Opportunities, barriers and enablers for Making Every Contact Count (MECC) to be introduced into the optometry curriculum and workforce training and development The Roundhouse Consultancy MK Ltd. Health Education England West Midlands Local Eye Health Network, NHS England West Midlands November 2016 1
Acknowledgements We are grateful to the following staff across the West Midlands region and nationally who willingly gave time and shared information for this review: Claire Roberts Chair of Local Eye Network, NHS England West Midlands Sally James Marcus Dye Alistair Bridge David Rowland Hannah Bartlett Olivia Hunt Jackie Martin Jo Mullin Jill Cheney Shamina Asif Prab Boparai Katrina Venerus Linda Hindle Public Health Workforce Specialist, Health Education England West Midlands General Optical Council Acting Head of Education and Standards General Optical Council Director of Strategy General Optical Council Head of Policy and Research Aston University Senior Lecturer and Admissions Tutor B.Sc Optometry Aston University Programme Director Optometry, B.Sc Optometry College of Optometrists Director of Education College of Optometrists Director of Policy and Strategy Community Optometrist Healthy Living Optometrists pilot scheme Dudley and Community Optometrist Walsall Principal Community Optometrist and Specialist Hospital Optometrist Managing Director, Local Optical Committee Support Unit (LOCSU) Public Health England, Lead Allied Health Professional and National Engagement Lead for Police and Fire Services 2
TABLE OF CONTENTS TERMS... 4 DEFINITIONS... 5 EXECUTIVE SUMMARY... 7 KEY RECOMMENDATIONS... 8 1. INTRODUCTION.10 2. MAKING EVERY CONTACT COUNT... 12 3. EYE HEALTH and BEHAVIOUR CHANGE... 18 4. AIMS OF THE REVIEW... 25 5. METHODS... 26 6. FINDINGS... 27 7. MECC IN THE CURRICULUM... 32 8. CONCLUSIONS... 36 3
Terms Ophthalmologists are doctors of medicine who complete the required medical school training plus further post-medical qualification specialist hospital training in eye care. They diagnose and treat medical and surgical eye problems Optometrists typically attend a three undergraduate honours degree course before starting a year-long pre-registration period (there are some universities however that offer a combined undergraduate and pre-registration four year programme). An optometrist examines eyes, tests sight and prescribes and fits spectacles or contact lenses for those who need them. They give advice on visual problems and detect ocular disease or abnormality such as cataracts, glaucoma or retinal disease, referring the patient to a medical practitioner if necessary. Opticians (also called dispensing opticians) are trained to dispense and fit spectacles and other optical aids, working from the prescriptions written by optometrists and ophthalmologists. EHCP an eye health care professional GOC- The General Optical Council (GOC) is the regulator for the optical professions in the UK and establishes the standards of education, performance and conduct amongst opticians. Approximately 29,000 optometrists, dispensing opticians, student opticians and optical businesses are on the register. 4
Definitions Ask, Assist, Advise- these are the three simple actions to support people to make a lifestyle change: Ask = raise the issue with simple question during day to day contact with someone Advise= give messages about healthy lifestyle change and tips to achieve them Assist= share information or encourage people to contact relevant organisations. Behaviour change - a change in an outcome behaviour resulting from a planned intervention. Behaviour change intervention- Single or multiple sessions of motivational discussion focussed on increasing the individual s insight and awareness regarding specific health behaviours and their motivation for change. Brief Advice- a short intervention (usually from 30 seconds to 3 minutes) delivered opportunistically in relation to a client s reason for seeking help. It can be used to raise awareness of, and assess a person s willingness to engage in further discussion about healthy lifestyle issues. Brief Intervention- Brief intervention is a generic term referring to a variety of encounters with a patient or client that that is likely to consist of 1 3 sessions of approximately 5 30 minutes. Healthy Conversation A term used to describe a conversation that takes place opportunistically and involves an individual being encouraged to consider their lifestyle and health with a view to identifying small but important changes. It is said to include three elements: Cue: A hook that enables the patient/client to raise a subject with the practitioner, or vice versa Conversation: The brief intervention Conclusion: Signposting to follow up / specialist support services. 5
Lifestyle- the ways in which people live that may influence their health e.g. eating an unhealthy diet, smoking, drinking alcohol excessively. 6
EXECUTIVE SUMMARY Aims: The aim of this review for the West Midlands region was to identify the opportunities, enablers and barriers to optometry workforce training and development to deliver behaviour change as a brief intervention or brief opportunistic advice and to make recommendations on the introduction of MECC within undergraduate Optometry programme. Methods: Interviews with practising optometrists and members of the Local Eye Health Network in the West Midlands and desktop research were carried out to identify the scope of MECC-related activity. Interviews were also conducted with the regulatory body, the General Optical Council, and the professional and examining body, the College of Optometrists. The curriculum of the B.Sc Optometry at Aston University was mapped against the Public Health Skills and Knowledge Framework to locate where public health competencies were being met and interviews were conducted with two staff and a focus group held with final year students. Findings: At the current time, although there is potential, and a willingness for public health to be embraced by the optometry profession, the public health role of optometrists is limited and so there are barriers to embedding MECC in the optometry curriculum. Public health is only touched upon in initial training and this is primarily in relation to risk factors for eye disease. Because optometry practice is commercially as well as clinically driven, some practising optometrists deemed the raising of lifestyle issues non-viable without additional funding. The General Optical Council is introducing a new code of conduct from April 2016, which includes providing lifestyle advice. This may provide opportunities to better educate the future workforce about the importance of public eye health and behaviour change approaches. The Healthy Living Opticians pilot scheme in Dudley will also provide insight into the knowledge, training and resources needed for this approach. 7
KEY RECOMMENDATIONS 1. Training on brief opportunistic advice should be offered to Optometrists within the existing workforce who have an interest in public health and who could be champions for MECC/brief interventions. The training should cover: Introductions to the evidence base on eye public health; Information packs on local lifestyle services and how to signpost to them; Links to online e-learning on how to offer brief opportunistic advice 1 2 and to the RSPH Understanding Health Improvement module; Case studies of the Dudley Healthy Opticians scheme. 2. Optometrists should have the tools readily available to advise and signpost members of the public and the understanding that it is in their gift to do so as part of their role as duty to the patient. For example, this could include: Exploring potential opportunities to build on the PHE One You campaign to include raising awareness of sight loss and prevention and links to lifestyle factors. Locally developed posters and leaflets on community lifestyle services such as smoking cessation and eye health. 3. Optometry should be seen as part of the wider system of public health alongside the allied health professions. A much greater emphasis should be given to partnership working between public health and optical sector: As an initial first step, Health Education England in the West Midlands and the Local Eye Health Network should host a workshop in the West Midlands for key stakeholders to explore the impact of sight loss on health and wellbeing at population level, and raise awareness of eye health and sight loss in line with the Public Health Outcomes Framework Indicators. 1 National Centre for Smoking Cessation and Training available online at http://www.ncsct.co.uk/publication_very-brief-advice.php [accessed 1 March 2016] 2 Making Every Contact Count available online at http://www.makingeverycontactcount.co.uk/training%20and%20resources/elearning.html [accessed 1 March 2016] 8
4. The findings from the recently developed pilot Healthy Living Optician scheme funded by Dudley Local Authority should be disseminated widely and considered by commissioners when reviewing the contracting of services to improve eye health at a local level. 5. There need to be greater educational opportunities for eye public health education: The MECC Higher Education Institutions Network in the West Midlands already includes Optometry could become an enabler to encourage broader public health skills development opportunities amongst academics and multi-disciplinary learning about eye health and sight loss. Ophthalmic public health should be a more integral part of initial training for optometrists and study in public health should be available more widely and promoted as Continuing Education and Training (CET) and development for optometrists. 6. The changes in GOC standards provide an opportunity to enhance the undergraduate Optometry curriculum for the future workforce, to strengthen the role of Optometrists in delivering brief opportunistic advice and signposting to lifestyle services. For public health to be part of the eye health care education it needs to be included as a professional competence. 7. The strongest lever for change would be to introduce a new aspect to the role where brief interventions are contractually required as part of the GOS contract. It is possible that the recent change in NHS standard contract to include MECC could prompt such a review of the GOS contract. However, the participants in this review thought change to the GOS contract was unlikely in the current financial context despite evidence of brief interventions contributing to lifestyle change, which, in turn, would contribute to the prevention of avoidable loss of sight and the achievement of longer-term eye health outcomes. 8. The findings from this review should be widely disseminated within the optical sector and public health. Specifically, they should be shared with the General Optical Council for consideration within their forthcoming review of the core competency framework. 9
1. INTRODUCTION Following discussions with West Midlands Local Eye Health Network, The Roundhouse Consultancy MK Ltd was commissioned by Health Education England in the West Midlands to undertake a review from November 2015 April 2016 of the opportunities, enablers and barriers to introducing MECC-related approach in eye health. MECC was developed in 2009 by NHS Yorkshire and Humber as a long-term strategy to help create a healthier population and thereby reduce NHS costs. It aimed to radically extend the delivery of public health advice to the public by training non- specialist staff from a wide range of service organisations for minimal investment, in the basic skills of health promotion and prevention and thus create an extended sales force for healthier living 3 The initial aim of MECC was expressed as mobilising the greatest asset of the NHS, its workforce, in delivering simple and timely advice to the vast potential number of service users they come into contact with on a daily basis 4. NHS Yorkshire and Humber developed a Prevention and Lifestyle Behaviour Change: A Competence Framework 5 that seeks to equip the workforce with the skills and knowledge they need to identify and make the most of every opportunity to help people live healthier lives. The framework identifies a function (a service the workforce is required to deliver) and the competence required to deliver it. The workforce competences for delivering behaviour change are defined within the four key levels of the framework: Level 1: Brief advice and signposting Level 2: Short behaviour change intervention e.g. brief intervention or motivational interviewing Level 3: Behaviour change intervention programme e.g. weight management programmes Level 4: Specialist / Advanced or specific lifestyle and behaviour change 3 Ion V (2011) Making Every Contact Count: a simple but effective idea. Perspectives in Public Health Vol. 131, No. 2, March 2011 4 Approximately 83% (51,220,337) of this population is registered with GP practices (The Health and Social Care Information Centre, 2010). In 2009 16,232,579 people were admitted to the NHS hospitals, 11,004,867 attended the first visit in outpatients' clinics (The NHS Information Centre, Hospital Episode Statistics for England. Outpatient statistics, 2008-2009) and 18,8 million individuals attended the A&E Departments from April 2008 to March 2009 (The NHS Information Centre, Hospital Episode Statistics: Accident and Emergency Attendances in England - experimental statistics, 2008-2009) 5 Available online at http://www.makingeverycontactcount.co.uk/docs/prevention%20and%20lifestyle%20behaviour%20 Change%20A%20Competence%20Framework.pdf [accessed 280415] 10
approaches to support individuals. Workers at this level are expected to act as a resource and support for others. MECC has come to be interpreted differently since 2009 but remains broadly a mechanism for providing brief advice or brief intervention on a range of health issues. The national advisory group has agreed a consensus statement on MECC that signals its potential: Anyone working with the public can promote good health and wellbeing as part of their day to day work. To achieve the radical upgrade in population prevention and public health described in the Five Year Forward View, it is key that promoting health and wellbeing is embedded into the work of public services, enabling staff to use every relevant contact that they have with a member of the public as an opportunity to improve health. NICE guidance outlines the importance of the role of brief interventions and advice, the principles of which underpin Making Every Contact Count. The guidance highlights the evidence from research into the effectiveness of brief intervention and advice, that behaviour change can impact on some of the largest causes of mortality and morbidity and that the NHS should equip practitioners with the necessary competencies and skills to support behaviour change using evidence-based tools 6. The term healthy conversation is often used and the RSPH have written a review of these opportunities for allied health professionals 7 and this term has some appeal for practitioners to describe what might be entailed. 6 NICE (2007) Behaviour change: the principles for effective interventions PH6. Available online at http://www.nice.org.uk/guidance/ph6/chapter/recommendations [accessed 1 March 2016] 7 Royal Society Of Public Health (2015) Healthy conversations and the allied health professional. Available online at: https://www.rsph.org.uk/filemanager/root/site_assets/our_work/reports_and_publications/2015/ah p/final_for_website.pdf [accessed 1 March 2016] 11
2. MAKING EVERY CONTACT COUNT 2.1 MECC as a brief intervention Within current health and social care practice the terms brief advice, brief intervention are widely used (see page 5) and in health promotion the concept of opportunistic health promotion was widely debated as health promotion became a field of activity in the 1980s. Motivational interviewing has been extensively researched in different settings. These interventions have been acknowledged as effective in certain situations, and opportunistic health promotion has routinely been included in policy and practice advice. Despite this, it has not routinely been included within curricula for professional training 8 although it is in the nursing curriculum in West Midlands HEIs and a module is available online as part of GP training. Evidence of the impact of health messages to encourage health-related behaviour change is limited. A review by Powell and Thurston claims that providing health messages is associated with smoking cessation and increases quitting from 1% to 3% 9. There is also some evidence that brief advice can be effective in increasing physical activity levels 10. Work is currently being undertaken by an advisory group at Public Health England to provide an accessible toolkit to enable local areas to evaluate MECC programmes and to identify its Return on Investment (ROI). Traditionally, the remit for this particular type of health promotion has been ascribed to medical and nursing staff; however the importance of the role of other front-line professionals has been argued 11. A study of pharmacy clients for example, found that they 8 E.g. Gill, J.S., and O May, F. P. (2011) Is it my job? Alcohol brief interventions: Knowledge and attitudes among future healthcare professionals in Scotland, Alcohol and Alcoholism, 46, pp. 441-50. 9 Powell, K. & Thurston, M. (2008). Commissioning training for behaviour change interventions: Evidence and best practice in delivery. Chester: University of Chester, Centre for Public Health Research. 10 Ogilvie D, Foster C.E.. Rothnie H., Cavill N., Hamilton V., Fitzsimons C.F., Mutrie N. (2007), Research Interventions to promote walking: systematic review BMJ;334:1204 (9 June), doi:10.1136/bmj.39198.722720.be. 11 Public Health England/Royal Society for Public Health (2015) Healthy conversations and allied health professionals. Available online at https://www.rsph.org.uk/filemanager/root/site_assets/our_work/reports_and_publications/2015/ah p/final_for_website.pdf [accessed 1 March 2016] 12
were willing to accept and discuss drinking and written information from pharmacists 12. Pharmacists were thought of as being more accessible than the GP; however concerns were expressed about feeling patronised or labelled and lack of privacy for having lifestyle-related conversations. The majority of literature on brief advice and opportunistic health promotion in primary care concentrates on alcohol, smoking and physical activity. This may be an indication that health care professionals restrict their advice to areas where they are less likely to impact on the patient relationship and they feel most confident. The appropriateness of the context in which discussion occurred is an important factor in patients acceptance. It may be important to have the right messenger delivering health advice. If the messenger is considered inappropriate, whether overall or at a particular time, this may lessen the impact or act as a disincentive to following advice. There is some evidence that the visible personal health behaviours of health care professionals may influence their willingness to offer public health advice and its credibility with patients 13. Public servants, who have bounded expectations that do not include health advice giving, may not be viewed as trusted sources of advice by members of the public. 14. Whilst opportunistic health promotion is recognised as good practice, staff may lack the training to deliver brief or opportunistic advice adequately. Some staff may not necessarily perceive delivering health promotion advice as part of their role. 2.2 Implementation of MECC with organisations and professional groups There is minimal published research to inform the implementation of MECC at an organisational level 15 16 17 18 and there is one evaluation of MECC based on interviews with 12 Dhital, R., Whittlesea, C.M., Norman, I.J., Milligan, P. (2010) Community pharmacy service users views and perceptions of alcohol screening and brief intervention. Drug and Alcohol Review, 29, pp. 596-602. 13 Kelly, M., Wills, J., Sykes, S., (2016) Do the personal health behaviours of health care professionals impact on patient outcomes? A systematic review. In press. 14 E.G. Offredy, M. (2002) Access to primary care: Decision making by GP receptionists. British Journal of Community Nursing, 7, pp. 480-85. 15 Elwell, L., Powell, J., Wordsworth, S., & Cummins, C. (2014a) Health professional perspectives on lifestyle behaviour change in the paediatric hospital setting: A qualitative study. BMC Paediatrics, 14(1), pp. 71. 13
stakeholders actively involved in the delivery, commissioning or training of MECC 19. Kislov et al 20 conducted a review of MECC viewing it as a workforce development intervention in the field of health promotion. They identify a number of organisational barriers to its implementation including: lack of education and training, lack of finance and resources, expectations of pay increase for enhanced roles, and management and accountability changes. Elwell s study of Birmingham Children s Hospital 21 found that finding the appropriate time for a chat about a patient s lifestyle has also been found to be a challenge, and there was a general concern that engaging in healthy conversations may have negative connotations. Participants felt that it was a challenge to couple clinical care and behavioural advice. They felt they could only comfortably give advice where it had a direct and obvious link to the reason for admission or patient s medical condition. The evidence suggests that staff may adopt avoidance behaviours in order to maintain a positive relationship with patients or clients. Staff were worried about being perceived as judgemental, alienating parents or a hospital stay being an inappropriate time to talk about lifestyle change. Participants in their study were of the opinion that if people didn t want to listen to them, they weren t going to change. They noted that staff reported only offering support to those families who had 16 Elwell, L., Powell, J., Wordsworth, S., & Cummins, C. (2014b) Challenges of implementing routine health behaviour change support in a children's hospital setting. Patient Education and Counselling, 96, pp. 113-19. 17 Lawrence, W., Black, C., Tinati, T., Cradock, S., Begum, R., Jarman, M.,... & Barker, M. (2014) Making every contact count : Evaluation of the impact of an intervention to train health and social care practitioners in skills to support health behaviour change. Journal of Health Psychology, pp.1-14. [Online]. DOI: 10.1177/1359105314522304 [Accessed 19 August 2014]. 18 Tinati, T., Lawrence, W., Ntani, G., Black, C., Cradock, S., Jarman, M.,... & Barker, M. (2012) Implementation of new Healthy Conversation Skills to support lifestyle changes what helps and what hinders? Experiences of Sure Start Children s Centre staff. Health & Social Care in the Community, 20(4), pp. 430-37. 19 Nelson, A., De Normanville, C., Payne, K. & Kelly, M.P. (2013) Making every contact count: An evaluation, Public Health, 127, pp. 653-60. 20 Kislov R, Nelson A, de Normanville C, Kelly M & Payne K (2012), Work redesign and health promotion in healthcare organisations: a review of the literature. Univ. Manchester Business School. Available online at: https://www.escholar.manchester.ac.uk/api/datastream?publicationpid=uk-acman-scw:184635&datastreamid=supplementary-1.pdf 21 Elwell, L., Powell, J., Wordsworth, S., & Cummins, C. (2014b) Challenges of implementing routine health behaviour change support in a children's hospital setting. Patient Education and Counselling, 96, pp. 113-19. 14
taken their advice or made changes in the past these were seen as worthwhile candidates for health advice. Participants reported that they preferred to engage in MECC with patients or clients with whom they had already built a relationship. Nurses in this study did not see the worth of engaging in MECC with patients or families who they might not come into contact with again in the future. One of the dangers in MECC implementation is the risk of selection bias if staff only provide advice to familiar faces, or those whom they perceive to be more likely to make a change. There could be countless lost opportunities with patients who are for example, perceived as stubborn, more complex cases, or presenting language barriers. Equally, there are patients with what is termed co-morbidities mostly from more intense exposure to risk factors, particularly smoking, obesity, alcohol and physical inactivity due to challenging personal, occupational, and societal factors throughout the life course including persistent and widening inequalities. These individuals are however, less likely to have a simple healthy conversation. Motivational interviewing guidance will suggest agenda-setting for such individuals 22. Low levels of confidence also presented a barrier to instigating conversations about change. There appears to be a circular relationship between training, confidence, and engaging in MECC 23. The fewer barriers perceived, the more frequently skills were used and vice versa 24. Elwell et al 25 noted that more experienced health professionals found broaching certain topics easier, which in turn reduced their concerns about negative outcomes stemming from such conversations. Participants felt challenged discussing a topic where they did not have personal experience, for example if they never smoked. Others felt that social barriers could make it difficult for staff to engage with patients, and that patients may feel more comfortable talking to someone who is on their level, such as a healthcare assistant or 22 Miller W, Rollnick S, Butler C (2008) Motivational Interviewing in Health Care. New York: Guilford Press. 23 Lawrence, W., Black, C., Tinati, T., Cradock, S., Begum, R., Jarman, M.,& Barker, M. (2014) Making every contact count : Evaluation of the impact of an intervention to train health and social care practitioners in skills to support health behaviour change. Journal of Health Psychology, pp.1-14. [Online]. DOI: 10.1177/1359105314522304 [Accessed 19 August 2014] 24 Tinati, T., Lawrence, W., Ntani, G., Black, C., Cradock, S., Jarman, M., & Barker, M. (2012) Implementation of new Healthy Conversation Skills to support lifestyle changes what helps and what hinders? Experiences of Sure Start Children s Centre staff. Health & Social Care in the Community, 20(4), pp. 430-37. 25 Elwell, L., Powell, J., Wordsworth, S., & Cummins, C. (2014b) Challenges of implementing routine health behaviour change support in a children's hospital setting. Patient Education and Counselling, 96, pp. 113-19. 15
pharmacy counter assistant 26. However, the studies here mainly reported the views of health professionals and clinical staff. More research is needed to examine the views of staff members at lower tiers of healthcare and public sector organisations, as well as patient preferences towards acceptability of speaking about lifestyle change with non-traditional sources of health advice. Knowledge of the impact of MECC specifically was largely confined to the impact of training on staff. There is a need for more research to evaluate the impact of MECC on patients or clients. Elwell et al 27 suggested that a feedback mechanism would be useful for staff to feel that their actions were worthwhile. Participants noted the various benefits of MECC, such as effecting change early on, saving the NHS money, and feeling like they had made a difference to someone s life. However, participants felt there was little visible evidence to them of the worth of providing such advice. 2.3 MECC in the education curriculum Increasingly, local Health Education England teams are working with Higher Education Institutes (HEIs) to ensure that commissioned pre-registration programmes for Allied Health professionals, nursing, midwifery and medicine improves public health capability of healthcare staff. Several of these programmes are mapped to ensure that knowledge is included about the public health agenda to reduce inequalities. Health Education England in the West Midlands has had for a number of years a MECC Higher Education Institutions Network to embed the principles of prevention and public health into the undergraduate curricula of its commissioned courses. It is less common to find specific public health competencies in relation to having a healthy conversation. Although optometrists are not classified as allied health professionals (AHPs) a report on the AHPs for Health Education Midlands and East did recommend that AHPs have the training and support to enable them to have healthy conversations as part of undergraduate training 28. 26 Nelson, A., De Normanville, C., Payne, K. & Kelly, M.P. (2013) Making every contact count: An evaluation, Public Health, 127, pp. 653-60 27 Elwell, L., Powell, J., Wordsworth, S., & Cummins, C. (2014a) Health professional perspectives on lifestyle behaviour change in the paediatric hospital setting: A qualitative study. BMC Paediatrics, 14(1), pp. 71. 28 Health Education Midlands and East (2015) Allied Health Professions (AHPs): vital workforce for future care. 16
Training for MECC was originally developed according to the NHS Yorkshire and Humber competence framework 29 that led to the identification of different levels of training as shown in Table 1. Specific workforces, including optometrists, who might provide brief advice alongside caring or clinical duties would normally undertake Level 1 Behaviour Change training. Table 1 Behaviour Change Training Level One: Very Brief Intervention (MECC) 30s seconds- 5minutes Chat for Change/brief opportunistic advice The worker is able to engage opportunistically with individuals and use basic skills of awareness, engagement and communication to introduce the idea of lifestyle behaviours change and to motivate individuals to seek further support 1.1: Ability to work and communicate effectively with individuals Raise awareness of health behaviours Assess willingness to engage in chat Advise re recommendations Signpost 1.2: Ability to develop rapport 1.3: Support and enable individuals to access appropriate information 1.4: Communicate with individuals about promoting their health and well-being 1.5: Ability to deliver information in a way that can be understood by the individual Follows an Ask, Advise, Assist structure 1.6: Ability to manage endings 1.7: Ability to recognise barriers and facilitators of conversations about health behaviours including own beliefs and attitudes. Health Education Wessex has developed Healthy Conversation Skills (HCS) training 30 and there are a variety of toolkits and online resources to support training in MECC, which will soon be available on a national platform 31. 29 http://www.makingeverycontactcount.co.uk/docs/prevention%20and%20lifestyle%20behaviour%20 Change%20A%20Competence%20Framework.pdf 30 Black C, Lawrence W, Cradock S, Ntani G, Tinati T, Jarman M, Begum R, Inskip H, Cooper C, Barker M & Baird J. Healthy Conversation Skills: increasing competence and confidence in front-line staff. Public Health Nutrition 2012;17(3):700-707. 31 http://www.makingeverycontactcount.co.uk/training%20and%20resources/elearning.html 17
3. EYE HEALTH and BEHAVIOUR CHANGE 3.1 Avoidable sight loss and public health According to the RNIB, the number of people with partial sight or blindness is set to increase by 115 per cent to nearly 4 million people by 2050. 100 people start to lose their sight every day and at least 50% of this is preventable if detected and treated in time 32 33. This places a huge burden on the individual and health care services. Overall, the NHS spent 2.3bn on eye health and eye care in 2012/13 in England with 62% on hospital ophthalmic services 34. Eye care is the sixth highest hospital attendance of 83 consultant specialties with over 700,000 hospital episodes in 2014/15 35. The total cost to the NHS spent on vision problems in 2010/11 was 2.14 billion 36. Tackling eye health improves performance against other public health priorities: Smoking - It has been estimated that more than a quarter of all cases of advanced agerelated macular degeneration (AMD) are attributable to current or past exposure to cigarette smoke 37 and a 3-fold increased risk of developing cataracts and smoking is also a risk factor for Diabetic Retinopathy 38. Diabetes How long a person has had diabetes for is the most important risk factor for development of Diabetic Retinopathy and after 20 years, Diabetic Retinopathy will develop 32 Access Economics (2009) Future sight loss UK (1): The economic impact of partial sight and blindness in the UK adult population. Available online at https://www.rnib.org.uk/sites/default/files/fsuk_report.pdf [accessed 1 December 2015] 33 Bosanquet, N (2010) Liberating the NHS: Eye Care Making a reality of Equity and Excellence Available online at http://centrallobby.politicshome.com/fileadmin/epolitix/stakeholders/liberating_nhs.pdf [accessed 1 March 2016] 34 NHS England(2014) Improving eye health and reducing sight loss - a call to action. Available online at: https://www.england.nhs.uk/wp-content/uploads/2014/06/eye-cta-pack.pdf [accessed 1 March 2016] 35 Health&Social Care Information Centre (2015) Hospital Episode Statistics, Admitted Patient Care - England, 2014-15. Available online at http://www.hscic.gov.uk/article/2021/website- Search?productid=19420&q=eye+care+consultant+admissions&sort=Relevance&size=10&page=1&ar ea=both#top 36 Cited in RNIB (2014) Sight loss: a public health priority. Available online at http://www.rnib.org.uk/sites/default/files/sight_loss_a%20public_health_priority.pdf [accessed 1 December 2015] 37 Chakravarthy U, Augood C, Bentham GC, de Jong PT, Rahu M, Seland J, Soubrane G, Tomazzoli L, Topouzis F, Vingerling JR, Vioque J, Young IS, Fletcher AE. (2007) Cigarette smoking and agerelated macular degeneration in the EUREYE study. Ophthalmology 114 pp 1157-1163 38 RNIB Smoking and sight loss. Available online at http://www.rnib.org.uk/eye-health-looking-afteryour-eyes/smoking-and-sight-loss [accessed 1 December 2015] 18
in almost all people with Type 1 and around 60% of people with Type 2 diabetes. Agerelated cataracts also occur earlier in diabetic patients 39 and regular eye examinations should be offered to all patients with diabetes. Guidance highlights the key role for eye health care professionals in the management of diabetes 40 Obesity - Obesity represents a significant modifiable risk factor for visual impairment and has been demonstrated as an independent risk factor for AMD, Diabetic Retinopathy and cataracts. Improving eye health may also help to reduce the public health target of health inequalities between communities. South Asian communities have an increased risk of diabetes and consequently diabetic eye conditions, including diabetic retinopathy. African and African- Caribbean groups have an increased risk of developing glaucoma. Additionally, people living in economically deprived communities are less likely to access primary eye care services and are therefore at greater risk of preventable sight loss 41. A study in Leeds found that lack of access to eye health could be associated with a lack of understanding by the public that an eye examination is more than just a sight test, a sense of fatalism and a perception that corrective treatment is too expensive. The study found however, a reluctance by community optometrists to address these equity issues because of the current contract and business models 42. 3.2 Behaviour change and vision strategy The UK Vision Strategy 43 initially developed in 2008 was the UK s response to the World Health Organisation s Global Action Plan for the Prevention of Avoidable Blindness (formerly the VISION 2020 Action Plan). Tackling preventable sight loss is now a priority in the Public Health Outcomes Framework and an eye health indicator tracks changes in the number of 39 RNIB Understanding eye conditions and diabetes. Available online at http://www.rnib.org.uk/eyehealth-eye-conditions-z-eye-conditions/understanding-eye-conditions-related-diabetes [accessed 1 December 2015] 40 Royal College of Opthamologists (2012) Diabetic Retinopathy Guidelines. Available online at: https://www.rcophth.ac.uk/wp-content/uploads/2014/12/2013-sci-301-final-dr-guidelines-dec- 2012-updated-July-2013.pdf 41 Johnson, M., Cross, V., Scase, M. et al (2012), A review of evidence to evaluate effectiveness of intervention strategies to address inequalities in eye health care. RNIB and De Montfort University, London 42 Farragher T, Shickle D, Mookhitar M, et al (2013). Inverse Eye Care Law: A geographical analysis of place of residence and deprivation of people receiving an NHS funded eye examination. 43 http://www.ukvisionstrategy.org.uk/about-strategy/what-strategy 19
people certified as blind or partially sighted as a result of glaucoma, age-related macular degeneration (AMD) and diabetic retinopathy. The RNIB have also produced Joint Strategic Needs Assessment (JSNA) guidance to support effective commissioning. Yet eye health is not yet embedded as a public health issue and a search of local vision strategies could identify only Lincolnshire that identifies that eye health is included in the Making Every Contact Count training programme and in public health campaigns on smoking and obesity. 3.3 Eye health care professionals and behaviour change Although there is recognition of the importance of health promotion in the role of eye health care professionals as they are in regular contact with members of the public who are healthy and therefore have enormous potential in delivering public health messages 44, a systematic review in 2011 found no studies of eye health care professionals and health promotion 45. Although several US studies recommend that all eye care professionals advise patients to quit smoking 46 47, a survey of optometrists in the UK found that only one in three regularly assessed patients smoking status and advised on smoking cessation 48. A majority did however report that they frequently provide dietary advice to patients with established AMD (67.9%) and those at risk of AMD (53.6%). A study by the RNIB 49 found that optometrists are well informed about eye diseases and believe that eye health promotion is a vital part of their role but one in six spend no time at all promoting eye health in an average week and on average only 12% of their time is spent on eye health promotion. A study in Shropshire found that only 4% of optometrists reported that they regularly took a smoking history and only about 12% provided regular advice on stopping smoking 50. 88% of respondents were unaware of the exact mechanism for referring patients to local specialist services. 44 Rowe F, Henshall V. (2005) Orthoptists and their Scope in Health Promotion. In: Scriven A, editor. Health Promoting Practice: The Contribution of Nurses and Allied Health Professionals Basingstoke: Palgrave Macmillan p. 270-282. 45 Needle J et al (2011) The allied health professions and health promotion: a systematic literature review and narrative synthesis. NIHR 46 Kennedy RD, Spafford MM, Schultz AS, et al.(2011) Smoking cessation referrals in optometric practice: a Canadian pilot study. Optom Vis Sci. 88(6):766-71. 47 Phillips ME, Marzban MM, Kathuria SS (2010) Treatment of thyroid eye disease. Curr Treat Options Neurol. 12(1):64-9. 48 Lawrenson J G and Evans J. R (2013) Advice about diet and smoking for people with or at risk of agerelated macular degeneration: a cross-sectional survey of eye care professionals in the UK BMC Public Health 13:564 49 RNIB (2010) GP and optometrists attitudes to eye health. Available online at https://www.rnib.org.uk/sites/default/files/attitudes_eye_health.doc [accessed 1 March 2016] 50 Lawrenson, JG., Roberts, CA., Offord, L., (2015) A pilot study of the feasibility of delivering a brief smoking cessation intervention in community optometric practice Public Health, 129, (2), pp 149-151 20
There are a number of barriers to eye health care professionals taking a more active role 51 52 53 that have been identified in several studies: Lack of time in a consultation Not knowing how to raise the issue or start a conversation about eye health Concern about how the patient might respond Lack of information to give to patients Not knowing how or where to refer patients Lack of training in how to raise lifestyle issues, advise, and signpost people to lifestyle services as appropriate. There are however, moves to develop the role of opticians. Dudley Borough and Dudley Local Optical Committee have recently developed the Healthy Living Optician scheme funded by Dudley Local Authority 54. The services extend beyond the traditional to focus on a spectrum of needs relating to healthy living and lifestyles, through direct provision of advice and interventions and signposting to other services. Accreditation for the service includes all staff but it seems to be mostly optical assistants who have taken the RSPH Understanding Health Improvement level 2 award. A small educational intervention with optometrists in Shropshire co-ordinated by the local Council's public health teams had a marked success in enabling community optometrists to engage with public health: in a pre-post survey, a much greater proportion of community optometrists reported taking a smoking history and offering advice on stopping smoking following the intervention. The short intervention included lectures on Targeting modifiable risk factors in AMD and the concept of Making Every Contact Count ; an information pack; a supply of locally developed posters and patient information leaflets for use in practices and 51 Lawrenson, JG., Roberts, CA., Offord, L., (2015) A pilot study of the feasibility of delivering a brief smoking cessation intervention in community optometric practice Public Health, 129, (2), pp 149-151 52 Public Health England/Royal Society for Public Health (2014) Healthy conversations and allied health professionals. Available online at https://www.rsph.org.uk/filemanager/root/site_assets/our_work/reports_and_publications/2015/ah p/final_for_website.pdf [accessed 1 December 2015] 53 RNIB (2010) GP and optometrists attitudes to eye health. Available online at RNIB (2010) GP and optometrists attitudes to eye health. Available online at https://www.rnib.org.uk/sites/default/files/attitudes_eye_health.doc [accessed 1 March 2016] 54 http://dudleyhlo.co.uk/ 21
a link to an online training module on how brief advice can be delivered. 55 3.4 The professional bodies The optical sector does have a commitment to increasing knowledge and skills on public health issues. As part of Vision 2020 the College of Optometrists held a round table on public health in 2014 56 and included in its recommendations were to: Include public health in the core curriculum for optometry students and encourage public health professionals from other disciplines to keep up to date with eye health developments; Identify ways in which to make public health an attractive issue for optometrists to consider in their daily practice (e.g. smoking cessation messages delivered as part of their consultation). However, optometry does not necessarily have the same leverage with public health in England as the allied health professions, and does not have a responsible officer In England. The Clinical Council for Eye Health Commissioning acts as a national clinical voice for eye health but has limited formal power or influence in proactively promoting public health and the eye health agenda. By contrast, Wales has a chief optometric officer who works with policy directorates and professionals across government and its eye health care delivery plan 57 includes a commitment to eye health public awareness and education that links good eye health with smoking cessation and healthy eating campaigns. The Welsh plan recognises the importance of partnership working across boundaries with primary and community care professionals, teachers, school nurses, the Third Sector and NHS Trusts and the national public health body (Public Health Wales) working together. 3.5 Professional Standards for Optometrists The General Optical Council (GOC) is the regulatory body for the optical professions and describes the knowledge and skills an optometrist or dispensing optician must possess in order to register and practise in the UK. Students and trainees of GOC approved programmes have to demonstrate that they are proficient in the associated core competencies. The core competences for optometry at stage 1 and stage 2 identify 55 Lawrenson, JG., Roberts, CA., Offord, L., (2015) A pilot study of the feasibility of delivering a brief smoking cessation intervention in community optometric practice Public Health, 129, (2), pp 149-151 56 College of Optometrists (2014) Healthy Eyes For All: an optical sector strategy to improve public health. Available online at: http://www.vision2020uk.org.uk/wpfbfile/healthy_eyes_for_all_roundtable_report_final_110414-pdf/ [accessed 010316] 57 Welsh Government Together for Health: eye health care 2013-2018 available online at: http://gov.wales/docs/dhss/publications/130916eyehealthcaredeliveryplanen.pdf [accessed 1 March 2016] 22
communication and professional conduct but do not specifically mention any awareness of public health messages 58. For public health to be part of eye health care education, it needs to be included as a professional competence. The General Optical Council (GOC) has reviewed the standards for practice and education standards and the revised standards came into effect from April 2016 59. These standards outline the expectations for professional practice. They include standard 1 Listen to patients and ensure that they are at the heart of the decisions made about their care and standard 2 Communicate effectively with your patients. According to the GOC they see MECC sitting with these standards that give a stronger emphasis to communication skills than previously. Standard 1.8 now refers to public health advice and states that: In conjunction with tutor or supervisor, a student must demonstrate supporting patients in caring for themselves including giving advice on the effects of life choices and lifestyle on their health and wellbeing and supporting them in making lifestyle changes where appropriate. The provision of lifestyle advice requires that the optometrist is able to raise these issues with the patient, knows the public health messages and can signpost or refer to other services as appropriate. This standard thus provides a clear driver to include MECC in the initial training in the curriculum. The standard 4 of the Royal Pharmaceutical Society for public health practice in pharmacy in 2014 60 is even more explicit stating that: Pharmacy teams use every interaction as an opportunity to provide health promoting messages, contributing to improving population health and reducing health inequalities, making every contact count. There is clearly a drive to include MECC in the role of health care professionals and standard 1.8 does make explicit the health improvement role for optometrists therefore the optometry curriculum will need to be fit to support the workforce of the future. The introduction of MECC to the Optometry curriculum would support this, however to become 58 https://www.optical.org/en/education/core-competencies--core-curricula/index.cfm 59 The General Optical Council (2016) Standards for Optical Students. Available online at : https://www.optical.org/en/standards/standards-for-optical-students.cfm 60 Royal Pharmaceutical Society (2014) Professional Standards for Public Health Practice in Pharmacy. Available online at: http://www.rpharms.com/support-pdfs/professional-standards-for-publichealth.pdf [accessed 1 March 2016] 23
embedded widely within the profession, MECC may need to be included as a core competence. 3.6 The contract for services The contract for the provision of services may also provide a lever to implementing brief advice in eye health care. The General Ophthalmic Services (GOS) contract for the bulk of optometrists NHS work i.e. sight tests has no specific provision for MECC but the NHS Standard contract 2016/17 61 section 8.6 makes an explicit expectation that MECC is used stating that: The Provider must develop and maintain an organisational plan to ensure that Staff use every contact that they have with Service Users and the public as an opportunity to maintain or improve health and wellbeing, in accordance with the principles and using the tools comprised in Making Every Contact Count Guidance. The GOS contract may be influenced, in the future, to include a similar requirement although without additional funding it is difficult to see how MECC could be built into this. 61 NHS Standard Contract 2016/17 Service Conditions (Full Length) (draft for consultation) https://www.england.nhs.uk/wp-content/uploads/2016/02/3-full-lngth-16-17-scs.pdf 24
4. THE AIMS OF THE REVIEW The aim of this review for the West Midlands region was to identify the opportunities, enablers and barriers to optometry workforce training and development to deliver behaviour change as a brief intervention or brief opportunistic advice and to make recommendations on the introduction of MECC within undergraduate Optometry programme. Objectives: To identify the professional requirements for optometry training and to identify where MECC might fit in the curriculum and dovetail with topics such as ophthalmic public health or communication skills; To understand and explore the barriers and enablers to the introduction of MECC into the undergraduate Optometry curriculum through data gathering from Aston university lecturers and optometrists from the Local Eye Health Network West Midlands; To understand how MECC might be integrated with practice development and how levels of competence might be identified and assessed. 25