|Author(s):||Helen Weatherlya; Francesco Longoa; Pedro Saramagoa;|
|Institution(s):||a Centre for Health Economics, University of York;|
|Production date:||February 2023|
|Acknowledgements:||We are grateful to the ESSENCE project advisory group for their helpful comments on earlier versions of this case summary.|
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Vision impairment, or sight loss, affected approximately 2 million people in the UK in 2013, a figure that is estimated to double by 2050 because of an ageing population.1 The total economic costs of sight loss and blindness is £16 billion. Of those, direct health system costs are £3 billion, indirect costs £6 billion, and costs linked to quality-of-life losses of £7 billion.1 Vision impairment can impact on a person’s health, wellbeing, functioning, including activities of daily living such as getting in and out of bed, and mental health.
In England, vision rehabilitation services, which support people who recently lost vision, are blind or who have low vision to continue living independently and maintain their quality of life, were recognised under the Care Act 2014 as a key preventative service that local authorities have a duty to provide. By supporting peoples’ independence they might prevent, delay or reduce demands on health and social care services and associated costs. However, overall, questions remain on how to best deliver such services cost-effectively, in particular whether they are more cost-effective when delivered in-house by local authorities versus contracted-out to an external organisation.
This summary presents evidence of an economic evaluation of community-based vision rehabilitation, which compared costs, experiences and outcomes for people using an in-house service with people using a contracted-out service.2
Vision rehabilitation includes a wide range of services that promote independence and health-related quality of life through improving or restoring functioning. Vision rehabilitation also aims to reduce the demand for other social care and health care services.3
Like other types of rehabilitation services, they are typically short-term and goal driven. They include training in independent living skills (e.g., dressing or cooking), orientation and mobility (e.g., shopping or going out with friends), and use of aids, adaptations, and equipment (e.g., liquid level indicators and talking labeller devices).
This case summary focuses on community-based vision rehabilitation. Vision rehabilitation services can be contracted-out, which means they are delivered through external agencies, or they can be provided in-house via local authorities. In-house versus contracted-out services differ in what they provide and how.
In-house vision rehabilitation services employ teams to conduct wider sensory impairment work, usually vision and hearing rehabilitation. They also undertake additional generic work such as arranging social care, advising on benefits and mental health services. This is carried out by the rehabilitation officer or via referral to other local authority services.
Contracted-out, external agencies generally employ teams which focus solely on vision rehabilitation. Therefore, in-house VR services tend to include a broader range of services, while contracted-out organisations tend to allocate more resources to sight loss specific group activities such as social events and leisure activities.
Findings from the economic evaluation reported in the case summary suggested that there is no difference in social care related quality-of-life or in vision-specific outcomes when vision rehabilitation services are provided in-house versus when they are contracted-out.
The main study (not published) found that typically people using vision rehabilitation services, whether in-house or contracted-out, were positive about the impact of the service on their confidence, motivation and independence. People aged 65 and under typically reported greater gains than over 65s and had similar feelings regarding independence and contentment with the service. People commonly reported a sense of security in knowing support was there if needed. Practical benefits were reported as the ability to make a drink or use the microwave, increased mobility, and access to specialist equipment.
People using in-house vision rehabilitation did not report different experiences compared to people using the contracted-out service with regards to the number and frequency of the visits, supply of equipment, and support with independent living skills and mobility training. They also had similar feelings regarding their independence and contentment with the service. However, there were some marked differences in their experiences of using the service with regards to waiting times. People using an in-house service waited 1 to 3 months whereas people using a contracted-out service waited less than a month.
There were also differences in what people said they received. Those using an in-house service reported receiving a wider range of one-to-one generic support (e.g., advice on benefits/form filling and help with arranging home adaptations and completing carers’ assessment forms), whereas people using a contracted-out service were more likely to report being offered group-based activities and signposted to other sight loss charities (e.g., for advice on benefits, IT training courses and cooking classes).
Several people using the contracted-out service who had taken up the group activities said that the sessions increased their social contacts and made them feel less isolated and more aware of other support available for people with sight loss. However, a few younger users (under 65s) felt the group activities did not match their interests.
Findings from the economic evaluation2 reported in this case summary suggest that when only the costs to the local authority for social care are considered, an in-house vision rehabilitation service is very likely (about 90%) to be cost-effective compared with a contracted-out service (using a threshold of between £13,000 and £30,000 per QALY). When costs to the local authority and NHS for social and health care are considered, a contracted-out service vision rehabilitation service is more likely to be cost-effective (about 75%).
People using in-house vision rehabilitation were less likely to use social care and more likely to access hospital services. It is not possible from the data to know what explained the differences in service use, and whether this reflects better and more appropriate access or potentially unnecessary or inappropriate use of services. A possible explanation is that people using in-house vision rehabilitation receive a better assessment of health needs, which leads to earlier identification of health conditions (e.g., early symptoms of dementia) and referral to hospital. It is also possible that people using the in-house service receive a more efficient assessment and better coordinated social care.
The findings indicated that users of in-house vision rehabilitation services tend to use more hospital services. This suggests that better coordination (or integration) between local authorities and NHS services, using a social care and health care perspective combined, might offer larger cost savings and better outcomes for the public sector as a whole. In contrast, people using contracted-out services are more likely to use social care and less likely to use hospital services. This might reflect more appropriate use of social care, thus reducing the need to refer to hospital.
The economic evaluation2 reported in this case summary is, to our knowledge, the only cost-effectiveness evaluation of in-house and contracted-out vision rehabilitation services. There remains a paucity of information on vision rehabilitation and the cost-effectiveness of in-house vs contracted-out services. Caution is required about generalising from the findings of this study.
In England, all people who have difficulty with activities of daily living related to sight loss are potentially eligible for free-of-charge community-based vision rehabilitation services.3 The importance of rehabilitation to local authorities (LAs) is highlighted in the Care Act 2014, which also sets out a duty for local authorities to ensure such services are provided. There is a lot of variation in what kind of service are provided, by whom, the type of support, structure and skills of teams, caseloads and waiting times. Some services, in particular those from the voluntary sector, experience substantial pressure on budgets and staffing ratios.
Full information on the study is published here:
Longo F, Saramago P, Weatherly H, et al ( 2020) Cost-effectiveness of in-house vs contracted-out vision rehabilitation services in England. Journal of Long Term Care 118 – 130.
To our knowledge, to date (August 2022) there is no new research that is underway on this topic.
NIHR School for
Social Care Research