruandBetsiCadwaladrECLOsbeingageover50yearsand71percentaged70orover.ECLOscanhelpimprovepatients’mentalwellbeingandreducetherisksassociatedwithpoormentalhealthbyprovidingemotionalsupportatthepointofdiagnosis.Signpostingtootherhealth,socialandcommunityserviceswillhelpthepatienttolivewellwithsightloss.

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•Mentalillhealthisknowntohaveasignificanteconomicimpact,costingWalesanestimated£7.2billionayear(21).

•Nearlyhalfofblindandpartiallysightedpeoplereportfeeling“moderately”or“completely”cutofffrompeopleandthingsaroundthem(22).Thissenseofisolationinevitablyhasanimpactonpeople’smentalandemotionalhealth.

•Sightlosshasbeenidentifiedasoneofthetopthreecausesofsuicideinolderpeople(23).

“Researchevidencesthatprovidingpracticalandemotionalsupporttopeoplewithhealthproblemshasmultiplebenefits–itincreasespeople’scapacitytoself-managetheircondition,improveshealthoutcomes,helpspeopleliveindependentlyandreducestheburdenonthehealthservicebyavoidingunnecessaryhospitaladmissions”(25and26).


•76percentof1,755patientslivedalone

•98percentof3,008patientswerereferredtolocalservices

•96percentof2,413patientswerereferredtonationalservices

•90percentof1,920patientsreceivedinformationonlowvisionaids/assessments

3.4 Poverty, unemployment and impact on physical and mental healthTheeffectsofpovertyandunemploymentonbothphysicalandmentalhealtharewelldocumented.Morethanthreequartersofolderpeoplewithsightlossliveinpoverty(25)and66percentofregisteredblindandpartiallysightedpeopleofworkingagearenotinemployment(26).PatientsofaworkingagearereferredontoRNIBCymru’semploymentservice,whichsupportsindividualstoretainorgainemployment.

Manypeoplewithsightlossarenotclaimingthebenefitstowhichtheyareentitled.ByreferringpatientsontoRNIBCymru’swelfarerightsservicetheECLOensurespatientsreceivethefinancialsupporttheyareentitledto.

In2012/13RNIBCymruandBetsiCadwaladrECLOsreferred81percentof1,709patientstotheRNIBCymruwelfarerightsservice.Over60percentoftheindividualsreferredtothewelfarerightsservicewerenotreceivingthecorrectbenefits.Theservicesecuredanaverageof£62.46perweekincreasepersuccessfuloutcome.Thisis£3,247perannum.

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Followupinterviewswithwelfarerightsserviceclientsevidencedthepositivebenefitstohealthandwellbeingarisingfromanincreasedincome:

•68percentofthoseinterviewedreportedanimprovementintheirmentalhealthandemotionalwellbeing.

•68percentofthoseinterviewedreportedanimprovementintheirphysicalhealth,includingfallsprevention.

•65percentofthoseinterviewedreportedanincreasedabilitytobeindependent.

Case study – welfare rights serviceMrandMrsWarearetiredcouple.MrsWhadrecentlybeenregisteredassightimpairedandherhusbandhadextremelypoormobilityduetovarioushealthproblems.

Whenthecouplewerevisitedtheyweresittingintheirloungewhichhadseveralbucketsandcontainersonthefloorastheyhadanumberofleaksintheirroofbutcouldnotaffordtofixit.Theywerestrugglingfinanciallyandemotionally,feelingisolatedandlackingsupportfromfriendsandfamily.Theywerestrugglingduetotheamountofmoneythattheywerepayingoutongenerallivingexpenses,whichhadincreasedduetotheirdisabilities.

WiththesupportoftheserviceAttendanceAllowancewasawardedtobothMrWandMrsW,CarersAllowancewasobtainedqualifyingthemfortwocarers’premiumsontheirpensioncredit,andtheywerealsoawardedtheCoupleDisabilityPremiumRate.Theirincomeincreasedby£288.65perweek.WitharrearsofbenefitsandthesupportofCareandRepairtheywereabletorepairtheirroof,vastlyimprovingtheirlivingconditionsandcomfort.

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4.0 Conclusion Theeyeclinicliaisonserviceishighlyvaluedbypatients,clinicians,socialandcommunitysupportservices.Theservicehelpsmitigatethesocial,emotionalandpsychologicalimpactofsightlossandhelpstoimprovethehealthoutcomesforindividualsandfamilies.TheserviceinWalesassiststheWelshGovernmentinthedeliveryofitsstatedpolicyobjectives.

UniversalcoverageinWalesiscurrentlyunderthreat.Thefutureprovisionofthiscriticalserviceisatrisk.RNIBCymruisnowurgingWelshGovernment,HealthBoardsandotherpartnerstoworktogethertoensurethisvitalserviceisnotlost.

Patient experience“Iwasregisteredsightimpairedanddiagnosedwith‘wet’AMD,myvision

deterioratedquiterapidly,whichwasarealshock.Ialsohaveotherhealthproblems.Ilivealonebutwasveryindependentandthoughtofasastrongindividualwhogenerallysupportedothersratherthantheotherwayround.

“PracticaltasksbecamedifficultandIhadproblemswithmymobilityoutandabout.Ifacedtransportissueswhichweremadeworsebyhavingnofamilylivingnear.

“TheECLOexplainedregistrationandavarietyofsupportservices.Sheprovidedemotionalsupport,referredmetothesensoryteamandarrangedforalowvisionassessmentwithvolunteertransporttoandfromthecentre.TheECLOalsoprovidedmewithcontactinformationonnationalandlocalsupportservicessuchasAgeConcernandRNIB.

“Iwassoveryappreciativeofthesupportprovided.”

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Appendix 1

Wales eye clinic liaison service partner detailsTheBigLotteryAdvantageprogrammefundstheWalesEyePatientAdvocacyService.ThisprojectisledbyRNIBCymruandisdeliveredinpartnershipwith:

•AbertaweBroMorgannwgUniversityHealthBoard

•BetsiCadwaladrUniversityHealthBoard

•BridgeVisSocietyfortheBlind

•CardiffandValeUniversityHealthBoard

•CardiffValeandtheValleysInstitutefortheBlind

•CwmTafHealthBoard

•HywelDdaHealthBoard

•NorthWalesSocietyfortheBlind

•TheRoyalCollegeofOphthalmologists

•VisionImpairmentWestGlamorgan(VIWG)

SightCymruprovideseyeclinicliaisonservicesinAneurinBevanHealthBoard.

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Hospital Weeklyhours Currentfunder

SingletonHospital,Swansea Fulltime RNIBCymru

RoyalGlamorgan,Pontyclun(1day)

YsbytyCwmRhondda,Llwynypia(1day)

PrinceCharles,MerthyrTydfil(1day)

21hours BIGLottery.WalesEyePatientAdvocacyService(ProvidedbyRNIBCymru)

PrincessofWales,Bridgend(2days)

NeathPortTalbotHospital,PortTalbot(1day)

21hours BIGLottery.WalesEyePatientAdvocacyService(ProvidedbyRNIBCymru)

AmmanValley,Ammanford(1day)GlanGwili,Carmarthen(1day)Withybush,Haverfordwest(1day)PrincePhillip,Llanelli(fortnightly)

21hoursintotal

BIGLottery.WalesEyePatientAdvocacyService(ProvidedbyRNIBCymru)

YsbytyGwynedd,Bangor 21hours BIGLottery.WalesEyePatientAdvocacyService(ProvidedbyRNIBCymru)

UniversityHospitalWales,Cardiff Fulltime CardiffInstituteforBlindPeople

RoyalGwent,Newport

NevilleHall,Abergavenny

Parttime,flexiblehours

SightCymru

TheStanleyEyeClinic,AbergeleHospital

4daysperweek

BetsiCadwaladrUniversityHealthBoard

WrexhamMaelor,Wrexham 30hours BetsiCadwaladrUniversityHealthBoardwithsupportfromRNIBCymru

NorthRoadEyeClinic,Aberystwyth NoservicefromApril13

Fundingbeingsought

Appendix 2Wales eye clinic liaison service and fundersTheserviceisprovidedin15ofthe16eyeclinicsinWales.RNIBCymruandtheBigLotteryfundafulltimeWalesECLOManager.

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References1. AccessEconomics(2009)FutureSightLossUK1:Theeconomicimpactofpartial

sightandblindnessintheUKadultpopulation,RNIB

2. AccessEconomics(2009)FutureSightLossUK1:TheeconomicimpactofpartialsightandblindnessintheUKadultpopulation,RNIB

3. WelshAssemblyGovernment(2012)NHSProgrammeBudgets2010/11.AccessedviaStatsWaleswebsite.

4. RNIBestimatebasedonpopulationdatafromtheOfficeforNationalStatisticsandtheindirectcostsofsightlossidentifiedinAccessEconomics,FutureSightLossUK1:TheeconomicimpactofpartialsightandblindnessintheUKadultpopulation(RNIB,2009)

5. RoyalCollegeofOphthalmologists(2007)CommissioningContemporaryAMDServices:Aguideforcommissionersandclinicians.London:RoyalCollegeofOphthalmologists.

6. NHS1000LivesPluscampaignnhs.uk/sites3/page.cfm?orgid=781&pid=48636

7. NHS1000LivesPluscampaignnhs.uk/sites3/page.cfm?orgid=781&pid=48636

8. Evans,JR,Fletcher,AE,Wormald,RP,‘Depressionandanxietyinvisuallyimpairedolderpeople’,Ophthalmology,114(2):283-288(2007)

9. Boyce,T(2011)Innovationandqualityinsightlossandblindnessservices:EyeClinicLiaisonOfficers.RNIB

10.AccessEconomics(2009)FutureSightLossUK1:TheeconomicimpactofpartialsightandblindnessintheUKadultpopulation,RNIB

11.RNIBestimatebasedondirectcostsintheNHSWalesProgrammebudgetfor2010/11,populationdatafromtheOfficeofNationalStatisticsandtheindirectcostsofsightlossidentifiedinAccessEconomics(2009)FutureSightLossUK1:TheeconomicimpactofpartialsightandblindnessintheUKadultpopulation,RNIB

12.RNIBCymruECLOServiceOpthalmologistQuestionnaire;CardiffandValeUniversityHealthBoard(2012)

13.Forexample:Mack,C(2008)EvaluationofECLOService(London,RNIB)andJohnston,A(2010)ECLOImpactReport:CostEffectiveandHighQualityCare:TheEvidenceforECLOs(London:RNIB)

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14.Scuffham,PA,Legood,R,Wilson,ECF,‘TheincidenceandcostofinjuriousfallsassociatedwithvisualimpairmentintheUK’,VisualImpairmentResearch4.1-14(2002)

15.ScuffhamP,ChaplinS,LegoodR(2003)IncidenceandcostsofunintentionalfallsinolderpeopleintheUnitedKingdom.JEpidemiolCommunityHealth,57:740–4.

16.StelVS,SmitJH,PluijmSM,LipsP(2004)Consequencesoffallinginoldermenandwomenandriskfactorsforhealthserviceuseandfunctionaldecline.A,geAgeing,33:58-65;McKayC,AndersonKE(2010)Howtomanagefallsincommunitydwellingolderadults:areviewoftheevidence.PostgradMedJ,86:299-306.

17.Lawrenceetal,Thecurrentcostsoftreatinghipfractures.Injury2005;36:88-91

18.Evans,JR,Smeeth,LFletcher,AE(2008)HospitaladmissionsinolderpeoplewithvisualimpairmentinBritain,BMCOphthalmology,8:16,1-5

19.Boyce,T(2011)Innovationandqualityinsightlossandblindnessservices:EyeClinicLiaisonOfficers.RNIB

20.Evans,JR,Fletcher,AE,Wormald,RP,‘Depressionandanxietyinvisuallyimpairedolderpeople’,Ophthalmology,114(2):283-288(2007)

21.FriedliandParsonage,Promotingmentalhealthandpreventingmentalillness:theeconomiccaseforinvestmentinWales(2009)

22.Pey,T,Nezegwu,FandDooley,G,functionalityandtheneedsofBlindandPartiallySightedPeopleintheUK:Aninterimreport(2006)

23.Waernetal,‘Burdenofillnessandsuicideinelderlypeople:case-controlstudy’,BritishMedicalJournal,June2002,324:1355(2002)

24.Boyce,T(2011)Innovationandqualityinsightlossandblindnessservices:EyeClinicLiaisonOfficers.RNIB

25.RNIB,Unseen:Neglect,isolationandhouseholdpovertyamongstolderpeoplewithsightloss(2004)

26.Douglas,G,Corcoran,C,andPavey,S,Network1000:OpinionsandcircumstancesofvisuallyimpairedpeopleinGreatBritain(UniversityofBirmingham,2006)

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