Low vision, partial sight and visual impairment are synonyms for the same state: reduced vision, with both eyes open, even with the best optical correction. The definition does not include those who are monocular: these patients have different problems and are rarely considered in this category. The term also implies that some form vision (i.e. the ability to recognise shapes, no matter how close they must be placed) remains, and that vision is not simply confined to light perception. ‘Regular lenses’ in this context include required distance refractive corrections and reading additions up to +4.00 DS. The latter forms a somewhat arbitrary dividing line, whose origin is historical: it has been assumed that the closest distance at which a patient would normally read is 25 cm, for which the normally sighted presbyope would require a +4.00 DS addition.
Disorder, Impairment, Activity Limitation and Participation Restriction
Whilst impairment describes the clinical status of the individual, different terminology is required to describe the effect on the individual in their everyday life. The International Classification of Functioning, Disability and Health (ICF) attempts to standardise the description of the functional consequences of disease at various levels. Thus, visual impairment , activity limitation and participation restriction are in fact used to describe the consequence to the bodily organ affected (the impairment) and the consequence to the patient, both in terms of their practical abilities (activity limitation) and the interaction with the society in which they live (participation restriction), of some disease or disorder of the anatomical structure or physiological function of the eye, which may be congenital, acquired or due to trauma.
Thus, clinical tests of physiological function, such as visual acuity or visual fields, are measures of visual impairment: on a recognised and standardised test, the patient does not perform as well as ‘normal’. Activity limitation is the lack, loss or reduction of an individual’s ability to perform certain tasks. Whether impairment causes activity limitation depends on the task to be performed or the practical skills to be exercised: if the impairment is the loss of one leg, for example, then this definitely limits the activity of walking, but the loss of one eye would usually cause very little limitation for watching television, even though there is no doubt that an impairment is present.
In the context of individuals with low vision, it is the so-called instrumental activities of daily living (IADLs) which are most significant, as they are important in order to live independently in the community. The mnemonic for the list of relevant activities is SHAFT 2 , representing the following list:
S hopping
H ousekeeping
A ccounting (managing money)
F ood preparation (including medication)
T ransportation (or travel)
T echnology (including telephones)
Whether the activity limitation becomes a participation restriction depends on how the patient reacts to it. If the patient feels, or actually is, at a disadvantage in society and cannot live their life as they expect or would choose to do (or at least not without making an enormous effort), that is participation restriction. The areas of life in which the individual may perceive that they are disadvantaged include, for example, education, employment, recreation and leisure, and personal relationships.
To apply these definitions in the case of the disorder of age-related macular degeneration (AMD), this can be identified as progressive degeneration of the photoreceptors in the macular area, causing a loss of acuity and partial central field loss. This would be detected as an impairment on a clinical test of the central field, such as the Amsler Grid, when the patient would notice distortion. This distortion would affect the visibility of anything the patient fixated centrally and may be noticed in the everyday task of recognising faces, on finding that only the outline and not the fine detail can be seen. This may become participation restriction if the patient worries about unwittingly ignoring, and thus alienating, a friend passed in the street. Some further examples are given in Table 1.1 , which illustrates the ICF as applied to ocular disease, showing the wide-ranging consequences at all levels.
| Level | Disease/disorder | Impairment: consequence at level of the organ | Activity limitation: consequence at level of patient | Participation restriction: consequence in the wider social environment | |
| Definitions | Ophthalmological diagnosis | A change in the structure or function of the eye or visual pathway | A problem in the performance of daily activities | Social disadvantage: the inability, or need for exceptional effort, to fulfill role in society considered appropriate for that individual | |
| Anatomical structure | Physiological function | ||||
| Examples | Age-related macular degeneration | Photoreceptor degeneration | Central scotoma: central vision patchy and distorted | Recognising faces | Fear of rejection by friends not acknowledged in the street |
| Cataract | Crystalline lens opacity | Poor contrast sensitivity: inability to detect low-contrast edges | Falling on steps and kerbs | Unable to go out alone | |
Low Vision Defined By Visual Acuity
Low vision can therefore be defined either in terms of the visual impairment which is created or the extent of the visual activity limitation, and both are used according to the particular situation. It may be decided to use the visual impairment to classify low vision and set a threshold visual standard which is considered ‘normal’ with any value below that representing ‘low vision’. There are difficulties in deciding on a suitably simple and repeatable visual test and determining exactly where the pass/fail boundary should be set. The most familiar test of spatial vision is the resolution task of Snellen acuity, which involves the ability to discriminate the smallest possible letters at maximum contrast (nominally 100%), and ‘normal’ performance is taken as 6/6 (0.0 logMAR). The test has the advantage that is in common usage, is easily performed, and the result is described by a single value.
The International Classification of Diseases 11th Revision (ICD-11) ( ) classifies vision impairment (VI) into two groups, based on presenting visual acuity for distance or near.
Distance vision impairment:
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Mild—visual acuity worse than 6/12 to 6/18
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Moderate—visual acuity worse than 6/18 to 6/60
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Severe—visual acuity worse than 6/60 to 3/60
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Blindness—visual acuity worse than 3/60 (or a visual field diameter <10°)
Near vision impairment:
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Near visual acuity worse than N6 or M 0.8 at 40 cm
These definitions of VI and blindness have changed considerably over time ( ). When first introduced in 1972, they were based on ‘best corrected’ visual acuity. This would still be a conventional definition to use for low-vision rehabilitation in high-income countries where refractive correction and medical treatment are widely available. In 2010, the change was made to ‘presenting’ visual acuity to reflect the considerable contribution of uncorrected refractive error to the everyday functioning of many individuals. The ‘mild’ category includes those people who may be considered to have ‘ socially significant’ vision loss: this is a group who would not be permitted to drive in many countries.
Low Vision Defined by the Need for Rehabilitation
As far as patients are concerned, however, they are more likely to identify their visual difficulties in terms of functional limitations, complaining of an inability to perform everyday tasks, such as reading, driving or recognising faces. It is extremely difficult to quantify such problems, or to relate them to a particular level of visual acuity (a particular degree of impairment). It is common in a low-vision clinic to encounter a patient with, for example, very constricted visual fields who navigates easily, whilst another patient with more moderate loss needs to use touch instead of vision to get around.
There is an ongoing search for a simple clinical test of impairment which can be easily and quickly performed in the consulting room and gives an accurate prediction about how limited a patient will be when carrying out a practical task such as reading or navigating in unfamiliar places: as suggested earlier, that correlation may not exist. It is certainly true that distance visual acuity has been found to be a poor predictor of mobility, face recognition and reading. Other tests, such as contrast sensitivity and visual field measurement, have been found to increase the accuracy of predictions, but often the only solution is to test the patient on the actual task—this is of course done routinely for reading, where samples of print paragraphs of various sizes are used. It can be argued that trying to link impairment and activity limitation is irrelevant: regardless of the patient’s acuity, if they are having visual difficulties with a task then they need rehabilitative help to allow them to perform it. Equally, the exact level of acuity which constitutes impairment is variable: if patients have a hobby or occupation which requires 6/4 acuity and they only have 6/9, then they will consider themselves to be visually impaired; someone whose main interests are watching television and going to the pub may be satisfied with 6/18 visual acuity. For this reason, it is important that low-vision services should be accessible to anyone who may benefit from them. World Health Organization (WHO) consultants emphasised that arbitrary visual acuity levels should not be used to determine whether the patient should have access to rehabilitation ( ), and this is a conclusion that would be endorsed by many service providers.
Low Vision Defined in Legislation
Most high-income countries have a system of social care where certain groups become identified to receive financial benefits or have access to appropriate services. The visually impaired and blind are one such group, and they are ‘registered’ in order to show their eligibility for special attention. Registration is undertaken with the aim to:
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assess what health and social work resources will be needed for the number of visually impaired people in a particular area and
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act as the patient’s passport to appropriate welfare benefits.
This leads to definitions of ‘legal’ blindness: a level of visual acuity and/or extent of visual field which the patient must not exceed if they are to be certified officially as ‘blind’; it is felt that such standards are required to prevent fraud.
There are problems in achieving a consistent definition of blindness as the WHO (1966) identified 65 different definitions of blindness worldwide, although the UK appears to be unique in having the dual categories of Sight Impairment (SI; previously called ‘Partially Sighted’) and Severely Sight Impairment (SSI; previously ‘Blind’). Even if a particular level of impairment could be (SI; previously called ‘Partially Sighted’) and Severely Sight Impairment (SSI; previously ‘Blind’). Even if a particular level of impairment could be universally agreed, this can still cause difficulties in interpretation ( ). A patient may, for example, have a ‘real’ acuity of 6/48, but this is not a letter size which is available on most standard Snellen charts. On the standard chart, when presented with a letter of ‘6/60’ and the next size of ‘6/36’, the patient’s vision will only be recorded as ‘6/60’. If the level of acuity required in order to be registered was chosen as 6/60, they would qualify, and yet a more accurate measure would have revealed that they were not eligible ( ). Similar difficulties arise when a particular extent of visual field is quoted as the registration criterion. It is possible to envisage a pathological condition where there is a very small island of central vision, but a much larger isolated peripheral crescent of functional visual field. In this case, patients are unlikely to be able to use the peripheral island of vision for useful navigation, yet officially their visual fields may be too large for them to be registered ( ). There is also doubt whether a measurement of the impairment by standard clinical tests would yield exactly the same measurement if repeated: there is evidence that performance (especially for contrast sensitivity) can be improved following an interview with an empathetic and encouraging clinician ( ).
Even if the vision test result is unequivocal, two patients with the same acuity might perform very differently, and more discriminating tests of vision (such as glare disability or contrast sensitivity) might offer a better indication of how the patient functions in everyday life. Some countries choose not to set a level of impairment to define ‘blindness’, but instead rely on a measure of activity limitation. In these terms, blindness might be determined as inability to walk across an unfamiliar room unaided. Of course, this brings its own complications: if a different task had been chosen, the patient may have performed much better, and there will be no standardisation in the type and size of ‘room’, its lighting or the arrangement and colour of its furniture.
In the UK, there is an attempt to use both impairment and activity limitation to define SSI (previously ‘blindness’) and SI (previously ‘partial sight’). The legal definition of blindness was based on being ‘so blind as to be unable to do any work for which eyesight is essential’. As this is based on ability it allows for individual discretion and interpretation, although there are recommended acuity and visual field levels to try to ensure consistency. The introduction of a category of ‘sight impairment’ in the UK in 1948, with acuity levels which are higher and which only allows access to some of the benefits available to the severely sight impairment, is another way to offer help to patients who require it but do not meet the ‘blindness’ criterion (although it will still not include all those who the WHO identifies as suffering from mild or moderate vision loss where a visual acuity standard of less than 6/12 is adopted).
Registration will therefore not identify all those in need. concluded that for a group of visually impaired patients of whom only 10 would be classified as blind when tested in the hospital clinic, 20 are functioning as blind because of their lower acuity under the generally poorer lighting levels in the home. The results of an Office of Population Census and Surveys (OPCS) survey ( ) suggested that 1,668,000 people in the UK suffered visual difficulties, including 25% of all those aged over 75 years, and 45% of over 85-year-olds in the UK had reported difficulties with their eyesight when completing their census return in 1980. In 2018, updated estimates suggest 1.93 million people in the UK have visual acuity <6/12 ( ).
The UK Registration System
In the UK, the Blind Persons Act 1920 legislation provided specific welfare facilities for the blind, and a definition of blindness was introduced (little changed to the present day) which established eligibility for those benefits ( ). The sight impairment (partial sight) category was added by the National Assistance Act in 1948.
The functional definitions are as follows:
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Severe Sight Impairment (SSI)—‘so blind as to be unable to do any work for which eyesight is essential’
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Sight Impairment (SI)—‘substantially and permanently handicapped by defective vision caused by congenital defect or illness or injury’
Despite the worthwhile nature of a definition related to activity limitation, there is obviously much scope for interpretation here, so an attempt has been made to quantify the corresponding impairment ( ), with the patient fully corrected and using both eyes: there is no provision for consideration of a loss in only one eye.
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Severe Sight Impairment (SSI)
3/60 or worse
6/60 or worse with field contraction
6/60 or better with contracted field causing functional impairment (e.g. reduction of inferior field or bitemporal hemianopia)
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Sight Impairment (SI)
3/60 to 6/60, full fields
6/24 to 6/60, with moderate field contraction (superior or patchy loss), media opacities or aphakia
6/18 or better if marked field defect such as hemianopia
It is difficult to apply any of these definitions to young children because of the inaccuracy in acuity measurement using a Snellen chart. It is therefore recommended that children are registered as sight impairment until the age of 4 years, unless obviously totally blind. When they reach this age they can be tested using an optotype chart with optimum refractive correction and registered in the same way as adults.
The patient is registered with the Local Authority, but the process starts with certification, which can only be carried out by an ophthalmologist using a form known as the Certificate of Vision Impairment (CVI) in England and Wales, the CVI (Scotland) in Scotland and the A655 in Northern Ireland. The CVI replaced the previous BD8 in England in September 2005 and Wales in April 2007 and replaced the BD1 in Scotland in April 2018. It is normally the ophthalmologist who will suggest registration and discuss it with the patient: social workers, eye clinic liaison officers, optometrists or other professionals may ask the ophthalmologist to consider this when appropriate. Note that people who are not currently under the care of a hospital eye clinic will need to be re-referred to an ophthalmologist for this to be done. If patients disagree with their registration category (e.g. so they can obtain the enhanced benefits associated with SSI registration), they can appeal for independent assessment to the Ophthalmic Referee Service. Patients can have their registration category changed, or even be deregistered if vision improves. Despite this, patients often perceive registration (particularly as SSI) as ‘the end of the road’ and assume there is no longer any hope of treatment: earlier and more recent surveys suggest that ophthalmologists perhaps consider it in much the same way, with patients receiving active treatment being least likely to be registered ( ).
The CVI Form
This is the ‘Record of Examination to Certify a Person as Severely Sight Impairment or Sight Impairment’. It is divided into four parts.
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Part 1 (to be completed by the ophthalmologist)—Patient details (name, address, telephone number, email address, date of birth, sex, NHS number), certificate of sight Impairment or severely sight Impairment, which indicates the registration category, and gives the date the form was completed: this is the date on which the patient becomes entitled to any associated benefits, name of the ophthalmologist who signs the document and hospital address.
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Part 2 (to be completed by the ophthalmologist)—Aspects of visual function including aided/unaided visual acuity, category of field defect (extensive loss of peripheral visual field—including hemianopia), and if the patient has been referred for low-vision services.
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Part 2a—Diagnosis of the disorder or disease causing the visual impairment for patients 18 years of age or over
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Part 2b—Diagnosis of the disorder or disease causing the visual impairment for patients under the age of 18
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Part 3 (to be completed by the patient (or parent/guardian if the patient is a child) and eye clinic staff (e.g. Eye Clinic Liaison Officer [ECLO]/Sight Loss Advisor))—Additional information for the patient’s local council including living circumstances (e.g. lives alone), support, physical mobility difficulties, hearing difficulties, learning disabilities, dementia, employment status, if in full-time education or if they are a baby, child, or young person, and are they known to the specialist visual impairment education service. Any additional relevant information can also be added here (e.g. risk of falls, medical conditions, emotional impact of sight loss, urgent support needed and the reasons why, or benefits of vision rehabilitation). Finally, the patient’s information and communication needs are added here (preferred method of contact, preferred method of communication, preferred format of information and preferred language).
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Part 4 (to be completed by the patient [or parent/guardian if the patient is a child] and eye clinic staff [e.g. ECLO/Sight Loss Advisor])—Consent to share information (declaration of permission for a copy of the CVI to be sent to the patient’s GP, the local council, and the Royal College of Ophthalmologists, Certifications Office at Moorfields Eye Hospital) and a declaration confirming that the patient has been informed that they must not drive.
In addition to renaming the BD8 as CVI, in 2003 two other new forms were introduced:
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The Hospital Eye Service Referral of Vision Impaired Patient for Social Needs Assessment (RVI)
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The Low Vision Letter or Low Vision Leaflet (LVL) (LVI previously)
The eye clinic staff member completes the RVI if they think that a patient would benefit from an assessment of their needs, even if registration is not appropriate at present. This form highlights the areas of concern (e.g. cooking unaided, getting about safely). The patient may not yet be eligible for registration, may be in the middle of treatment which might alter their status, or may have refused registration. Once completed, the RVI is sent to Social Services and one copy is kept in the patient’s hospital notes, another copy is sent to the GP and a third copy will be kept by the patient.
The second form (LVL) is used when a community optometrist identifies a person with significant sight problems. This form is distributed from Social Services to local optometrists or can be downloaded by the optometrist. This form is to be given to the patients with sight problems whom the optometrist feels would benefit from advice and assessment. The patient should send the form to Social Services, giving details of their age, circumstances (e.g. living alone) and problems (as on the RVI).
The Legislative Background
Section 29 of the National Assistance Act 1948 lays down the responsibilities of the local authority for those registered as blind and partially sighted.
Mandatory functions are as follows:
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Keeping the registers of the people who are severely sight impairment and sight impairment.
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Providing a social work service, advice and support for those living in their own home or elsewhere.
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Making available facilities for social rehabilitation and for adjustment to the disability: this includes teaching techniques for communication (such as Braille) and mobility.
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Providing facilities for social, recreational, occupational and cultural activities.
Additional services which can be provided include accommodation, transport and holiday homes.
The Chronically Sick and Disabled Persons Act 1970 provides for a wider range of services to be offered by the local authority, when it identifies a need for them, such as:
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Practical help and adaptations in the home
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Supply of radio, television, library or similar recreational facilities
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Provision of, or assistance in obtaining, a telephone and any special equipment necessary to enable the use of a telephone
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Holidays
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Recreation and education away from the home, and transport to them
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Meals in the home, or elsewhere
Some local authorities interpret need more generously than others, and this may not be in the same way as the potential recipient who feels that a particular service is essential to him or her.
The Care Act 2014 legislates to provide those persons with visual impairment with care services and support, tailored to their own individual needs (a ‘care plan’), which will allow them to live independently in their own homes (if possible). Any individual can request an assessment of their needs, which in the case of VI, will be carried out by a specialist team within Adult Social Services which may specialise in VI, or combine hearing and vision care within a broader Sensory Team.
If a need is identified which the local authority does not have the staff to provide, then it is required to buy in the services of, for example, a voluntary society or a freelance consultant. The recipient may have to make some contribution to the cost of some services: there is no uniform policy on charging, but it is usually based on the individual’s income and savings.
The rights of visually impaired children are specified in the Children and Families Act 2014 , which was intended to achieve a better integration of health, education and social care provision. Each local authority must publish its ‘Local Offer’ which describes the provision it makes for the young people in its area. It provides information for young people, their parents and carers, and professionals regarding education, health and care services, leisure activities and support groups. The Local Offer should also be responsive to the needs of the individuals using the services, who are encouraged to provide feedback about what is needed.
The local authority draws up a register of disabled children within its area, but this is not the same as the SSI and SI registers, and it is not necessary for the child to be registered as visually impaired in order for their needs to be assessed. For the purposes of this list, disability (defined by the Equality Act 2010 ) is ‘a physical or mental impairment which has a long term (i.e. a year or more) and substantial adverse effect on their ability to carry out everyday activities’. Local Education Authorities (LEAs) identify children from 2 years of age (up to the age of 25 if they are still in full-time education) who are likely to have ‘special educational needs’ (SEN) or are disabled. A child has SEN if they ‘have a disability which prevents/hinders them from making use of educational facilities usually provided for children of that age’. So-called ‘special’ schools now usually cater for pupils with additional nonvisual disabilities and health needs. Regardless of the degree of visual impairment, most children with VI in the UK attend mainstream schools.
The SEND Code of Practice 2015 covers the provision for children (0–25 years old) with SEN, and each mainstream school has a SENCO (SEN Coordinator). If the school does not have the resources to support the child from its SEN budget (e.g. if the child requires specialist equipment or one-to-one classroom support) then an assessment can be carried out by the Local Authority to determine if it is necessary to provide an Education, Health, and Care Plan (EHCP) for the child, which is reviewed annually.
Children with VI should have access to the full National Curriculum, but may also need some formal training in the ‘life skills’ which normally sighted children may pick up from observing peers and parents, and in independent mobility. These will ideally be taught by a Registered Qualified Habilitation Specialist (RQHS), who will work with the child within the school. Children with VI in a mainstream school may be withdrawn from classes for a few hours each week in order to have special tuition from a Qualified Teacher of the Visually Impaired (QTVI) such as in Braille or touch-typing. Some schools have an attached unit for children with VI. The QTVI can also visit the parents and the child at their home and in an early years setting, providing advice, guidance and support. The QTVI is a key person in the educational development of the child with visual impairment and will remain supporting the child throughout their school years,
These professionals may be based within the local authority’s specialist service for children and young people with visual or hearing impairment which might be called the Inclusion Team (IT), Children’s Sensory Service or VI service.
This service will:
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offer support and advice to families about their child’s sensory impairment;
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provide assessments regarding the child or young person’s sensory impairment;
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write advice and provide strategies to support children and young people in their learning and development;
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provide specialist equipment when needed;
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teach Braille and British Sign Language as appropriate;
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train teachers and other professionals about sensory impairment;
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liaise with parents and other professionals;
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provide awareness-raising sessions for peers;
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attend meetings and reviews; and
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signpost families to other services.
All children should be referred to this service directly from the hospital eye department when the eye condition is diagnosed. Any parent or professional can contact this service directly in the event that the expected referral has not taken place correctly.
University students (undergraduate and postgraduate) can get help with the extra costs they incur because of their disability, via the Disabled Students Allowance. This could cover specialist equipment (such as computer software or an Electronic Vision Enhancement System [EVES]); nonmedical help (e.g. a note-taker or reader); and the extra travel costs (perhaps taxi fares where public transport is not available). Extra costs related to their accommodation are covered by the university if the student is in a hall of residence.
Finding employment is a major problem for people with low vision and unemployment is far higher in the visually impaired population. The employment benefits which are available are linked to the patient being registered as ‘disabled’. This is not automatic and should be requested by the visually impaired person at their local Jobcentre. It is likely that any person registered as severely sight impairment and sight impairment will be eligible for registration as disabled. Work Coaches based in the Jobcentre Plus are trained to help the person with disabilities to find work or to gain new skills for a job. They will conduct an employment assessment to understand what type of work would suit the person best and can help with work preparation, recruitment, interview coaching and even confidence building. The length of time an employment assessment takes depends on the person’s individual needs and can last from half a day to a few days or longer. After the assessment, the person will agree to a plan of action with the Work Coach, which may include training or taking part in a programme such as Access to Work, Residential Training or Work Choice. The Work Coach can also provide referrals to a specialist work psychologist, if necessary, for a more detailed employment assessment ( ).
Residential training courses can help people with visual impairment to get a job, gain more experience to keep a job or become self-employed. People who are severely sight impairment or sight impairment and unemployed can apply for residential training if there are not any suitable training courses available locally. Courses are run by the Jobcentre or the Royal National College for the Blind (RNC) ( ). The World Blind Union (WBU) have recently developed Project Aspiro ( )—a career planning and employment website for people who are severely sight impairment and sight impairment (as well as service providers, friends and family, and employers). The website includes information and helpful tools that address the career planning process, including living independently, learning and education, preparing for work, and working life. There are explanatory videos and audio clips as well as profiles of organisations, programmes, services and useful websites around the world.
‘Access to Work’ is a scheme to enable employed or self-employed people with a visual impairment to work more efficiently, or to increase their capacity for work. The specific types of help may include: the cost of a taxi to work if public transport is inappropriate; special equipment, or modifications to existing equipment; adaptations to the premises or working environment; a personal reader or assistant at work. For the visually impaired person this may well be the route by which an electronic magnifier, text-to-speech, or Braille device, could be obtained for work. Financial limits to the aid available depend on if the person is employed or self-employed, how long they have been in their job, the size of the employer and the type of help they need. The Access to Work scheme normally pays the full cost of any adaptations if the person has been in the job for less than 6 weeks, if the person is self-employed, and if the person needs funding for a support worker, travel to work or interviews and communication support at interviews. If the person applies for the scheme after having been in the role for more than 6 weeks, the employer might need to contribute towards the cost of adaptations and gadgets paid for by Access to Work. Funding is ongoing and will be reviewed every 3 years or if the person’s condition changes. The employer owns the equipment bought through Access to Work and is also responsible for the maintenance, insurance and disposal costs ( ). Some of the adaptations required in the workplace to make it accessible to an employee with VI would be considered as reasonable adjustments under the Equality Act, and funding would not be available for these. Disability Confident (DC) is a government scheme to encourage employers to make their working environment, practices and recruitment process as inclusive as possible: for example, guaranteeing an interview to any disabled applicant who has the essential qualifications.
Advantages of Registration
Legislation is largely concerned with specifying the provision by the local authorities, but the exact form which this takes will vary depending on the geographical area in which the visually impaired person lives. This variation is inevitable as local authorities may be buying in rehabilitation services from a variety of different sources, including voluntary societies. Local authorities offer services according to need rather than registration, but registration is likely to be a passport to obtaining the most appropriate help with the minimum difficulty, and it acts as a trigger or catalyst in the awareness and receipt of services. Registered individuals are always proportionately more aware of available services and gadgets, and use them more: to take a simple example, 31% of people registered visually impaired, but only 2% of people who were unregistered with the same vision, owned a talking clock or watch ( ).
Under the provisions of the Care Act, anyone can request an assessment by their local authority Social Services Department to determine what would be required to allow them to live as full and independent lives as possible in their own homes. This often takes the form of Home Care Services (a home help to assist with cleaning, cooking and shopping), and Meals on Wheels. Many social services departments employ rehabilitation workers/officers to work with the visually impaired to meet their particular needs to perform daily living tasks, and to have safe mobility and travel. This may involve advice on specialist equipment, or adaptations to the home (such as improved lighting, or handrails). If the person is registered as SSI, the Blue Badge scheme, run by local authorities, allows drivers to park in spaces reserved for disabled people. The Blue Badge scheme does not fully apply in the City of London but allocated parking is provided for people with disabilities in the Square Mile.
Although the details vary depending on the locality, there are usually concessions for public transport. For example, in Greater Manchester, a person registered as SSI is eligible for a free travel pass on buses and trains and those who are registered SI are eligible for a concessionary travel permit. People who are registered SSI or SI in Merseyside are eligible for an English National Concessionary Travel Pass which offers free travel on all buses, trains and Mersey Ferries river crossings. In London, everyone whose vision is too poor to qualify for a driving licence can apply to their local borough council for a Freedom Pass for free travel on all bus, tram, Tube, Docklands Light Railway (DLR), London Overground and Transport for London (TfL) Rail services in all zones. Several areas also provide vouchers for discounted taxi fares for those registered as SSI. Everyone who is registered as SI or SSI can apply for a disabled persons’ railcard which gives one-third off all rail fares for the holder and an accompanying person.
Other sources of help available to people with visual impairment are central government, (national) voluntary agencies, and commercial organizations. Within these categories, the benefits may be available only to those who are registered as SSI, to any registered person, or also to those who are not eligible for registration. Registration is necessary to qualify for most financial benefits and for help from a number of voluntary agencies and commercial organisations.
Financial benefits come within the remit of central government, and are limited to:
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An addition to the personal allowance (the amount of money that can be earned before starting to pay income tax) of a SSI person in work (Blind Person’s Allowance). This can be transferred to a spouse if the registered person is unemployed.
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A 50% discount on the television licence if the person is registered as SSI (a SSI person could also purchase a sound-only receiver for which no licence is required).
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Disabled Living Allowance (DLA, for those under 16 years) and Personal Independence Payment for older individuals. These are not automatic and not means-tested. There are ‘care’ and ‘mobility’ components in each benefit, if the individual can give evidence of their need in these areas (and the RNIB provide detailed guidance on how to present a claim). It is expected that all children need care from their parents, but DLA is designed to recognise the additional care needed by a child with VI compared to a child of the same age without VI.
There is no other benefit which is given because of visual impairment, but there are some general benefits which operate with special conditions for those with disabilities. Most are on the basis of financial need and are ‘means-tested’: a calculation is made of the minimum amount which is considered necessary to live on, and there is an entitlement to benefit if the amount of income and savings does not reach this level. Benefits and allowances are not always cumulative, however, and receipt of one payment can be deducted from another entitlement: specialist individual advice must be sought by applicants, and a number of organisations operate telephone helplines. More up-to-date information is provided by the charities, the , Henshaws Society for the Blind People ( ), or www.sightadvicefaq.org.uk .
Both SI and SSI people qualify for:
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A free General Ophthalmic Services (GOS) Sight Test (also including payment to the optometrist of the fee for a domiciliary visit if that is necessary), although there is no special eligibility for a GOS Spectacle Voucher to be used for the supply of spectacles. People registered as SSI and SI cannot have their prescriptions dispensed by an unregistered supplier.
It is worth noting that optical (but not electronic) low-vision aids are prescribed through the Hospital Eye Service (HES), and supplied free on permanent loan at the discretion of the optometrist to anyone who needs them: registration is not required. There is no formal provision for the supply of aids through the GOS by high-street optometrists, although it may be possible to use a GOS Spectacle Voucher towards the purchase of some spectacle-mounted aids (see Chapter 22 ). Throughout Wales, optometrists, ophthalmic medical practitioners (OMPs) and dispensing opticians (DOs) based in high-street practices provide Low Vision Service Wales (LVSW), through which the low-vision aids are available on loan and free of charge. The scheme additionally offers (free of charge) an electronic pocket magnifier and spectacle-mounted low-vision aids ( ). In England, there are commissioned enhanced clinical pathways in some local areas which allow community practitioners to participate in similar schemes (see Chapter 22 ).
- 5.
Exemption from VAT (value added tax) when buying products designed and manufactured exclusively for the use of disabled: an example of such device might be an EVES.
The national voluntary organisations are open to anyone seeking information and advice: the RNIB, for example, has an online shop on their website. Registration gives extra entitlements, however, because those who are registered get some items free of VAT. A radio and/or a portable smart device can be supplied by the British Wireless for the Blind Fund, but only to those who are registered SSI, SI, over the age of 8 years and in receipt of a means-tested benefit. Commercial organisations also offer concessions: BT makes no charge for directory enquires for a registered SSI or SI person who registers with the service in advance: they are given a Personal Identification Number to quote when requesting a number. Bank and Building Societies websites and apps should be fully accessible to SSI and SI people and will ensure that the person has a fully accessible way of obtaining their account details or provide the person with equipment to enable access to their account. Braille, large print or audio statements and information leaflets are usually provided on request.
Although an enormous range of benefits and services exist, they are extremely complex and diverse and, individually, quite small. It takes a great deal of persistence in seeking out information by people with visual impairment in order to find out what might be of benefit to them, and all possible measures need to be taken to publicise available services. Some selected findings from the RNIB survey ( ) highlight problems in several areas. Although those registered as visually impaired tend to be proportionately more aware than the unregistered, the lack of knowledge is surprising: although many have very low incomes and are often dependent on state benefits, only 29% had received any expert advice on their entitlements; only 11% had received practical advice on daily living skills from Social Services staff; and over one-third could not name a single voluntary organisation involved in helping those with sight problems. The low-vision practitioner can play a significant role by pointing out the possible benefits of registration, and encouraging this whenever possible.
Equality and Accessibility
In 1993, the United Nations adopted the ‘Standard Rules on the Equalization of Opportunities for Persons with Disabilities’ ( ) which showed a shift in concepts of disability from the ‘medical model’ to the ‘social model’. The so-called medical model looks at what is ‘wrong’ with the disabled person. It creates low expectations, and stereotypes, with pathways being decided for them (e.g. blind people being directed to work as basket weavers or piano tuners). The social model acknowledges that much disability is caused by the way that society is organised. The focus is on removing barriers (physical and attitudinal) to allow individuals who are different to be equal in society, with control over their own lives. The prevailing terminology uses words such as ‘independence’ ‘choice’ ‘empowerment’ ‘enablement’.
In the UK, the Equality Act 2010 superseded the requirements of the Disability Discrimination Act 1995 which stated that individuals should not be discriminated against on the basis of disability (or eight other ‘protected characteristics’). Any service provider (i.e. a public or private organisation) must not treat a person with disability ‘less favourably’, whether providing a free service or one for which a charge is made. They are required to make ‘reasonable adjustments’ in order to ensure that the disabled individual does not encounter any barriers to accessing services. A very simple ‘reasonable adjustment’ is the provision of documents in large print by banks and utility companies.
One of the services which individuals with visual impairment often experience great difficulty in accessing is healthcare. There are several barriers which have been identified, such as the difficulties and cost of travelling, and safety when out and about ( ).
As well as physical access to healthcare, there is also a lack of access to information ( ). Since 2016 there has been a requirement that all healthcare information should be accessible in a suitable format ( ) so the provider should discuss this with each of their service users. However, when a review of this implementation was carried out in 2017 (NHS; ) over 40% of respondents had not heard anything about the standard, and only 20% had noticed any improvement. Reading medication labelling is another often-reported difficulty, and guidance is available as to how this should be done appropriately ( ).
The Icf
As noted previously, the ICF attempts to standardise the description of the functional consequences of disease at various levels.
Obviously there are many differences between individuals in lifestyle, which will influence the activities they wish to undertake, but there are environmental and personal factors which can also affect how successfully the impairment can be managed.
The environment includes the individual’s home, workplace or school (for example), and the people they interact with in those settings (‘local’). However, it also includes the society in which they live: the voluntary agencies and public services, and the prevailing attitudes, awareness and legislation about disability (‘global’).
Personal factors refer to the characteristics of the individual with visual impairment: their race, age, sex, religious beliefs, upbringing, coping strategies, mental and physical health and education. In a mixed low-vision population, physical and mental health were found to be the most important of these factors in determining rehabilitative outcomes ( ). In an AMD population, the personality trait of neuroticism (a tendency to anxiety and pessimism) was a significant predictor of successful outcomes ( ).
Fig. 1.1A shows how these components fit within the theoretical model, and Fig. 1.1B gives a simple example. This is a patient who finds that their reading is now very difficult due to AMD. They are very determined and keen to be independent, because they have no family close by. The patient attends the hospital low-vision clinic and is provided with a magnifier to assist with reading correspondence. They are also registered as SI and receive a visit from the Social Services Department who provide a reading lamp. The patient contacts the bank who arrange to provide all correspondence in large print.
