Benchmarking Report.
Visual Impairment Benchmarking Study Summary Report.
Visual Impairment and Visual Impairment Services in Wales.
This section of the report provides an overview of levels of visual impairment across Wales and the way in which visual impairment services are planned, delivered and evaluated in different areas.
Assessing local need.
A basic means of identifying levels of need is to measure the number of people in a given area that are registered as having a visual impairment. Registration occurs typically following the issuing of a BD8 — effectively a certificate of blindness or partial sight — by an eye clinic. Once a BD8 has been issued, local authorities have a statutory obligation under the National Assistance Act to register the user. In some cases users can be referred to specialist teams dealing with sensory or visual impairment from another part of social services or the local authority. Such cases can then be taken on immediately, or referred back to the eye clinic for registration prior to specialist intervention, depending on local practice.
It is widely accepted that people who have been formally
registered represent only a relatively small proportion of those with visual
impairment in the population at large.
Assessing the full extent of visual impairment including those not registered is
not simple, although a number of different approaches have been developed across
Wales. In one area the Local Disability Forum ran a household survey to assess
different levels of need within the area, while in another the council has
developed a form which captures the details of people making contact with social
services who have a visual impairment which is not severe enough to qualify them
for registration.
However the problem of identifying and responding to the needs of those who are unable or unwilling to present themselves to any official agency clearly remains.
The difficulty in assessing unmet need means not only that there is likely to be a high number of vulnerable people across Wales who are not aware of, or do not have access to, available support — but also that it is impossible to make any sensible assessment of levels and volume of service provision needed to meet the full extent of local need.
Service planning and review.
Every local authority in Wales is now required to produce a Health, Social Care and Wellbeing Strategy, linked to an overarching Community Strategy, assessing need and setting service priorities and targets for its area based on those needs. These Strategies are a powerful means of raising the profile of specific services and focusing resources and effort on delivering them in partnership with other agencies.
Less than half of councils have sections within their plans containing specific service aims, objectives and targets for visual impairment services in their area. This suggests that there is still some way to go in raising the status and profile of visual impairment services to equal that of other disability services. Only 8 authorities report having a budget specifically dedicated to visual impairment services — in others the allocation for visual impairment services is subsumed into wider budgets. Whilst this in itself need not mean a constraint in resources for visual impairment services, the need is clear for effective financial management to ensure adequate budgetary provision in all areas.
Similarly, less than half of authorities have developed local standards and performance indicators to measure the quality of services, or set performance targets to drive ongoing improvement. Less than a third report that they regularly use sources such as epidemiological data, care management records, complaints, certification and registration records to measure outcomes against service aims, objectives and targets.
CASE STUDY: NEWPORT CITY COUNCIL.
Newport City Council formed a Visually Impaired Development
Group in 2003.
The group's purpose was seen as promoting a partnership approach to planning and
developing services for visually impaired people, and identifying ways of
improving services through joint working.
Since its inception, the group has met quarterly, chaired by the Service Manager (Adults with Disabilities). The group has been multi-agency and has included user representation.
A number of areas have been tackled by the group, including:
- production of information leaflets in large print, and plans to provide information on CD;
- discussions between the council, NHS Trust and the local voluntary organisation for people with visual impairment, on providing emotional support for people newly diagnosed with a sight loss; and
- introduction of an interim registration form pending the introduction of the new BD8 in Wales.
- Provision by the local association for the blind of visual awareness training to social services staff, and inclusion of refresher sessions in the department's annual training plan.
An absence in many councils of strategic planning means it can be difficult to secure adequate levels of funding, or ensure that the resources available are appropriately deployed. The lack of meaningful performance information means that councils and their partners are often not well placed to objectively evaluate delivery and modify and improve services, identify and address service deficiencies, or recognise and learn from more positive trends in performance. A lack of information relating to users' preferred formats for information, or where they live, further impedes effective planning.
Examples of PIs currently used by councils in visual impairment services.
- number of referrals responded to within 10 working days;
- number of rehabilitation plans prepared within 5 days of specialist assessment;
- percentage of rehabilitation plans reviewed annually; and
- percentage of care plans reviewed annually.
Consultation and user engagement.
Engaging service users in the planning and evaluation of
services is vital if the services provided are going to be truly responsive to
changing needs and expectations.
This is true of local services generally, but the need is made greater in the
context of specialist services provided to a client group with specific and
challenging needs.
There is some encouraging practice in this area across Wales, and other respects in which improvements are clearly needed. It is encouraging that 18 councils are actively involved in establishing and maintaining user support groups for people with visual impairment.
CASE STUDY: TORFAEN COUNTY BOROUGH COUNCIL.
Specialist social workers in Torfaen have established a gentle exercise class, a fitness group that meets at a local leisure centre and 2 information technology classes helping users work towards a Computer Literacy and Information Technology (CLAIT) qualification.
Combined with the stated objectives of improved health, learning, wellbeing and social inclusion, these groups play a vital role as forums for obtaining user feedback and views and ideas on service development. As a result of ideas emanating from these groups, the Council has organised an information day for service users and provided support for users in the development of assertiveness.
The same number of authorities run periodic postal surveys inviting users to comment on the services they have received, with telephone surveys and focus groups being used by an increasing number of councils. Other approaches that have been used include workshops for providers and users, incorporating questions relating to visual impairment as part of generic council surveys, and providing the opportunity for electronic feedback via websites.
Although only 7 councils report having a formal policy or strategy for consulting with users and potential users of visual impairment services, just over half of Welsh authorities have a structured framework for feeding back the results of consultation to those that were involved, and more widely to service users. Ensuring this happens is vital if confidence in consultation processes are to be developed, and greater participation encouraged.
16 councils report having processes in place to feed consultation findings into the future planning, commissioning and evaluation of visual impairment services. However, there is a recognition that these need to be refined, and that mechanisms need to be put in place in all authorities to ensure that consultation data informs the future development of services.
CASE STUDY: FLINTSHIRE COUNTY COUNCIL.
Flintshire County Council and the Flintshire Local Health Board (LHB) have established a strategic partnership which meets quarterly to plan and evaluate services for visually impaired people in the County. The partnership comprises representatives from statutory agencies and the voluntary sector, and includes user representatives. Funded by the County Council, the partnership provides an invaluable vehicle for ongoing consultation and dialogue with users of visual impairment services in Flintshire.
Service levels and structures.
There is a very mixed picture across Wales when it comes to the size and shape of visual impairment services. Approximately half of Welsh councils have dedicated sensory services or impairment teams, whilst in other councils visual impairment and other sensory services are incorporated into specialist teams with a wider set of responsibilities.
Staffing levels also vary considerably, with councils having between 1 and 9.1 Full Time Equivalent (FTE) staff working in visual impairment (including managerial and admin staff). The median figure across Wales is 3 FTE. Actual staffing levels do not appear to have any direct correlation with the number of local people with a registered visual impairment, as evidenced by the following graph which shows the numbers of people with a registered visual impairment per 'frontline' FTE working on core visual impairment functions (excluding managerial and administrative staff).
[CHART]
This suggests a widely varying ratio of FTE staff per person registered with a visual impairment, from 1 FTE per 1,019 people, to 1 per 109.
A number of authorities seek to broaden the scope of services
available to people with visual impairment by commissioning rehabilitation and
other support from partner agencies. One council, for example buys in services
including rehabilitation, welfare benefits advice and a talking book service
from its local Association for the Blind. Another buys in rehabilitation,
supervision and specialist training from the Guide Dogs for the Blind
Association. Whilst this 'mixed economy' of provision is to be welcomed in that
it provides enhanced levels of service and potentially more responsive support,
it highlights the need for robust
commissioning arrangements, and for providers across sectors to work effectively
together in providing seamless and joined up services.
CASE STUDY: NEWPORT CITY COUNCIL.
A DeafBlind Services Group was established in Newport in 2002. The Group meets quarterly, is chaired by the Service Manager for Adults with Disabilities and is multi-agency in nature. It has been involved in a number of tasks, including:
- compiling a list of Deafblind people identified as per categories referred to in Welsh Assembly Government Circular 10/1;
- undertaking specialist assessments of those identified;
- developing specialist service provision through a working partnership with Sense Cymru;
- running a Multi-Agency Conference;
- developing a Training Policy for staff;
- ensuring that services for Deafblind people are also available for ligible users within Children's Services;
- focusing on specialist needs, for example Usher Syndrome, and considering how to meet them through service delivery;
- receiving presentations from users and their guardians on their service needs and experiences; and
- developing a strategy for future service development which will
be included in
departmental service plans and discussed within the Health, Social Care & Wellbeing policy groups.
Staff development, recruitment and retention.
Currently visual impairment services across Wales suffer from a lack of a clear, recognised career structure. There are particular problems in relation to rehabilitation services, namely:
- The service lacks a strong, recognised career path or clear route through to management.
- There is no consistent approach to continual professional development.
- Development and other support for staff are also inconsistent across Wales. Whilst all councils report providing regular individual supervision for staff, in most councils this is not undertaken by rehabilitation specialists. Other more innovative methods such as job-related training and cross-organisational peer exchange are used by only a small number of authorities.
Moreover, there is no standardised qualification structure for people working in visual impairment services generally, although commonly held qualifications include Diplomas in social work and rehabilitation, CSQW, Certificate in counselling and various levels of NVQ in care.
More than half of the authorities report having experienced
difficulties in recruitment and retention of visual impairment staff. Suggested
reasons for this include applications by unsuitable candidates, internal
financial constraints forcing a freeze on recruitment, and a lack of benefits
such as essential car user allowance for staff working in this field.
Moreover, the general shortage of qualified workers in this area is well
rehearsed.
The establishment of a Welsh programme for training rehabilitation workers is a goal long aspired to. Discussions are underway with the Welsh Assembly Government over funding such a programme. In the meantime, a WCB officer provides support to Welsh rehabilitation workers undergoing an existing course at the University of Central England, and a programme of seminars as a contribution to continuous professional development.
Good Practice Guide 3 contains detailed recommended standards in respect of staffing levels, structures and training and development.
Recommendations.
We recommend that:
- Local authorities review their current arrangements for identifying need for visual impairment services within their communities. Local approaches should focus on awareness-raising and need to take into account national estimates of prevalence, alongside other factors such as age and deprivation profile.
- Social Services use data from local needs assessment to inform and review existing service levels and resource allocation. These levels need to be reflected locally within Health, Social Care and Wellbeing strategies, and should be reviewed regularly in consultation with ophthalmic practitioners, other partners and users.
- All Social Services Departments establish a specialist team of qualified workers for people with visual impairment.
- Each local authority considers identifying an elected member 'champion' for visual impairment services. They should be responsible for and effective in raising the profile of visual impairment services within the council and the wider community.
- A nationally sponsored research study be conducted on best practice approaches to consultation with people with visual impairment. These approaches need to provide ways for meaningful input by users into the planning, commissioning and delivery of services.
- The findings of the ADSS report 'Social Work in Wales: A Profession to Value' recommending the development of a national strategy for the recruitment and retention of social care workers, be applied to those working in visual impairment.
INFORMATION PROVISION.
Provision of accurate, up to date and timely information on services and how to access them is a crucially important factor in empowering people with visual impairment and ensuring they receive appropriate levels of specialist services, and enjoy the same benefits from other services as the remainder of the population.
Problems in this area have been identified at a number of levels. Firstly, general awareness among the population, and particularly vulnerable groups, of visual impairment services appears to be typically fairly low although a number of authorities have launched initiatives to publicise services over recent years. Examples include:
- councils inviting a visit from the Action for Blind information bus to their area;
- regular awareness training for non-specialist staff in care homes, schools and carers; and
- holding open days at the local sight resource centre.
More critically, high quality information on visual impairment
services available in a given area is not routinely available to users or
potential users. Such information is not automatically available to people
identified as having a visual impairment, usually at an eye clinic, nor is it
consistently displayed in locations such as GP surgeries or libraries.
This undoubtedly hinders awareness of services available and how to access them.
CASE STUDY: CONWY COUNTY BOROUGH COUNCIL.
A social services presence in the Eye Clinic at Ysbyty Llandudno was established six years ago. The Social Worker attends the clinic twice weekly, working with nursing staff and ophthalmologists to promote social care and raise awareness of services available.
Patients attending the clinic are given the opportunity to speak to the social worker regarding their visual difficulties, and this discussion often takes place prior to them seeing medical staff.
Advice and information is available in the clinic setting and referrals are also taken for input from the Sensory Impairment Team at the County Borough Council or Low Vision Clinic.
Their work is preventative and prepares patients for registration as either blind or partially sighted. The registration process can be extremely difficult for people adjusting to sight loss and can be extremely difficult for people adjusting to sight loss and can have an air of finality, especially when there is no further medical intervention available to them. Offering early advice on the process, and any rehabilitation services to which they are likely to be entitled, can significantly reduce anxiety and help prevent isolation.
Medical staff agree that the presence of a social worker in the clinic is a good practice and emphasises the benefits of partnership working.
More importantly, clients or patients can access information on services available at the most appropriate time.
However, a number of councils enter formal agreements with voluntary sector providers to support the development and provision of information on local services — for example, one council provides a joint directory of services in partnership with Vision Support, and another authority sponsors the production of a pilot information leaflet by Wales Council for the Blind. But the current picture is one of information being provided in an ad hoc and inconsistent manner, and there is no evidence that users across the country have equal access to timely, up to date and accurate information on services available and how to access them.
Finally local authorities need to take appropriate measures to ensure that generic information on their services is available to users in an accessible format, in accordance with the letter and spirit of the Disability Discrimination Act. Less than half of authorities have an 'accessible information strategy' to address the requirements of the Act, although a number of councils have supporting initiatives in place, such as corporate access strategies, and clear print guidelines outlining the use of appropriate fonts. The general picture is that councils are prepared to do their utmost to provide accessible information on request, but they tend to be reactive, and the onus remains very much on the user to make an initial request.
CASE STUDY: GWENT ASSOCIATION FOR THE BLIND.
Responding to criticism of the local statutory authorities' performance in providing information in accessible formats, a joint health and social care working group was set up to review the issues and propose some key actions. An initial meeting included a presentation by RNIB Cymru and input from the local deaf community. After reporting back initial findings to the Council's Strategic Director for Corporate Governance and the Health, Social Care and Wellbeing Physical Disabilities & Sensory Issues Group, the Provision of Information in Accessible Formats (PIAF) group was formally mandated to identify some short term gains (for example standardising Arial 14 font in all publications) and outline a longer term strategy to improve performance in this key area.
Good Practice Guide 1 contains detailed recommended standards in respect of information provision.
Recommendations.
We recommend that:
- Social Services Departments take proactive measures, working
with health partners to ensure that appropriate information on specialist
services, benefits and entitlements available to people with visual
impairment is available at eye clinics, and all known points of access.
This information should relate to services provided by the local authority and its partner agencies. - Local authorities take proactive steps at a corporate level to ensure that all information and publicity relating to their services is available in formats accessible to people with visual impairment, as required by the Disability Discrimination Act, and Disability Equality Duty from December 2006.
- Official correspondence and communication between local authorities and visually impaired users be made available in preferred format.
- All contact databases held and maintained by local authorities and their partners include a field for preferred format for information and communication.
Recommended PIs.
Percentage of people with a registered visual impairment whose preferred formats for information and communication is recorded by the authority.
Percentage of people with a registered visual impairment receiving personal information in preferred formats relating to (i) visual impairment services and (ii) local authority services generally.
REFERRAL, ASSESSMENT AND REHABILITATION PLANNING.
Referral and assessment.
Ensuring a swift and clear route from initial referral through specialist assessment to provision of appropriate rehabilitation is vitally important for people with visual impairment. Wherever people enter the system, it is imperative that they are treated sensitively, are signposted to services to which they are entitled, and receive appropriate levels of support within the shortest possible timescale. It is vital that prolonged assessment processes and delays between different stages are avoided as far as possible.
From April 2006, all local authority adult social care services
are required to comply with the Welsh Assembly Government's Unified Assessment
and Care Management Process.
This is to ensure that all agencies, including the health service, take a
holistic approach to assessing and managing care. Assessment and rehabilitation
planning needs to be person-centred and proportionate to need. The duplication
between health and social care agencies of information, assessments and
paperwork should be minimised with advantages therefore for service users, their
families and carers.
At the current time, there is a significant variation both in
how people with an identified visual impairment get a specialist assessment and
how the assessment is carried out.
Differences include whether or not the initial and specialist assessments are
carried out face to face, and in a location selected by the user, time taken to
complete stages of the assessment, and how successfully the full range of
potentially eligible users are identified and helped through the assessment
process. A number of issues need to be addressed. These include:
- Enhancing processes for accurate and timely referrals from health via BD8 registration.
- Ensuring appropriate referral to specialist sensory or visual impairment teams from other parts of the local authority, or points of access in the health and voluntary sector. This will require training and awareness raising among first point of contact staff in different parts of local authorities, and in other agencies.
- Reducing the time taken between initial referral to completing the specialist assessment and agreeing a rehabilitation package. Setting clearly defined targets and monitoring delivery against them is likely to help drive improvement in this area.
CASE STUDY: WREXHAM COUNTY BOROUGH COUNCIL.
Specialist social workers for visually impaired people within Wrexham Social Services provide visual impairment awareness training to a cross section staff working in the authority. The training, which is provided on a regular basis and is usually oversubscribed, is aimed primarily at direct care staff and frontline staff. It aims to increase sensitivity and understanding to those dealing with people who are blind or partially sighted. The training is practical and covers a wide spectrum of issues, from eye conditions to daily living tasks, including mobility. The training team includes a blind service user whose contribution, which includes an account of their personal experiences, is usually regarded as the most valuable part of the course.
The following is an example of the referral and assessment processes in Rhondda Cynon Taf and Cardiff Councils:
[MISSING: FLOWCHARTS]
Good Practice Guide 2 contains detailed recommended standards in respect of referral and assessment processes.
Rehabilitation.
Once specialist assessment has been completed, it is crucial to ensure that people who are eligible for rehabilitation support receive a package of support that meets identified needs, is provided and supervised by appropriately qualified people, and is subject to regular review.
Practice and service quality varies across Wales in this area, with a marked inconsistency in levels of rehabilitation available, and the experience and qualifications of staff involved in providing and supervising support. Due in no small part to the difficulties encountered in recruitment and retention, a large number of councils do not have adequate numbers of staff, or suitably experienced workers, to manage and oversee rehabilitation plans. As well as having potentially detrimental effects on the quality of services provided, this also means that effective ongoing evaluation of the care, and revision of plans where appropriate, does not always take place.
Good Practice Guide 3 contains detailed recommended standards in respect of rehabilitation.
Recommendations.
We recommend that:
- All people registered with an identified visual impairment be provided with an individual specialist assessment, unless specifically declined.
- Specialist assessment be carried out either by a social worker with a suitable qualification or experience in visual impairment services, or a qualified rehabilitation worker.
- Throughout the assessment process there is ongoing coordination with other specialist services as appropriate, in keeping with UAP requirements.
- The specialist assessment results in a written rehabilitation plan.
- Local authorities ensure all first point-of-contact staff and staff involved at any stage in the assessment have initial visual impairment awareness training as part of their induction, and ongoing 'refresher' training at regular intervals.
- Formal mechanisms are established to ensure appropriate referral for specialist visual impairment assessment from children's and other specialist teams.
- Initial information on local services provided to people identified with visual impairment includes information about rehabilitation services.
- All users who have a rehabilitation plan in place receive regular reviews of the plan.
- All local authorities employ a minimum of one suitably qualified rehabilitation worker in place to manage this area of service (see Good Practice Guide 3).
Recommended PIs.
- Number of people in local authority area with identified visual impairment.
- Number of specialist visual impairment assessments conducted per annum.
- Number of specialist visual impairment assessments conducted on behalf of non-registered people with a visual impairment.
- Percentage of adults registered as blind or partially sighted who have received visual impairment rehabilitation from a specialist worker within the past year.
- Percentage of people who have undergone specialist assessment who have a written Service Delivery Plan.
CHILDREN AND YOUNG PEOPLE.
Across Wales, many children and young people receiving specialist care through
children's teams have a complex set of needs, which in a number of cases
includes visual impairment.
Evidence suggests that a significant proportion of these children and young
people miss out on a specialist visual impairment assessment, either because the
condition becomes 'lost' among their other needs, or because staff working in
the children's teams are unaware of the services provided by sensory or visual
impairment teams in the same authority.
This situation can be compounded where, as in the majority of cases, sensory and visual impairment teams reside solely in adult services. There is a continuing presumption in many authorities that children's social workers are best placed to deal with all aspects of care, and a lack of awareness of, or in some cases access to the services provided by specialist teams in other parts of social services to respond to specific needs among children and young people.
Only 7 councils in Wales have a specific policy for dealing with children with a visual impairment. Less than half of councils report having regular formal interaction between staff in social services and education to consider the needs of young visually impaired people. This can result in the needs of young people not being picked up or addressed, and mitigate against effective planning for transition arrangements post 16.
As a result, children and young people with a visual impairment frequently face diminished prospects of receiving appropriate and rounded support and enjoying maximum independence.
Good Practice Guide 4 contains detailed recommended standards in respect of children and young people.
Recommendations.
We recommend that:
- Local authorities develop local policies for working with children and young people with visual impairment and their carers. Local policies should require that all children and young people with an identified visual impairment have access to the specialist visual impairment team within the local authority. The policies need to ensure appropriate sharing of information between specialist and children's teams.
- Similar arrangements be established with respect to users with learning and physical disabilities, who access these teams initially and are identified as having a visual impairment.
- Local authorities establish local policies for joint working between sensory / visual impairment teams and education, to ensure that children and young people with visual impairment receive a joined up and consistent services. These should include stipulated arrangements for transition to post-16 services.
- Rehabilitation assessment and relevant services be made available to all children and young people with an identified visual impairment.
- Local authorities take appropriate steps to raise awareness of visual impairment issues and services among staff working in children's and disability teams.
Recommended PIs.
- Percentage of children registered as blind or partially sighted who have received visual impairment rehabilitation from a specialist worker within the past year.
- Number of specialist visual impairment assessments conducted on children per annum.
- Number of specialist visual impairment assessments conducted on behalf of non-registered children with a visual impairment.
- Percentage of children who have undergone specialist visual impairment assessment who have a written Service Delivery Plan.