Executive summary

Background

Between 30 August 2023 and 16 October 2023 NHS England engaged with patients, parents and carers, schools, and the Optical profession on proposed changes to the service model to support the rollout of sight testing in special educational settings. Whilst the engagement allowed individual respondents to share their views anonymously, we also received contributions from representative groups for the ophthalmic profession, commissioners, the voluntary sector, schools, parents and carers, and patients with lived experience. Overall, 124 pieces of feedback were received via a bespoke online form and emails, and we are grateful to all that took time to provide valuable feedback.

This report summarises the feedback NHS England received along with how we plan to act as a result of the feedback received. An easy read version of this report is available here.

Findings

The engagement document invited comment on several specific proposals, as well as wider comment about the combined effects of the planned proposals. A full list of proposals may be found within appendix 1 of this document.

Apart from feedback received in relation to proposal 4 (consent to eye testing) responses indicated broad support for all the proposals. However, to note, none of the proposals attracted complete consensus or acceptance. Even where there was broad support for a proposal, there were specific suggestions around how the proposal may be implemented. In some instances, there were concerns around the effects of the proposals, and, often, suggestions as to how these may be addressed. We have reflected upon these suggestions and sought specific external advice as required when developing our responses which are detailed in this document and are reflected in the service specification which Integrated Care Boards will be expected to commission against to deliver the NHS Planning Guidance commitment.

Conclusions

The purpose of this engagement was to identify key changes required to support sight testing in special educational settings to be rolled out across England, and covered areas such as team formation, equipment, professional requirements, consent, issuing and utilisation of an optical voucher, engagement with schools and the local system, and supporting templates/school and patient information literature. The valuable feedback received has been used to modify and provide clarity to the future national commissioning standard and service specification.

We also received feedback and comments which relate to issues outside of the specific programme of providing sight testing and dispensing of glasses in special educational settings. These have been collated and will be shared with appropriate policy colleagues in government.

Contact

If you have any questions or queries regarding the content of this report please email, england.dentaloptoms@nhs.net.

Introduction

The engagement undertaken sought comments and feedback from key stakeholders around the future care model to be used to deliver eyesight testing for children and young people in all special educational settings (Engagement – in school eye testing for pupils in special schools in England).

The proposals for the care model build upon an independent evaluation of a Proof Of Concept model that has operated in 83 schools across England since April 2021. These proposals sought to maximise the beneficial and positive aspects that were identified in the evaluation, whilst also recognising that some aspects required adaptation, both to enable a wider national roll- out and to encourage uptake by special educational settings (Engagement – in school eye testing for pupils in special schools in England).

How the engagement was conducted

The engagement ran online from 30 August 2023 until 16 October 2023. Stakeholders were invited to give feedback by completing an online form, or by emailing comments to england.specialschooleyecareservice@nhs.net.

An easy read version of the report was also made available, which invited readers to provide comments using the form, or by emailing directly.

We also held four virtual engagement sessions during September 2023 and October 2023 with key stakeholders in the programme, and one public webinar.

The purpose of these sessions was to provide an opportunity for further clarity on the evaluation report, and for participants to provide additional feedback on approaches and the future direction of the service. The sessions also gave those who attended the opportunity to ask questions. Qualitative feedback was captured during the sessions, and this has been considered alongside the feedback received by email, and through the completion of the online form. All those who attended were also encouraged to provide feedback directly through the online form or by direct email.

Responses received

The proposals themselves attracted different numbers of comments, from individuals and different groups.

We have set out the findings as follows:

• a summary of some themes that recurred across the different proposals;
• proposal by proposal summary of responses;
• what people said – what we thought they meant; and
• what we intend to do

Potential limitations of the analysis

We were made aware that in some instances representatives of the ophthalmic profession felt unable to comment as there was no consensus around how issues should be approached.

We recognised the strength of feeling on different issues suggested by the multiple duplicate submissions and tried to reflect that within our response, where possible.

Some of the responses represented opposing points of view. Due to the breadth of these views, we recognised that it would be impossible for these to be incorporated into future proposals. Where we have needed to reconcile opposing viewpoints, we have given careful consideration to the arguments presented and sought further, specialist advice to support this where necessary.

Respecting the anonymity afforded to contributors, we have not included any direct quotations from the feedback we received.

We also noted some ambiguity in the briefer comments to some of the proposals. For example, those that commented on Proposal 1 by saying ‘essential’ might suggest that they feel the makeup of teams is essential – which is not what the proposal says – or, alternatively, could mean that the proposal is essential.

Approach to analysis

Thematic analysis software was not employed in the consideration of the responses. Each response was read individually, and an inductive approach was taken to analysing the responses. All of the themes contained within the responses were recorded, without any prior expectation that any particular views would be expressed. The major themes were assessed by their frequency, taking extreme care not to overlook valid statements that were made by a very small number of respondents.

Overall comments

Many of the responses we received acknowledged the complexity of the area, and the attempts made by NHS England and the Department of Health and Social Care (DHSC) to reconcile a broad spectrum of views. Accordingly, whilst the engagement invited comments on nine separate proposals, many of the comments related, understandably, to more than one of the proposals.

Themes that spanned the proposals include:

• a call for more guidance to allow commissioners to assure themselves of the quality of the service;
• the suggestion that success depends upon engagement with the local community, and upon communication with all stakeholders
• a concern that the policy proposals may not apply equally to all age groups
• a concern about whether and how the proposals would support children after they leave school or further education
• concerns around administrative and financial burdens that the proposals might introduce
• a request that the proposals are harmonised – in particular, respondents advocated:
  1. proposals 1, 2 and 3 could be implemented with supporting guidance that covered all 3 topics (teams, equipment, and training)
  2. proposals 4 (the consent model), 6 (community engagement) and 9 (Eye Health Outcome Report) could all support one another by communicating consistent messages in every appropriate communication
• proposals 4, 6 and 9 (as above) could be used to support Proposal 7 (Avoidance of potential over-treatment).

We recognise many of the themes raised, in particular the importance of engagement with the local community and other stakeholders, and this will be built into our commissioning standard and service specification moving forwards. We also accept the need for additional support in implementing a sight testing model in special schools and have considered what supporting information could be provided. We continue to engage with our stakeholders to develop and offer a range of templates to support service implementation at a local level.

Proposal 1: creation of eye care teams

The responses we received

• Indicated generally strong support for the proposal that the format of teams would not be prescribed but should ensure the inclusion of professionals who possess the necessary skills that would ensure the provision of an equitable service for SEND children and young people attending special educational settings
• Suggested that teams would need to ensure that specialist dispensing is available where required and that teams either worked together with, or alongside, orthoptists to ensure that all recipients of the service received the best all round care possible

• There was strong support for retaining the dispensing optician as part of the eye care team with many respondents highlighting the importance of this role and the specific knowledge and specialist skills they possessed that were required to provide the best service possible
• Suggested that the proposal, when implemented, should be supplemented with guidance for those responsible for commission eye testing services. We received similar calls for guidance with respect to proposals 2 and 3

• Suggested the precise make up (membership) of the team, and/or the way it needs to operate (its function) – for instance noting that the same team must work together continuously to provide a stable/non-transient workforce who can familiarise themselves with the patients
• Suggested that the operation of teams should be ‘audited’ after one year
• Included other suggestions such as a database of authorised team members, and the introduction of a competency-based requirement
• Reflected positively on experience of similar models
• Included queries about how this would work in the ‘real world’
• Called for robust scrutiny to ensure evenness of care

Those who responded negatively to the proposal felt that NHS England should mandate the makeup of teams.

How we are responding

Whilst there were opposing views expressed as to whether NHS England should prescribe the composition of eye care teams, the weight of responses advised against this. As described in the engagement report, there was support for focusing less upon roles and more upon the necessary skills required to deliver this care. NHS England also acknowledges that there are benefits to patients, school communities and commissioners of a stable workforce in this service, as in others. Whilst ensuring provision of this should be a consideration for commissioners, the delivery of this is primarily a responsibility for the service provider.

We have set out in the commissioning standard and service specification that future contractors will be required to format teams to ensure they have capacity and competence to meet the needs of the school population being served. These expectations will also be a clear requirement within any invitation to tender documentation and part of the provider selection process.

Contractors will be expected to collaborate with local commissioners as part of mobilising and managing future delivery of contracts, providing the necessary assurance around service delivery and associated workforce.

Proposal 2: provision of equipment

The responses we received

• Indicated generally strong support for the proposal that equipment would not be specified or provided under any future contract
• Suggested that the proposal, when implemented, should be supplemented with guidance for those responsible for commissioning eye testing We received similar calls for guidance with respect to proposals 1 and 3
• Strongly suggested that the guidance could define a core recommended equipment list, informed by experienced clinicians, which would include specialist equipment for children and young people with a wide range of abilities. There were further suggestions that the future model should include the ability to assess visual acuity for non-verbal patients who may need their vision checked using the observation of eye movement methods which is often not available in a typical high street environment. Additional comments suggested that the list of prescribed equipment was necessary due to the nature of the specialist assessments needed to be performed
• The recommended equipment list should meet the clinical requirements of the service and the ophthalmic professional guidelines of both the College of Optometrists and Association of British Dispensing Opticians in relation to sight testing and paediatric dispensing
• Additional suggestion that whilst most of the required equipment was standard, the range of visual acuity tests should be more defined to avoid variation between providers which would hinder long-term monitoring and patient follow-ups
• New providers may need upskilling or support to use specialist equipment which is not commonly used
• Highlighted that there is a wide range of test resources that are required to assess visual function and behaviour over and above those that are required for children and young people who are seen in a high street environment
• Suggested that the proposal needs to address (or take into account) the availability of equipment at the starting point, and how it is financed. It was noted that the need to provide equipment may be a barrier to entry for competent potential providers and suggested that additional equipment provision could be factored into the wrap around fee structure to encourage potential providers to come forward.
• Included offers to work with NHS England to provide guidance
• Reflected positively on experience of similar existing arrangement
• Indicated that the school should have no responsibility for the provision or storage of the equipment.

How we are responding

NHS England has noted the strength of feeling with regards to the provision of further support to contractors to enable them and their staff to ensure that they have the necessary equipment and that they understand how this may be used to make reasonable adjustments to ensure the delivery of a comprehensive sight test to SEND children and young people attending special educational settings. NHS England has worked with professional bodies to produce advice to contractors detailing how to make reasonable adjustments to the provision of a sight test to ensure comprehensive delivery and the equipment which may be required to support this. This is annexed to  the commissioning standard and service specification.

Proposal 3: professional requirements and training

The responses we received

• Indicated generally strong support for the proposal that professional requirements and training would not be specified or provided under any future contract
• Suggested that the proposal, when implemented, should be supplemented with guidance for those responsible for commission eye testing We received similar calls for guidance with respect to about proposals 1 and 2
• Indicated a particular need for clarification of which qualifications might be sufficient – there were suggestions that providers should be able to self-identify learning needs and be able to identify appropriate training/experience that has already been undertaken which would enable them to provide this service safely. Extensive experience and previous study should be accepted as evidence of skills and competency
• Concerns were raised around the competencies required for individuals to perform sight tests on children and young people with learning disabilities and autism – neither stage 1 nor stage 2 of GOC registration fully prepares individuals for this
• Each member of the team should have their own relevant professional qualifications
• Paediatric training/experience was deemed as essential for professionals who would be working with children and young people with SEND with competencies in the provision of alternative testing and techniques suitable for this SEND children and young people attending special educational settings
• Safeguarding training was identified as essential services
• Expressed concern about some training packages – and felt that evidence of completion of them would not be sufficient evidence of suitability to deliver the services
• Expressed concern about whether not mandating training may lead to the lack of available training
• Acknowledgement that the POC training felt too comprehensive but did provide the team with additional confidence to deliver the service in a significantly different environment. POC providers have fed back that without the training and shadowing provided they would have been under-prepared to deliver this service
• Highlighted that the provision of information around specific and appropriate available  training would be useful alongside recommended reading materials which would ensure future providers understood the complex needs associated with SEND children and young people attending special educational settings
• If training requirements are not put in place how will the schools know that the providers have all the training they need?
• All staff delivering care in a special educational setting would benefit from training regarding the delivery environment – there needs to be specialist training around Is there evidence that the Oliver McGowan mandatory training is sufficient to support pupils safely and effectively across special educational settings?
• Training needs to be consistent and high-quality to ensure that ongoing services are of the highest standard. If the training package is changed then there need to be a quality assurance mechanism in place.

Those who responded slightly negatively felt that the proposal must promote the value of training and/or shadowing. Additionally, even among those who had preference for mandatory training, there was acknowledgement that it may be hard to achieve consensus over what training would be best.

How we are responding

NHS England fully acknowledges the views expressed that providers of this service should be experienced and competent in the provision of care to SEND children and young people attending special educational settings. We also note the varying views expressed as to how this could be achieved and subsequently demonstrated. Given this variance, and the lack of consensus as to the level of training required, NHS England remains of the view that a specific approach to training should not be defined. In addition to the core professional requirements of clinical staff, any contractor wishing to provide in school eye-testing should have clear evidence of completion of the Oliver McGowan Mandatory Training in learning disability and autism.

Given the strength of feedback received on training, and to support commissioners and future contractors with service implementation, NHS England has clearly set out expected training requirements of future contractors in the commissioning standard and service specification, covering key areas, qualifications and accreditation of clinical staff, safeguarding, competency and supervision.

Proposal 4: consent to sight testing

The responses we received

• Did not, on balance, support the proposal of moving to an ‘opt-in’ model although it was acknowledged that better engagement with parents from the outset would be beneficial
• Acknowledged that ‘opt-in’ and ‘opt-out’ models both have benefits and challenges associated with them
• There were both positive and negative reflections on both the ‘opt-in’ and ‘opt-out’ models:
  1. Moving to the ‘opt-in’ model would have negative impacts on inequalities, equality, and equity – the aim of the programme was to have equity and changing to an opt-in system would create an imbalance and the most vulnerable patients are likely to miss out
  2. Moving to the ‘opt-in’ model would have a large impact on uptake for a variety of reasons linked to health inequalities including poverty and parents not speaking English as a first language who may struggle to fill in the required forms. With it already being difficult to engage with parents and obtain responses this would put up further barriers for provision of the service
  3. Moving to the ‘opt-in’ model would be unmanageably burdensome and chasing for parental consent is very time consuming
  4. On the positive side, opting in would also help to prevent duplication of care and enable consent for refractions where children require eye drops
  5. Opt-in would also create parental involvement and help to provide detailed eye health history.
  6. The model used needs to be aligned with the GOC standards of conduct and explicitly referenced in any official documentation
• Suggested that whatever policy is adopted, clear communication with all stakeholders including, most importantly, parents would be essential to achieving positive outcomes. Parents often only see the value of the service after they have engaged so those who do not opt-in will never experience the benefits of the service

• Queried how ‘active consent’ is defined – consent should be able to be given verbally, by telephone, by SMS or by email as well as via a signed There needs to be multiple ways and options of how and when to provide consent
• Queried how to follow up on those cases where consent had not been gained and ensuring that there was adequate eye care provision in place for those children and young people.
• Included suggestions of alternative proposals – for instance, an opt out model for eye tests and an opt in model for dispensing. Keen to share reassuring experiences that the opt-in model works well
• Reflected positively on experience both of ‘opt-in’ models and ‘opt-out’ models
• Although the ‘opt-out’ service would likely lead to an increase in service take-up and improve accessibility, if an ‘opt-in’ service were used then this could be incorporated into a wider consent process incorporated by schools to ensure children and young people are less likely to miss out
• All attempts should be made to obtain consent but the original ‘About My Childs Eyes’ forms were too long for many parents to complete and in some cases, these have been completed by speaking to the parent over the phone
• Described the opportunity to harmonise the proposal with proposals 6 and 9.

How we are responding

NHS England received many responses to this proposal, with varying viewpoints from a range of stakeholders. While we have listened and heard the conflicting views, in the best interest and safety of patients, we are bound by the law in this area and have sought further legal advice in determining our response.

NHS England is committed to working within the confines of the law around consent, in line with the NHS constitution, and safeguarding of this vulnerable group of patients. A recent safeguarding review available here: Safeguarding children with disabilities in residential settings: government response – GOV.UK (www.gov.uk), for children with disabilities and complex health needs in residential settings 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.

The NHS Constitution for England – GOV.UK (www.gov.uk) commits to people having the right to accept or refuse treatment offered to them and for them not to be given any physical examination or treatment unless they have given valid consent. For consent to be valid it must be voluntary and informed, and the person consenting must have the capacity to make the decision. By voluntary we mean that decision to consent or not must be made by the person without being influenced by pressure from clinicians, other staff, friends, or family. Informed means that the person must have been given all the information about what the examination or treatment involves, including risks and benefits, alternatives and what will happen if the examination or treatment does not go ahead. Having capacity means that the person can understand the information given to them and can use it to make an informed decision.

Guidelines state that for children under 16 years of age, the consenting clinician should first judge whether the young person is able to give informed consent. If not, consent should be sought from those who have parental responsibility. For young people over 16 years of age, capacity to consent to the procedure should be assumed in line with the Mental Capacity Act 2005. If the consenting clinician judges that a young person does not have the capacity to consent to the procedure, then they should follow the process outlined in the current Mental Capacity Code of Practice available on the GOV.UK website: Mental Capacity Act Code of Practice – GOV.UK (www.gov.uk) .

We fully agree with the responses which noted that consent is a process which is based in part upon the provision of information. We are grateful to those who responded to highlight the importance of the relationship between the service provider and the school community in building the knowledge of children, young people and their parents in relation to understanding the potential benefits of sight testing. We see this relationship and knowledge building as being critical to the wider success of this service. We also note the positive comments about an informed consent process having the potential to contribute to the safety of the service being provided and to minimising unnecessary and potentially distressing duplication of care. Therefore, having considered the legal position, the service going forwards will require an opt in model.

We do however acknowledge some concerns raised regarding an opt in model. Future service provision, as described above, will be dependent on working relationships across all stakeholders, pupils, parents/carers, schools and contractors. We therefore envisage a system whereby, with close working withs schools and parents/carers, that informed consent could be requested at the commencement of the academic school year, or where service commences or prior to any sight test being undertaken. This would be with agreement from each individual school .

We also acknowledge that some of the current paperwork which parents, young people, contractors, and schools have been required to complete has been unnecessarily burdensome and we have worked with the profession and others to minimise this in order to support uptake of the service moving forward.

Proposal 5: selection of glasses (where required)

The responses we received

• Indicated generally positivity about the proposals relating to the selection of glasses, including the ability to dispense on-site which was less stressful to the patient and parent/carer
• Expressed some concern about different aspects of the ‘high street’ offer, including high street opticians’ capacity to provide:
  • frames suitable for complex prescriptions
  • high levels of after-care, where glasses need to be repaired and/or the person using them requires advice or support to familiarise themselves with the glasses
  • a suitable environment for patients with special needs – would it be possible to compile a list of practices with SEND clients that parents can be signposted to?
  • Prescribing and dispensing needs to be closely linked to avoid poor decision making that may undermine the aims of this service. Separating the two areas for this SEND children and young people attending special educational settings is more of a risk as individuals have greater needs and are less able to report issues

• Indicated that there needed to be access to a wide selection of frames across each of the voucher values, particularly those that were more specialist, and that these were available for dispensing in the SES so that patients did not need to visit the high street to get more choice. There was feedback on how the range has reduced since the NHS vouchers were introduced and this has led to less quality for the children
• There needs to be clarity on how repairs and replacements are undertaken and whether provision of these is via the same route as they were dispensed and whether this service would also be available during school holidays. There were concerns over whether patients would receive the same level of care if dispensing were done separately and via the high street
• Concerns were raised over the cost of specialist frames and the affordability, particularly with SEND children and young people attending special educational settings where spectacles are damaged more frequently. This could lead to frames being provided of insufficient quality which do not meet the needs of the patients. Suggestions of having a SES top up voucher to help with this
• Second pairs should be provided for this programme as patients break their spectacles more often and then experience delays whilst waiting for repairs or replacements. This affects the pupils if they need their spectacles for school work.

NHS England note there were several respondents who advocated that using high street opticians may be a useful opportunity for people with special needs to become more familiar with social settings and situations outside of the educational environment and this can be particularly beneficial for older children to help with transition.

How we are responding

NHS England welcomes the views of respondents who highlighted the importance of SEND children and young people having access to a choice of frames which are clinically suitable and attractive within this service. We are committed to children and young people having this choice as we expand the service to all SES setting and will expect contractors to hold a suitable range of frames at a variety of prices and aligned to voucher values.

We recognise the concerns raised about the potential for a difference in experience on the high street. Whilst we would expect most children and young people to be able to select a frame in the school setting, we nevertheless are of the view that if the frames available are not acceptable, that these children and young people should have the choice to take a voucher elsewhere.

NHS England are therefore:

1. Working with the Department of Health and Social Care (DHSC) to ensure any vouchers issued can be redeemed in the service or on the high street and clearly set out expected requirements of future contractors in the commissioning standard and service specification with regards to provision of a choice of frames, availability of repairs and replacements and the appropriate provision of second pairs; and
2. Supporting ICB commissioners by establishing a clear policy statement in the ophthalmic policy booklet and supporting practice inspection template, to ensure SEND children and young people attending special educational settings are able to access vouchers on the high street.

Proposal 6: engagement with the school community

The responses we received

• Indicated very strong support for the proposals with respondents feeling that any services set up needed to include the development of good relationships with the SES, their staff, and pupils particularly where the SES has pupils with more complex needs and where several visits are required in order to conduct full testing
• Contained some concern that the proposals needed to be more specific
• Reflected positively on experience of current arrangements: how well stakeholders communicate with each other and the positive effect this has on the quality of care received
• Made specific suggestions about which different stakeholders need to be considered part of the community including other health care providers involved in the child’s care
• Suggested that any new service put in place should involve communicating with HES to find out if any history exists
• Highlighted the importance of communication with the community and the need for eye care teams to develop good relationships with the schools, staff, and pupils with the suggestion of familiarisation visits being undertaken prior to testing starting
• Described the opportunity to harmonise the proposal with proposals 4 and 9.

How we are responding

The feedback reflected the importance of positive relationships between contractors, schools, parents, children, and young people in determining the success of any in-school sight testing offer. NHS England is keen to see these relationships being developed as the service is expanded as they are crucial to engagement, information sharing and ultimately consent and uptake decision-making. It is important that providers of this service can adapt their engagement approach to the needs of schools, parents, children and young people.

As noted in the engagement report, the process of relationship building should start from the point that a service is being considered for commissioning. Therefore, NHS England will be providing additional support for ICBs to support engagement with the school community and local provider market, at the procurement stage of wider roll out. This will help to determine the interest from schools in the service and the provider base to deliver the service.

There will be a clear requirement for contractors to build strong working relationships with the SES and the wider SES community to promote both the availability of the service and wider understanding of eye health challenges for SEND children and young people. NHS England’s commissioning standard and service specification  sets out the ongoing requirements of the successful provider to engage with schools and the local system, including eye health networks, secondary care providers, and other relevant local stakeholders.

Proposal 7: avoidance of potential over-treatment

The responses we received

• Indicated opposing views of the proposal
• Several responses described the potential advantages of a system that allows for what might be perceived as ‘over-treatment’
• In particular, there was concern that guidance around the frequency of eye tests has been developed for the wider population, not this group of people
• Some responded whether there is any evidence to suggest potential over-treatment is an issue which is significant enough to require checks to be in place at all, as set out in the proposal.
• Others described the potential for repeated tests for the same individual as inefficient, and potentially stressful for all stakeholders – especially patients and their carers
• Suggested operational guidance may help to clarify operational and clinical proposals
• Suggested that although an annual sight test under the POC may be useful to some, for low risk patients this seems unnecessary and is not in line with GOS so is not appropriate
• Highlighted that parents are asked to return a questionnaire which asks about previous treatment and parents/carers are given the option to transfer treatment to school if preferred
• At least one third of UK Special Schools are served by an Orthoptic led service and any service should be amalgamated with existing provision
• The service is dependent on parents filling in the forms accurately when it comes to previous history, this is often not the case as there is confusion around what services have been accessed. A lot of admin time is taken up trying to get clarification
• Instigating a standalone system to record sight tests in special schools has removed the mechanism to check on whether patients have been seen earlier, this needs to be rectified in any future model.
• Effective information sharing is vital
• Noted that the consent model (proposal 4), engagement with the school community (proposal 6) and the Eye Health Outcome Report (proposal 9) could be used to tackle this issue (i.e., by using those communication methods to describe the issues associated with over-treatment).

How we are responding

The POC was not integrated into existing processes for checking when the child or young person last had a sight test. Instead, contractors were dependent upon parental recall of when this occurred, and NHS England notes the feedback above that clarifying previous sight testing history could be time-consuming. As we expand the service to all SES settings, we will implement a new national claim form for the SES service which will seek to reduce this burden by enabling contractors to check whether the child or young person has had a sight test in primary care in the preceding year.

NHS England recognises the concerns described above that the optimal recall frequency for some of these children is currently unknown. In the absence of an evidence base to inform these decisions NHS England and the local ICB commissioner will expect the provider to adhere to the established Memorandum of Understanding (MoU), which sets out the minimum interval between sight tests.

However, as in other settings, where a clinician feels that a child or young person would benefit from having their sight retested earlier than the agreed MoU between NHS England, Department of Health and Social Care, and Association of Optometrists and Federation of Ophthalmic and Dispensing Opticians this will be supported through appropriate recording on the national claim form. As previously indicated, we recognise the importance of engagement with the local community and other stakeholders, and this will be built into our planning moving forwards.

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

The responses we received

• Indicated strong, broad support for the proposal although there were concerns around affordability for parents particularly with the high turnover of repairs and replacements for SEND pupils. There was a suggestion that there could be a funding model specifically to meet the needs of these children
• Reinforced the need to take a consistent approach to all patients
• Noted that there is a risk that patients and carers may be commercially “exploited” by a lack of frames that are both suitable and acceptable to the patient and/or carer
• Expressed a particular concern that the patient group tend to need a second pair of glasses due to the frequency of repairs and replacements, and that this should be the default clinical The need for this was recognised in the POC and should be continued
• Concerns over how repairs and replacements are dealt with during the holiday periods when no sight testing clinics are Will a service be available during these periods to make sure patients are not disadvantaged?
• Concerns were raised around payments on school premises with providers becoming ‘retailers’ and parents being expected to attend appointments if payment is required which is not always possible. How would schools manage this – this would be very challenging for schools
• There needs to be a full range of spectacles available within all voucher values and for all ages
• Concerns were raised over the cost of specialist frames often required by SEND children and young people attending special educational settings and whether this will lead to poorer quality frames being provided in order to reduce the costs to parents. This in turn will lead to more frequent repairs and replacements. Similarly, if parents do choose more specialist frames and provide co-payment then this will need to be repeated for every replacement which may place unsustainable costs of families if there are regular breakages
• There needs to be assurance that there will be no financial abuse of this position, particularly with this vulnerable How will commissioners identify contractors who upsell within a school and how will this be managed?
• Clear guidance needs to be shared on additional payments, repairs and replacements
• Concerns raised that aligning this service to High Street services is ill-advised as high street services do not work for disabled children and young people, promoting equity along the POC approach feels more in line with the aim of the programme
• Concerns were raised about inequalities. The POC is being reduced in the name of equality, but the reality is that to achieve equity of care and equality of outcome there needs to be more favourable treatment of this group. Equity needs to be around the sight correction not equality with the High Street offer. The needs for these patients are different.

How we are responding

NHS England welcomes the feedback that we should be consistent in our approach to all children. We also recognise the concerns raised for some stakeholders and have taken steps to mitigate some of these in our commissioning standard and service specification, particularly in relation to the provision of a range of affordable and suitable frames and access to repairs and replacements during holiday periods. The aim of commissioning this service in SES settings is to address the barriers that many of these children and young people experience when trying to access sight testing on the high street by bringing the service to them. It does not seek to address some of the wider issues raised in feedback such as co-payment for frames and lenses which potentially impact upon all those who access NHS support for dispensing. NHS England has however sought to attempt to mitigate some of these challenges within the commissioning standard and service specification and through utilising a commissioning rather than an Any Qualified Provider model of provision as this allows for greater oversight.

Subject to regulatory change, NHS England’s commissioning standard and service specification will ensure the provider offers parity of the NHS principles on co-payment, replacements, second frames, and additional criteria for pupils aged over 16 years.

Each pupil within SES who requires corrective lenses should be offered financial support towards the cost of any corrective lenses required for their prescription in the form of GOS 3 optical vouchers. This voucher may be redeemed with the in-school provider or the high street. Where eligibility criteria are met then pupils will be entitled to a voucher for a second pair of glasses.

It will be a contractual obligation to offer genuine choice between an appropriate choice of suitable frames provided by the school testing dispensing service, which is regularly reviewed and updated, and a voucher to be redeemed at a high street optician.

Proposal 9: production of an eye health outcome report

The responses we received

• Indicated very strong support for the proposal with this being seen as a key element of the service. The report needs to include as much information as possible around the sight test, prescription, and additional factors to take into consideration such as reasonable adjustments, seating, and lighting arrangements
• Focussed on the exact purpose of the report, how this would affect its content, and the way it will be communicated to stakeholders
• Concerns were raised about the length of the report and how this would make it too time consuming to complete, highlighting the risk that making it too lengthy would leave it unread. The time taken to complete should be considered and funded appropriately
• There should be a national template to avoid variation, duplication and gaps
• The report should be shared with parents, schools and health care staff and integrated into the ECHP if one is in place
• Described the opportunity to harmonise the proposal with proposals 4 and 6

How we are responding

The production of an eye health outcome report has been a success. This report 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. This has had a direct impact on pupils learning and development needs.

NHS England therefore propose no variation to the approach in the future national model. However, we  welcome stakeholders’ views on the content of this report and have undertaken further engagement with stakeholders to ensure completeness of the report template.

Appendix 1

Proposal 1: creation of eye care teams

During the POC, NHS England created the eye care teams. 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 ophthalmic 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 specifically required team of two professionals (one optometrist and one dispensing optician) for a contract to be awarded. 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 provider 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 provider 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 SEND children and young people attending special educational settings and have evidence of completion of the Oliver McGowan training in learning disability and autism as this is now mandatory for NHS providers.

Proposal 4: consent to sight testing

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 providers of the service to work together to describe a process which is bespoke to the needs of their community.

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 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.

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.

Publication reference: PRN00950