Engagement – in school eye testing for pupils in special schools in England

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The Long Term Plan 2019 committed to the provision of in school eyesight testing for autistic children and young people and children and young people with a learning disability attending a residential special school. To help understand how best to deliver this service NHS England set up a proof of concept (POC) model which has operated in 83 schools in England since April 2021.

Following a positive evaluation of this POC, on 19 June 2023 NHS England announced its intention to extend in-school eye testing to pupils in all special schools (day and residential settings) in England from April 2024 onwards.

NHS England is now seeking to engage with interested parties and key stakeholders on the care model to be used as this service is rolled out to all special educational settings. The POC model will continue in participating schools until revised commissioning arrangements are in place from April 2024.

This document describes:

  • The care model utilised in the proof of concept.
  • Our assessment of the strengths and weaknesses of this model, incorporating the findings of an independent evaluation and
  • the care model we are proposing for wider roll-out as a result of this assessment.

Development of the proof-of-concept care model

The proof-of-concept (POC) sought to address some of the challenges faced by autistic children and young people and children and young people with a learning disability, autism or both, particularly in regard to access to eye care services. Previous attempts at local commissioning of solutions to address this had proven unsuccessful, with low uptake from providers. The POC enabled NHS England to test the service model along with associated processes that were developed such as the dispensing model, training programme, payment claims, data collection platform, and the service fee.

The core elements of the POC care model follow the clinical regulations which set out the basic legal requirements for an eye examination and is built on within documentation produced by the College of Optometrists. The basic legal requirements for an eye examination are:

  • Performing an internal examination of the eye
  • Performing an external examination of the eye
  • Performing a refraction (which will show if your vision can be enhanced with glasses and reveal any changes in the eyes, such as the development of a cataract).
  • Issuing a written prescription for glasses or statement
  • Keeping a full record
  • Performing additional examinations as appear to the doctor or optician to be necessary.

The testing of sight is defined as:

‘Determining whether there is any and, if so, what defect of sight and of correcting, remedying or relieving any such defect of an anatomical or physiological nature by means of an optical appliance prescribed on the basis of the determination’ Opticians Act 1989 section 36.

The legal requirements of an eye examination apply in all settings where a sight test is performed and to both adults and children. In meeting this standard, there is an element of clinically led discretion as to precisely how the test is conducted depending on the presenting needs of the person. The legal and clinical requirements for eye examination under the POC are no different to the requirements in other eye care settings and it is important for professional discretion to be maintained in any future model.

In addition to the clinical standards for eye testing described above, the POC operated on the following basis, determined in conjunction with a wider working group:

  • Each school was allocated an eye care team of two people: an optometrist and dispensing optician. To create these teams, NHS England national team called for expressions of interest to participate from interested professionals. Expressions of interest detailed the discipline of the person submitting the application, the geographical location they were based within and the maximum distance they would be prepared to travel to deliver services. NHS England then undertook a labour-intensive task of trying to match optometrists with dispensing opticians to work together. In most cases the pairing of teams worked, however in some cases the professional working relationship broke down or a team could not be matched. Where a team could not be matched then the person expressing an interest in providing the service was unable to do so as the POC replicated an existing with a team of two professionals (one optometrist and one dispensing optician) for a contract to be awarded.
  • Each eye care team was provided with a prescribed list of equipment determined by the working group. NHS England offered grants to help towards the cost of this equipment. Whilst this additional money acknowledged that the service was a POC the requirement to hold a prescribed list of equipment is over and above similar services such as domiciliary care. Outside of the POC the usual expectation is that providers will have the relevant equipment required to deliver the services they are contracted to provide.
  • The eye care team engaged with schools who had expressed an interest in the programme and co-ordinated with appropriate school staff on the planning of clinics in school.
  • Consent for sight testing was not mandatory and the POC operated on an ‘opt-out’ basis. This means that children and young people received a sight test unless their parent/carers(s) withdrew them from the programme, including where they were already in receipt of other primary or secondary eyecare (or both).
  • Eyecare teams were paid the agreed fee for an eye test and dispensing of glasses, with up to two frames being ordered via appointed laboratories and paid for directly by NHS England.
  • The eye care team issued an outcome report after each test to inform any recommended adaptations in the school or home environment to support the child or young person’s vision and eye health needs. This was issued to the school and to the parent/carer.

Summary of evaluation of the POC

An evaluation of the POC was commissioned in August 2022. The full evaluation report can be found at appendix A. In addition to this evaluation NHS England also undertook:

  • Engagement with key stakeholders and academics on the pros and cons of the overall POC model.
  • Engagement with commissioners on the potential terms of service for any future model of care.
  • Analysis of NHS data on sight tests conducted under the POC (a summary of this is at appendix B).
  • Internal analysis of our equalities’ duties and of wider-available public data relating to special educational needs in special schools in England.
  • Review of academic literature and evidence in relation to the needs of children and young people attending special schools in England.

Overall, the qualitative evaluation identified that the POC model was generally well received by schools, parents/carers and providers. However wider analysis of the associated delivery of the POC identified some issues, particularly in relation to consent, parent/carer engagement and the misalignment with the level of NHS support offered in other care settings. We have already amended the programme from 1 April 2023 to bring it into line with the universal NHS sight test offer for all children and young people, whereby financial support for purchasing glasses is in line with that offered when accessing services on the high street.  This means, routine entitlement to one frame, or two under exceptional circumstances.

The published academic literature (Little et al 2015, Black et al 2016) is supportive of the feasibility and benefits of sight testing in special educational settings, particularly day schools, especially given the increased incidence of visual problems of children and young people attending these settings and relatively low utilisation of existing services.

Feedback from our evaluation has clearly supported the establishment of an in-school sight testing service. Most children and young people who have been seen in the POC had not previously accessed existing high street or domiciliary services in line with findings of previous research, suggesting there is unmet need amongst children and young people attending special schools. NHS England data collected during the POC indicates that:

  • Almost 53% of pupils tested declared no previous history of General Ophthalmic Services (GOS) eyecare.
  • More than 300 referrals to hospital eye services have been made as a consequence of in school eye testing to date, indicating value in identifying wider eye health issues which otherwise may have remained undetected.
  • Almost 9% of people who have received glasses under the POC were receiving their first set of glasses, i.e., frames which they otherwise would not have received outside of the POC.

In relation to the number of first eye tests conducted and the volume of children and young people who subsequently identified as requiring corrective lenses, we found the numbers were comparable across day and residential school settings. However, we recognise that children and young people living in a residential special school may experience greater social vulnerability, as highlighted in phase one of the Safeguarding Children with disabilities and complex health needs in residential settings (October 2022).

Whilst an in-school sight test and optical dispensing model has been well received by most parents/carers and participating schools, we cannot assume that all schools will be willing or able to support an in-school testing approach and not all schools offered to be part of the POC responded. The current model also places demand on schools with regards to an appropriate physical space, storage of equipment and administrative support and we should ensure any future offer does not disincentivise uptake of in school testing for this reason.

Additionally, a key feature of the POC care model, which the evidence suggests we should retain and is provision of a written report. This goes beyond the existing GOS legal requirement to provide a written prescription, to a report which incorporates more holistic advice on adjustments to support an individual child or young person’s vision such as optimal lighting levels, seating in a classroom and how to approach children and young people with a limited field of vision. This also supports schools in their achievement of reasonable adjustment standards as highlighted in the DfE/DHSC SEND and Alternative Provision Improvement Plan (March 2023).

Discussion with clinical experts has highlighted that, on an individual basis, there is no difference in the clinical objectives of the sight test and the eye health check offered in schools when compared to those offered in other settings. However, it is accepted that many, if not all, of these children and young people may require reasonable adjustments to be able to complete the test. These could include:

  • additional time for appointments to allow a successful eye check to be achieved.
  • additional and/or different equipment to be used.
  • a written report being provided which describes required adjustments beyond the provision of corrective lenses.

4. Proposals for the future care model and variation from proof-of-concept

The proposed future care model seeks to build upon the beneficial and positive aspects of the POC whilst recognising that some aspects will require adaptation to enable wider roll-out and encourage uptake by special schools.

In summary, the proposed future care model will include:

  • Expansion of the sight test offer to all children and young people in both residential and day special educational settings
  • Each pupil will be eligible for an annual sight test (unless a more frequent interval is clinically indicated) with parent/carer consent. Parents/carers should also be offered the opportunity to attend this appointment.
  • Each pupil who requires corrective lenses should be offered financial support towards the cost of any corrective lenses required, in line with GOS voucher values for their required glasses prescription.
  • Co-payment from the parent/carer will be required where the total cost of the selected frame and lenses is greater than the GOS voucher value.
  • The parent / carer should determine whether the financial support should be used to select from:
    • the range of frames provided by the in-school provider or
    • the range of frames offered in a high street setting.
  • Each pupil to be provided with an eye health outcome report.
  • Engagement with schools who wish to take part in this service will be via commissioners. Successful bidders to provide the service will be expected to build strong relationships with the school and the wider school community to promote both the availability of the service and wider understanding of eye health challenges in this cohort of children and young people.
  • Commissioner consideration of the eye care pathway required by children and young people in special schools to minimise the potential for duplication of effort between this service, the high street and secondary care and associated potential for over-treatment.

Our initial assessment suggests that adaptations from the POC are required in the following areas whilst ensuring that commissioning decisions need to secure this NHS offer for children and young people, be fair to contractors and provide value for money for the tax payer:

  • Creation and commissioning of eye care teams and providers
  • Securing parent/carer consent to sight testing and engagement with glasses selection
  • Alignment with the standard NHS support offer.

Most of these proposed adaptations are intended to maintain alignment with the principles of the POC model but seek to minimise any associated bureaucracy by reducing the levels of mandated activities and encouraging providers to adapt their approach to the needs of individual schools.

Proposals are numbered in the following sections to make it easier to submit comments.

5. Creation and commissioning of eye care teams and providers

Proposal 1: Creation of eye care teams

During the POC NHS England created the eye care teams as described earlier. This has proved to be complicated and time consuming for the 83 schools operating the POC and is therefore not feasible in a wider roll-out of the service. NHS England is proposing that in the future a prospective contractor will be required to demonstrate that they have the adequate professional teams in place to deliver services. The makeup of these teams will not be mandated.

We therefore propose that any future tendering of services do not specify the format of teams but that potential contract holders would be required to demonstrate sufficient capacity and competence to meet the testing and/or dispensing needs of the relevant school(s) as per the invitation to tender documentation issued by the relevant commissioner.

Proposal 2: Provision of equipment

Whilst a range of prescribed equipment was required as part of the POC for use in the school and was part funded by NHS England, some schools responded noting the burden of storing such equipment. Prescription of equipment, as detailed within the POC, is not a requirement within any other sight testing service such as domiciliary care provision. Rather, the expectation is that the contractor will ensure they have sufficient and appropriate equipment to adequately perform the sight test. Some professionals felt the POC to be over prescriptive in relation to what equipment should be used for what purpose, including where non-mobile equipment was mandated but mobile equipment would be preferential.

We therefore propose that equipment is not specifically specified or provided under any future contract. Equipment to be used should be left to the discretion of professionals in association with any professional guidance issued in support of the legal clinical requirements for eye testing. It will therefore be a requirement of any future contract that the contract holder will have access to all relevant equipment to ensure the eye testing and dispensing can be delivered effectively to the legal clinical standard.

Proposal 3: Professional requirements and training

Under the POC, providers were required to complete a specified training programme which involved online training on communicating with autistic children and young people, and children and young people with a learning disability as well as in person mentoring/shadowing events at live eye testing clinics in special schools. Some providers have shared with NHS England that they found this approach overly prescriptive or reductive. What is critical to this programme moving forward is that providers can demonstrate competence and confidence in the delivery of care to children and young people attending special schools. This may be evidenced in several ways including attendance on training programmes.

As required under POC and to provide any sight testing services, we propose that the future model will continue to require the following:

  • Optometrists, orthoptists, and dispensing opticians must hold a current qualification and be registered with and approved by the appropriate regulatory bodies. Their qualification ensures competency in core areas including working with children and young people and vulnerable people.
  • All clinical staff should complete appropriate safeguarding training, be able to identify safeguarding lead to contact where safeguarding concerns arise and be Disclosure and Barring Service (DBS) checked.

However, we do not propose to maintain the requirement for specified, additional provider training to be undertaken. In addition to the core professional requirements, potential providers will need to demonstrate competence in the care of this cohort of children and young people and have evidence of completion of the Oliver McGowan training in learning disability and autism as this is now mandatory for NHS providers.

Phase 2 of the Safeguarding children with disabilities and complex health needs in residential settings review clearly outlined that respect for children and young people’s views is a key principle of the United Nations Convention on the Rights of the Child, giving every child and young person the right to express their views on matters that affect them, and for those views to be taken into consideration. The importance of the parental/carer voice was also highlighted within this review and any future commissioning model for in-school eye testing should therefore actively seek to enable both the child and young person’s and parent/carer’s voices to be fully and clearly heard.

In an opt out model, as demonstrated by the findings of our POC evaluation, there is greater risk of both the child and young person’s and the parent/carer voice being lost because decisions are made, albeit with positive intent, without their active involvement and without providing choices for decision. There is a risk also that the full emotional, physical and medical needs of the child and young person are not understood or that important information about previous primary or secondary care treatments is not communicated or recorded. Whilst an opt-out model may minimise delay in children and young people being treated by removing the administrative burden of securing consent, we have also had a small number of powerful reports, including one formal complaint of parents/carers not feeling involved with their child or young person’s eye care, not having been aware that sight testing was taking place and then not having been engaged in glasses selection.

Finally, parents/carers are of course best placed to understand and support the needs of the child or young person being tested including to calm anxieties, understand and support their communication and offer emotional support. We have therefore concluded that securing the active consent of the parent/carer to in-school testing and offering opportunity for them to attend the eye test is critical to ensuring their own voice is heard and to enabling the voice of the child or young person to be fully heard in relation to all potential choices. This approach will enable the child or young person’s wider eye health and home environment to be better and more fully understood, which can in turn inform the outcome report issued following conclusion of the test.

We envisage contract holders and schools working with parents/carers to understand their child or young person’s potential visual needs. We also propose testing should be planned, where the parent/carer wishes to attend, to accommodate their wider commitments as part of a clear offer for parent/carer participation in eye testing and dispensing (where required). The principles of active parent/care consent and the offer of participation in testing appointments will be embedded into the service specification and contractual requirements.

Proposal 5: Selection of glasses (where required)

The POC only offers frames from the selection available from the current eye care team operating with the contracted school (optometrist or dispensing optician). This contrasts with the wider range of frames which may be available on the high street and risks reducing the choice of frames a child/young person and parent/carer may wish to purchase. We have heard strong representation from stakeholders that not all frames are suitable for all prescriptions and that full freedom of choice may therefore not be attainable. This professional view needs to be balanced against some of the feedback we have received which suggests that some parents/carers and children/young people felt disengaged with the choice of frames. Negotiating the balance between preference for a particular frame and meeting the clinical needs of the child or young person is a critical aspect of sight testing and glasses dispensing.

In the future, we are proposing that providers of this service will be expected to hold a selection of frames, suitable to the needs and preferences of children and young people attending special schools and their parents/carers, at a range of price points. To encourage the development of relationships, and for parents/carers to receive appropriate clinical advice which may impact upon the selection of frames, we are also proposing that parents/carers are invited to any appointment where a choice of frames is to be discussed.

However, we also recognise that it is unlikely that providers of this service will be able to offer the same level of choice as high street providers. Therefore, if a child or young person or their parents/carers are not able to select an acceptable frame from the range available they should be offered a GOS3 voucher to enable them to select frames from a high street setting of their choice.

Proposal 6: Engagement with the school community

Strong relationships between providers of this service, schools, their staff and the wider school community will be key to the success of the service. They will help ensure that the service runs smoothly from an operational perspective and is delivered in a manner which is acceptable to children, young people and their parents/carers. The POC was prescriptive in mandating a process as to how this would be achieved and required there to be familiarisation days between the eyecare team and associated school staff as part of forming working relationship and to support subsequent planning and conduct of in-school clinics.

Whilst there was support for these during the POC, we do not propose that we continue to be prescriptive as to how relationships should be built in any future service. We anticipate that any future service would be underpinned by more engagement and clear planning with schools prior to commissioning and commencement of sight testing. We therefore anticipate the requirement to build relationships to be a key feature of any future commissioning model and that bidders to provide the service would need to describe how this would be achieved but we do not anticipate mandating a specific process of familiarisation days. This should support schools and provides of the service to work together to describe a process which is bespoke to the needs of their community.

7. Alignment with the standard NHS support offer

Proposal 7: Avoidance of potential over-treatment

During the POC there were no checks to confirm whether a child or young person was due a sight test or if they had had one recently. This contrasts with the high street where there are checks in place to determine if a sight test has been performed in the last 12 months. The Memorandum of Understanding between the Department of Health and Social Care, Association of Optometrists and Federation of Ophthalmic and Dispensing Opticians (the MOU) sets out the minimum interval between sight tests as follows:

  • Under 16 years, in the absence of any binocular vision anomaly one year
  • Under seven years with binocular vision anomaly or corrected refractive error six months
  • Seven years and over and under 16 with binocular vision anomaly or rapidly progressing myopia six months
  • 16 years and over and under 70 years two years
  • 70 years and over one year
  • 40 years and over with family history of glaucoma or with ocular hypertension and not in a monitoring scheme one year
  • Diabetic patients one year

If a child or young person is having their sight retested earlier than this, then the optometrist is required to confirm the reasons for this.

During the POC there have been instances of children and young people either having their sight testing done in both secondary care and in-school services, representing a misuse of resources and potential for distress for the child or young person, or of parents/carers discontinuing secondary care eye health appointments inappropriately. There is also evidence of children and young people having been in receipt of GOS high street care who may have been retested earlier than required under the MOU and who received new frames as a result where no new prescription was required.

Conversely, the roll-out of an in-school sight testing services offers the potential for some children and young people to be safely discharged from secondary care services to a known provider of on-going care, and we have some instances of this happening under the POC.

In future, we are proposing that the usual checks that take place in high street services should apply to avoid the potential for over-treatment. We are also exploring how best to support commissioners to consider the eye care pathway these children and young people require and how to support safe and effective discharge from secondary care to in-school services where clinically appropriate.

Proposal 8: Cost of frames and parental/carer co-payment

The POC originally offered two frames to all pupils which were directly paid for by NHS England under contract with nominated laboratories, although of parents/carers who responded to the evaluation only 41% of children and young people actually had these dispensed. Since April 2023, the POC has been aligned to GOS principles in respect of voucher values. In other settings, vouchers are issued to every child and young person under the age of 16 who requires glasses following a sight test. The value of these vouchers is dependent on the level of corrective lenses required. We would expect any provider of services to offer a range of frames and lenses within the voucher values. However, children and young people/parents/carers can also choose spectacles that exceed the voucher value with a level of co-payment where the value of the selected frame exceeds this. This change brings the future service in line to the wider GOS sight test offer available to all children and young people. This alignment will also be applicable to the provision of repairs and second pair of glasses available to the wider population.

We propose that the alignment to the wider NHS sight test offer should continue to ensure parity in treatment across all school groups where in receipt of in-school testing or accessing the high street offer. This means the NHS principles on co-payment, replacements, second frames and additional criteria for pupils aged over 16 years should be maintained.

We recognise that taking this approach may cause some anxiety as to how to secure a second pair of glasses if this is clinically indicated and in relation to access to repairs and replacements. Whilst the NHS has a standard process to support this which is managed by the NHS Business Services Authority on behalf of commissioners, we are interested in better understanding clinicians, children and young people and parents/carers experiences of this and any proposals as to how this could be improved.

8. Outcomes to support patients, children and young people, parent/carers and schools

Proposal 9: Production of an eye health outcome report 

The POC requires the production of an eye health outcome report and has been used to inform subsequent change in both domestic and school settings to ensure the pupil’s needs can be met i.e., by way of reasonable adjustments, seating arrangements, lighting arrangements. We propose no variation to the approach in the future model.

We welcome views on whether the sharing of this report be widened to be included within the child or young person’s education health and care plan.

Appendix A

Appendix B

Summary: NHS Data on eye tests conducted under the proof of concept (POC) between April 2021 and October 2022.

Eye tests

  • Total Eye Tests – 7209 eye tests had been conducted in the 83 schools where the POC is live.
  • First Eye Tests – 3662 (50.8% of 7209) of all eye tests conducted were definitely true first eye tests as no prior GOS history was declared by the parent/carer.
  • However, in 140 cases (19.56% of 7209) GOS history was neither confirmed nor denied meaning that the number of true first eye tests could be as high as 70.36% of all eye tests conducted.

Dispensed frames

  • Total Pupils Receiving Frames – 3057 (42.4% of 7209) pupils received frames under the POC.
  • First Eye Test Leading to First Frames791 pupils (11% of 7209) required frames to be dispensed for the first time. This is 26% of all children receiving frames (26% of 3057).
  • Eye Test Leading to Replacement Frames – 2266 pupils (74% of 3057) receiving frames already had frames.
  • Replacement Frames with no Variation to Prescription673 pupils (29% of 2266) receiving replacement frames did so without there having been any variation to their existing prescription following their eye test.
  • Replacement Frames with Updated Prescription1593 pupils (71% of 2266) benefited from updated prescriptions and frames.

Publication reference: PRN00196i